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1.
Artigo em Inglês | MEDLINE | ID: mdl-34783176

RESUMO

BACKGROUND: The anatomical structure around the pancreatic head is very complex and it is important to understand its precise anatomy and corresponding anatomical approach to safely perform minimally invasive pancreatoduodenectomy (MIPD). This consensus statement aimed to develop recommendations for elucidating the anatomy and surgical approaches to MIPD. METHODS: Studies identified via a comprehensive literature search were classified using the Scottish Intercollegiate Guidelines Network method. Delphi voting was conducted after experts had drafted recommendations, with a goal of obtaining >75% consensus. Experts discussed the revised recommendations with the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. RESULTS: Three clinical questions were addressed, providing six recommendations. All recommendations reached at least a consensus of 75%. Preoperatively evaluating the presence of anatomical variations and superior mesenteric artery (SMA) and superior mesenteric vein (SMV) branching patterns was recommended. Moreover, it was recommended to fully understand the anatomical approach to SMA and intraoperatively confirm the SMA course based on each anatomical landmark before initiating dissection. CONCLUSIONS: MIPD experts suggest that surgical trainees perform resection based on precise anatomical landmarks for safe and reliable MIPD.

2.
Artigo em Inglês | MEDLINE | ID: mdl-34719123

RESUMO

BACKGROUND: Surgical views with high resolution and magnification have enabled us to recognize the precise anatomical structures that can be used as landmarks during minimally invasive distal pancreatectomy (MIDP). This study aimed to validate the usefulness of anatomy-based approaches for MIDP before and during the Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (February 24, 2021). METHODS: Twenty-five international MIDP experts developed clinical questions regarding surgical anatomy and approaches for MIDP. Studies identified via a comprehensive literature search were classified using Scottish Intercollegiate Guidelines Network methodology. Online Delphi voting was conducted after experts had drafted the recommendations, with the goal of obtaining >75% consensus. Experts discussed the revised recommendations in front of the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. RESULTS: Four clinical questions were addressed, resulting in 10 recommendations. All recommendations reached at least a 75% consensus among experts. CONCLUSIONS: The expert consensus on precision anatomy for MIDP has been presented as a set of recommendations based on available evidence and expert opinions. These recommendations should guide experts and trainees in performing safe MIDP and foster its appropriate dissemination worldwide.

3.
Cancers (Basel) ; 13(14)2021 Jul 19.
Artigo em Inglês | MEDLINE | ID: mdl-34298818

RESUMO

Patients with resectable pancreatic cancer are considered to already have micro-distant metastasis, because most of the recurrence patterns postoperatively are distant metastases. Multimodal treatment dramatically improves prognosis; thus, micro-distant metastasis is considered to be controlled by chemotherapy. The survival benefit of "regional lymph node dissection" for pancreatic head cancer remains unclear. We reviewed the literature that could be helpful in determining the appropriate resection range. Regional lymph nodes with no suspected metastases on preoperative imaging may become areas treated with preoperative and postoperative adjuvant chemotherapy. Many studies have reported that the R0 resection rate is associated with prognosis. Thus, "dissection to achieve R0 resection" is required. The recent development of high-quality computed tomography has made it possible to evaluate the extent of cancer infiltration. Therefore, it is possible to simulate the dissection range to achieve R0 resection preoperatively. However, it is often difficult to distinguish between areas of inflammatory changes and cancer infiltration during resection. Even if the "dissection to achieve R0 resection" range is simulated based on the computed tomography evaluation, it is difficult to identify the range intraoperatively. It is necessary to be aware of anatomical landmarks to determine the appropriate dissection range during surgery.

4.
BMC Gastroenterol ; 21(1): 257, 2021 Jun 12.
Artigo em Inglês | MEDLINE | ID: mdl-34118881

RESUMO

BACKGROUND: Cholangiocarcinoma is frequently observed in patients with congenital bile duct dilatation (CBDD). Most cholangiocarcinomas are adenocarcinomas. Other types, especially neuroendocrine carcinomas (NECs), are rare. To the best of our knowledge, this is the third reported case of an NEC of the common bile duct associated with CBDD and the first to receive adjuvant chemotherapy for advanced disease. CASE PRESENTATION: A 29-year-old woman presented with upper abdominal pain. Preoperative imaging indicated marked dilatation of the common bile duct and a tumor in the middle portion of the common bile duct. She was suspected of having distal cholangiocarcinoma associated with CBDD and underwent pylorus-preserving pancreaticoduodenectomy. Pathological and immunohistological findings led to a final diagnosis of large-cell NEC (pT3aN1M0 pStageIIB). The postoperative course was uneventful, and she was administered cisplatin and irinotecan every 4 weeks (four cycles) as adjuvant chemotherapy. She has remained recurrence-free for 16 months. CONCLUSIONS: NEC might be a differential diagnosis in cases of cholangial tumor associated with congenital bile duct dilatation. This presentation is rare and valuable, and to establish better treatment for NEC, further reports are necessary.


Assuntos
Neoplasias dos Ductos Biliares , Ductos Biliares Extra-Hepáticos , Carcinoma Neuroendócrino , Adulto , Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Intra-Hepáticos , Carcinoma Neuroendócrino/diagnóstico por imagem , Carcinoma Neuroendócrino/cirurgia , Ducto Colédoco/diagnóstico por imagem , Ducto Colédoco/cirurgia , Dilatação , Feminino , Humanos , Recidiva Local de Neoplasia
5.
Surg Today ; 51(11): 1813-1818, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33907898

RESUMO

PURPOSE: Clinically relevant postoperative pancreatic fistulas (CR-POPF) occurring after distal pancreatectomy often cause intra-abdominal infections. We monitored the presence of bacterial contamination in the ascitic fluid after distal pancreatectomy to clarify the bacterial origin of intra-abdominal infections associated with CR-POPF. METHODS: In 176 patients who underwent distal pancreatectomy, ascitic fluid bacterial cultures were performed on postoperative days (POD) 1-4 and when the drainage fluid became turbid. The association between postoperative ascitic bacterial contamination and CR-POPF incidence was investigated. RESULTS: CR-POPF occurred in 18 cases (10.2%). Among the patients with CR-POPF, bacterial contamination was detected in 0% on POD 1, in 38.9% on POD 4, and in 72.2% on the day (median, day 9.5) when the drainage fluid became turbid. A univariate analysis revealed a significant difference in ascitic bacterial contamination on POD 4 (p < 0.001) and amylase level on POD 3-4 (p < 0.001). A multivariate analysis revealed the amylase level and ascitic bacterial contamination on POD 4 to be independent risk factors. CONCLUSIONS: In the CR-POPF group, ascitic bacterial contamination was not observed in the early postoperative stage, but the bacterial contamination rate increased after pancreatic juice leakage occurred. Therefore, CR-POPF-related infections in distal pancreatectomy may be caused by a retrograde infection of pancreatic juice.

6.
Surg Today ; 51(7): 1212-1219, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33420821

RESUMO

PURPOSE: Laparoscopic hepatojejunostomy (HJ) with continuous sutures is commonly performed in laparoscopic pancreaticoduodenectomy (LPD). This study aimed to investigate the long-term surgical outcomes of HJ in LPD. METHODS: We retrospectively evaluated 103 consecutive patients who underwent pancreaticoduodenectomy via laparoscopic HJ with continuous suturing using multifilament (n = 48) or monofilament-absorbable sutures (n = 47). RESULTS: During follow-up, anastomotic stricture of HJ was identified in 8 (7.8%) patients via balloon enteroscopy-assisted cholangiography. The median time from surgery to confirmation of stricture formation was 7.6 months (range 3.6-19.4). The incidence of HJ stricture was significantly higher in patients with a thin bile duct (diameter < 6.0 mm) than in those with a thick bile duct (diameter ≥ 6.0 mm) [7/27 (25.9%) vs. 1/76 (1.3%), respectively, p < 0.01]. Similarly, it was significantly higher in the monofilament group than in the multifilament group [7/54 (13.0%) vs. 1/49 (2.0%), respectively, p = 0.04]. In the monofilament suture group, 37.5% of patients with thin bile ducts developed stricture after HJ. A multivariate analysis revealed that a thin bile duct was an independent risk factor for HJ stricture (hazard ratio: 25.3, p < 0.01). CONCLUSIONS: Stricture after laparoscopic HJ using continuous sutures frequently occurs in patients with thin bile ducts, particularly when monofilament-absorbable suture is used.


Assuntos
Anastomose Cirúrgica/efeitos adversos , Ductos Biliares/patologia , Jejunostomia/efeitos adversos , Laparoscopia/efeitos adversos , Pancreaticoduodenectomia/efeitos adversos , Técnicas de Sutura/efeitos adversos , Suturas/efeitos adversos , Ductos Biliares/diagnóstico por imagem , Ductos Biliares/cirurgia , Constrição Patológica/etiologia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Tomografia Computadorizada por Raios X , Resultado do Tratamento
7.
Front Oncol ; 10: 1112, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32850319

RESUMO

Background: Non-randomized studies have investigated multi-agent gemcitabine-based neo-adjuvant therapies (GEM-NAT) in borderline resectable pancreatic ductal adenocarcinoma (BR-PDAC). Treatment sequencing and specific elements of neoadjuvant treatment are still under investigation. The present meta-analysis aims to assess the effectiveness of GEM-NAT on overall survival (OS) in BR-PDAC. Patients and Methods: A meta-analysis of individual participant data (IPD) on GEM-NAT for BR-PDAC were performed. The primary outcome was OS after treatment with GEM-based chemotherapy. In the Individual Patient Data analysis data were reappraised and confirmed as BR-PDAC on provided radiological data. Results: Six studies investigating GEM-NAT were included in the IPD metanalysis. The IPD metanalysis was conducted on 271 patients who received GEM-NAT. Pooled median patient-level OS was 22.2 months (95%CI 19.1-25.2). R0 rates ranged between 81 and 95% (I 2 = 0%, p = 0.64), respectively. Median OS was 27.8 months (95%CI 23.9-31.6) in the patients who received NAT-GEM followed by resection compared to 15.4 months (95%CI 12.3-18.4) for NAT-GEM without resection and 13.0 months (95%CI 7.4-18.5) in the group of patients who received upfront surgery (p < 0.0001). R0 rates ranged between 81 and 95% (I 2 = 0%, p = 0.64), respectively. Overall survival in the R0 group was 29.3 months (95% CI 24.3-34.2) vs. 16.2 months (95% CI 7·9-24.5) in the R1 group (p = 0·001). Conclusions: The present study is the first meta-analysis combining IPD from a number of international centers with BR-PDAC in a cohort that underwent multi-agent gemcitabine neoadjuvant therapy (GEM-NAT) before surgery. GEM-NAT followed by surgical resection improve survival and R0 resection in BR-PDAC. Also, GEM-NAT may result in a good palliative option in non-resected patients because of progressive disease after neoadjuvant treatment. Results from randomized controlled trials (RCTs) are awaited to validate these findings.

8.
Surg Today ; 50(12): 1664-1671, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32577883

RESUMO

PURPOSE: The left renal vein is technically difficult to expose during laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma despite being an important landmark for posterior dissection. We hereby propose a novel technique to safely expose the left renal vein while avoiding the associated anatomical pitfalls. METHODS: The anatomy of the left renal artery and vein was analyzed using multidetector computed tomography. We initially exposed the left renal vein on the left posterior side of the superior mesenteric artery followed by exposure toward the left kidney. We retrospectively examined the perioperative results of this technique in 33 patients who underwent laparoscopic distal pancreatectomy. RESULTS: 15.7% of the patients had an accessory left renal artery coursing cranial to the vein. In 43.1%, the left renal arterial branch ventrally traversed the vein at the renal hilum, thereby posing a risk for arterial injury. The location of the left renal vein varies cranial (17.6%) or caudal (82.4%) to the pancreas. The left renal vein was exposed without any vascular injury using this technique. The median operative time was 259 min, blood loss was 18 mL, and R0 resection rate was 97.0%. CONCLUSIONS: The initial exposure of the left renal vein should, therefore, be on the left posterior side of the superior mesenteric artery.


Assuntos
Variação Anatômica , Carcinoma Ductal Pancreático/cirurgia , Laparoscopia/métodos , Pâncreas/irrigação sanguínea , Pâncreas/cirurgia , Pancreatectomia/métodos , Neoplasias Pancreáticas/cirurgia , Veias Renais/anatomia & histologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Ductal Pancreático/diagnóstico por imagem , Feminino , Humanos , Masculino , Artéria Mesentérica Superior/anatomia & histologia , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , Neoplasias Pancreáticas/diagnóstico por imagem , Artéria Renal/anatomia & histologia , Artéria Renal/diagnóstico por imagem , Veias Renais/diagnóstico por imagem , Estudos Retrospectivos , Segurança
9.
J Hepatobiliary Pancreat Sci ; 27(9): 640-647, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32506646

RESUMO

BACKGROUND: Few reports describe the relationship between preoperative cholangitis and surgical site infections (SSIs) after pancreaticoduodenectomy (PD). We aimed to determine the association between the incidence of preoperative cholangitis and surgical site infection following PD. METHODS: The surgical outcomes of 359 patients who underwent PD were compared between patients with (n = 92) and without (n = 267) preoperative cholangitis. Bacterial cultures from the postoperative drainage fluid were examined. Risk factors for postoperative infectious complication were evaluated. RESULTS: The incidence of postoperative infectious complications including grade B/C postoperative pancreatic fistula was high among patients with preoperative cholangitis (P < .01). The positive rate of bacterial culture in the drainage fluid until postoperative day 3 (P < .01) and the detection rate of Enterococcus species (P < .01) were higher in the preoperative cholangitis group. The most common cause of preoperative cholangitis was drainage device dysfunction mainly with plastic stent occlusion. In the multivariate analysis, preoperative cholangitis (odds ratio 2.04, 95% confidence interval 1.13 to 3.69; P = .02) was an independent risk factor for postoperative infectious complications. CONCLUSIONS: Preoperative cholangitis significantly increased ascitic bacterial contamination and the incidence of postoperative infectious complications. after PD. Appropriate preoperative biliary drainage for the prevention of preoperative cholangitis is important for improving outcomes after PD.


Assuntos
Colangite , Neoplasias Pancreáticas , Colangite/epidemiologia , Colangite/etiologia , Drenagem , Humanos , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Cuidados Pré-Operatórios , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia
10.
Surg Case Rep ; 6(1): 134, 2020 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-32542451

RESUMO

BACKGROUND: There is no standard surgical method for treating pancreatic head tumors with fat replacement of the pancreatic body and tail. Total pancreatectomy procedures are usually performed to excise pancreatic head tumors and lead to endocrine function loss and subsequent development of diabetes. We present a rare case where the adipose tissue was preserved during pancreaticoduodenectomy in a patient with a solid pseudopapillary neoplasm and fat-replaced pancreatic body and tail. CASE PRESENTATION: Contrast-enhanced computed tomography scans of a 43-year-old man revealed a tumor measuring approximately 3 cm in size with calcification in the pancreatic head. Magnetic resonance cholangiopancreatography showed that the pancreatic ducts in the body and tail were completely disrupted. Furthermore, endoscopic ultrasonography showed no pancreatic parenchyma in the body and tail of the pancreas, with disruption in the main pancreatic duct. Endoscopic ultrasonography-guided fine-needle aspiration led to the final pathological diagnosis of a solid pseudopapillary neoplasm, and laparoscopic total pancreatectomy was performed. However, intraoperative findings indicated that the tumor was located in the pancreatic head. Pancreatic parenchyma was not observed in the pancreatic body or tail, as it had been completely replaced with adipose tissue. Nevertheless, the shape of the pancreas was identifiable. Therefore, pancreaticoduodenectomy was performed to transect parenchyma at the pancreatic neck, while preserving the adipose tissue present in the pancreatic body. The main pancreatic duct could not be identified at the cut surface. Therefore, we performed modified Blumgart-style pancreaticojejunostomy to cover the cut end instead of reconstructing the pancreatic duct. The patient was discharged on postoperative day 12 without complications and is being followed-up as an outpatient. His fasting blood sugar and hemoglobin A1c levels according to the National Glycohemoglobin Standardization Program reports were within normal limits, indicating that the endocrine function (insulin secretion ability) was preserved during the 1.5 years following surgery. CONCLUSIONS: In patients with pancreatic head tumors, pancreaticoduodenectomy that preserves fat-replaced pancreatic body and tail tissues can preserve postoperative endocrine function.

11.
J Hepatobiliary Pancreat Sci ; 27(10): 731-738, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32563216

RESUMO

PURPOSE: To evaluate the feasibility of pancreaticoduodenectomy with resection of the second jejunal vein (J2V) for pancreatic ductal adenocarcinoma (PDAC). METHODS: Among 114 patients with PDAC undergoing pancreaticoduodenectomy with portal-superior mesenteric vein resection (PVR), surgical outcomes, and prognoses of 10 patients with resection of J2V or later branches of the superior mesenteric vein (J2VR) were compared to 104 patients with PVR above J2V (standard PVR). The reconstruction methods in the J2VR group were reviewed. RESULTS: There were no significant differences in the operative time (470 vs 435 min), morbidity (30% vs 27%), presence of portal vein stenosis (10% vs 5%) or thrombosis (10% vs 1%), and induction of adjuvant therapy (80% vs 88%) between the J2VR and standard PVR groups, although blood loss was higher in the J2VR group (1184 vs 494 ml; P = .002). R0 proportion and 2-year survival rates were not significantly worse in the J2VR group compared to the standard PVR group (90 and 88%; 67 and 45%, respectively). At least one branch of the superior mesenteric vein was reconstructed in the J2VR group. CONCLUSION: Pancreaticoduodenectomy with J2VR for PDAC can be safely performed with a satisfactory overall survival rate.


Assuntos
Adenocarcinoma , Neoplasias Pancreáticas , Adenocarcinoma/cirurgia , Humanos , Veias Mesentéricas/cirurgia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia , Veia Porta/cirurgia , Resultado do Tratamento
12.
Medicine (Baltimore) ; 99(10): e19474, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32150110

RESUMO

The modified Blumgart method for pancreaticojejunostomy has been shown to reduce the rate of postoperative pancreatic fistula (POPF) in open surgery. We describe a modified Blumgart method using LAPRA-TY suture clips to facilitate laparoscopic pancreaticojejunostomy.We prepared a double-armed 4-0 nonabsorbable monofilament, which was ligated using the LAPRA-TY clip at the tail end, 12-cm in length. Next, the U-suture was placed through the pancreatic stump and the seromuscular layer of the jejunum. We performed duct-to-mucosa suturing with a 5-0 absorbable monofilament. After completing the duct-to-mucosa suturing, as a final step we placed the sutures through the seromuscular layer of the jejunum on the ventral side and tightly secured the thread with the LAPRA-TY clips. We performed laparoscopic Blumgart pancreaticojejunostomy during pancreaticoduodenectomy in 39 patients. We compared the surgical outcomes of 19 patients who underwent Blumgart pancreaticojejunostomy using the LAPRA-TY clips (LAPRA-TY group) with 20 patients undergoing surgery not using the LAPRA-TY clips (conventional group).The rate of clinically relevant postoperative pancreatic fistula in the LAPRA-TY group was 21.1%, which did not differ significantly from the rate of the conventional group. However, the mean time of pancreaticojejunostomy in the LAPRA-TY group was 56.2 min (range, 39-79 min), which was significantly shorter than that of the conventional group (69.7 min; range, 53-105 min, P < .001).Although the modified Blumgart pancreaticojejunostomy using LAPRA-TY suture clips did not improve the pancreatic fistula rate, it allowed for shorter operative times. Thus, this procedure lends itself to positive surgical and patient outcomes.


Assuntos
Anastomose Cirúrgica/instrumentação , Laparoscopia/instrumentação , Fístula Pancreática/cirurgia , Pancreaticojejunostomia/instrumentação , Instrumentos Cirúrgicos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia , Complicações Pós-Operatórias , Técnicas de Sutura , Resultado do Tratamento
13.
J Hepatobiliary Pancreat Sci ; 27(6): 342-351, 2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32048456

RESUMO

BACKGROUND: The aim of the present study was to investigate the feasibility of resection based on the nerve and fibrous tissue (NFT) structures around the superior mesenteric artery (SMA) for resectable pancreatic adenocarcinoma (R-PDAC) patients. METHODS: NFTs around the SMA were classified into four "intensive NTFs area" with spreading the NFTs around the SMA and three SMA nerve plexus regions without branching nerves according to autopsy findings. Complete dissection of four "intensive NTFs areas" was performed by pre-exposing three SMA nerve plexus regions without branching nerves as "dissection-guiding points" with SMA nerve plexus preservation (NFT-based resection). Among 157 R-PDAC patients undergoing pancreaticoduodenectomy, surgical outcomes of 78 patients with NFT-based resection were compared with 59 patients with half-SMA nerve plexus dissection and 20 patients without NFTs dissection. RESULTS: In the NFT-based resection group, 76.5% had tumor involvement and metastasis in each intensive NTFs area. Operative time, blood loss, and postoperative diarrhea rate were significantly lower in NFT-based resection than in half-SMA nerve plexus group (321 vs 390 min; P < .01, 228 vs 550 mL; P < .01, 5.1% vs 15.3%; P = .04, respectively). R0 rate and median overall survival significantly improved in NFT-based resection than in non-NFT dissection group (93.6% vs 65.0%; P < .01, 49.6 vs 23.6 months, P = .01). CONCLUSION: NFT-based resection may become a novel method for R-PDAC patients.


Assuntos
Adenocarcinoma/cirurgia , Artéria Mesentérica Superior/anatomia & histologia , Mesentério/inervação , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Idoso , Idoso de 80 Anos ou mais , Pontos de Referência Anatômicos , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Diarreia/epidemiologia , Estudos de Viabilidade , Feminino , Humanos , Japão , Masculino , Duração da Cirurgia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Estudos Retrospectivos , Taxa de Sobrevida
14.
Ann Surg Oncol ; 26(6): 1629-1636, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30610555

RESUMO

BACKGROUND: The efficacy of neoadjuvant therapy (NAT), including neoadjuvant chemotherapy (NAC) and neoadjuvant chemo-radiotherapy (NACRT), for patients with borderline resectable pancreatic cancer (BRPC) has not been elucidated. This study aimed to clarify the efficacy of NAC and NACRT for patients with BRPC. METHODS: The study analyzed the treatment outcomes of 884 patients treated for BRPC from 2011 to 2013. Treatment results were compared between upfront surgery and NAT and between NAC and NACRT using propensity score-matching analysis. Overall survival (OS) was calculated via intention-to-treat analyses. RESULTS: The overall resection rates for the patients who underwent NAT were significantly lower than for the patients who underwent upfront surgery (75.1% vs 93.3%; p < 0.001). However, the R0 resection rate was significantly higher for NAT than for upfront surgery (p < 0.001). Additionally, the OS for the patients who received NAT was significantly longer than for those who underwent upfront surgery (median survival time [MST], 25.7 vs 19.0 months; p = 0.015). The lymph node rate for the patients with NACRT was significantly lower than for those who underwent NAC (p < 0.001). However, the resection rate for the NACRT cases was significantly lower than for the NAC cases (p = 0.041). The local recurrence rate for the NACRT cases was significantly lower than for the NAC cases (p = 0.002). However, OS did not differ significantly between NAC and NACRT (MST, 29.2 vs 22.5 months; p = 0.130). CONCLUSIONS: The study showed that NAT has potential benefit for patients with BRPC. Compared with NAC, NACRT decreased the rates for lymph node metastasis and local recurrence but did not improve the prognosis.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimiorradioterapia/mortalidade , Quimioterapia Adjuvante/mortalidade , Terapia Neoadjuvante/mortalidade , Neoplasias Pancreáticas/mortalidade , Especialidades Cirúrgicas/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/terapia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
15.
Surg Laparosc Endosc Percutan Tech ; 29(2): e15-e19, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30520812

RESUMO

Hand-sewing (HS) and stapling are common parenchymal closure techniques after distal pancreatectomy. However, these methods cannot completely prevent postoperative pancreatic fistula (POPF). The mechanisms of POPF formation after closure are unknown. We performed distal pancreatectomy in mongrel dogs to identify the mechanisms of POPF formation after HS and staple closure. We measured the closed pancreatic duct burst pressures and examined the histology of the remnant pancreas. The after staple-closure burst pressures depended on stapler height; lower pressures were associated with greater stapler heights. Post-HS closure burst pressures were significantly higher than those at each stapler height (P<0.01). Post-HS closure pathologic findings showed extensive necrosis (day 3), and some regenerated pancreatic duct stumps (day 5). Necrosis was not observed around the stapled tissues. Although HS completely closes the pancreatic ducts, stump necrosis and blood flow disturbances may cause POPF. With stapler closure, pancreatic fluid leakage may occur even with appropriate stapler heights.


Assuntos
Pancreatectomia/efeitos adversos , Fístula Pancreática/etiologia , Grampeamento Cirúrgico/efeitos adversos , Técnicas de Sutura/efeitos adversos , Animais , Cães , Necrose/patologia , Pâncreas/patologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/patologia , Complicações Pós-Operatórias/fisiopatologia , Pressão , Deiscência da Ferida Operatória/etiologia , Deiscência da Ferida Operatória/patologia , Deiscência da Ferida Operatória/fisiopatologia
16.
Gland Surg ; 7(1): 12-19, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29629315

RESUMO

Neuroendocrine tumors of the pancreas (pNETs) are a rare group of neoplasms that originate from the endocrine portion of the pancreas. Tumors that either secrete or do not secrete compounds, resulting in symptoms, can be classified as functioning and non-functioning pNETs, respectively. The prevalence of such tumors has recently increased due to the use of more sensitive imaging techniques, such as multidetector computed tomography, magnetic resonance imaging and endoscopic ultrasound. The biological behavior of pNETs varies widely from indolent, well-differentiated tumors to those that are far more aggressive. The most effective and radical treatment for pNETs is surgical resection. Over the last decade, minimally invasive surgery has been increasingly used in pancreatectomy, with laparoscopic pancreatic surgery (LPS) emerging as an alternative to open pancreatic surgery (OPS) in patients with pNETs. Non-comparative studies have shown that LPS is safe and effective. In well-selected groups of patients with pancreatic lesions, LPS was found to results in good perioperative outcomes, including reduced intraoperative blood loss, postoperative pain, time to recovery, and length of hospital stay. Despite the encouraging results of studies from highly specialized centers with extensive experience, no randomized trials to date have conclusively validated these findings. Indications for minimally invasive LPS for patients with pNETs remain unclear. This review presents the current state of LPS for pNETs.

17.
J Gastrointest Surg ; 22(7): 1179-1185, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29520646

RESUMO

BACKGROUND/PURPOSE: The proximal jejunal vein which branches from the dorsal side of the superior mesenteric vein (SMV) usually drains the inferior pancreatoduodenal veins (IPDVs) and contacts the uncinate process of the pancreas. We focused on this vein, termed the proximal dorsal jejunal vein (PDJV), and evaluated the anatomical classification of the PDJV and surgical outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) with PDJV involvement (PDJVI). METHODS: The jejunal veins that branch from the dorsal side of the SMV above the inferior border of the duodenum are defined as PDJVs. We investigated 121 patients who underwent upfront pancreaticoduodenectomy for PDAC between 2011 and 2017; PDJVs were resected in all patients. The anatomical classification of PDJV was evaluated using multidetector computed tomography. Surgical and prognostic outcomes of pancreticoduodenectomy for PDAC with PDJVI were evaluated. RESULTS: The PDJVs were classified into seven types depending on the position of the first and second jejunal veins relative to the superior mesenteric artery. In all patients, the morbidity and mortality rates were 15.7 and 0.8%, respectively. The rates for parameters including SMV resection, presence of pathological T3-4, R0 resection, and 3-year survival were 46.2, 92.3, 92.3, and 61.1%, respectively, when there was PDJVI (n = 13). When there was no PDJVI (n = 108), the rates were 60.2, 93.5, 86.1, and 58.3%, respectively. Overall, there were no significant differences. CONCLUSIONS: Pancreaticoduodenectomy with PDJV resection is feasible for PDAC with PDJVI and satisfactory overall survival rates are achievable. It may be necessary to reconsider the resectability of PDAC with PDJVI.


Assuntos
Carcinoma Ductal Pancreático/cirurgia , Veias Mesentéricas/patologia , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/métodos , Neoplasias Vasculares/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Ductal Pancreático/diagnóstico , Feminino , Humanos , Masculino , Veias Mesentéricas/cirurgia , Pessoa de Meia-Idade , Invasividade Neoplásica , Neoplasias Pancreáticas/diagnóstico , Estudos Retrospectivos , Resultado do Tratamento , Neoplasias Vasculares/cirurgia
18.
Surg Endosc ; 32(9): 4044-4051, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29484553

RESUMO

BACKGROUND: Although the artery-first approach is widely used in open pancreaticoduodenectomy, it is difficult to laparoscopically expose the origin of the inferior pancreaticoduodenal artery (IPDA) from the left side of the superior mesenteric artery (SMA). By contrast, damaging the inferior pancreaticoduodenal veins (IPDVs) is possible when approaching the IPDA from the right side of the SMA. To facilitate the artery-first approach in laparoscopic pancreaticoduodenectomy (LPD), we focused on the proximal-dorsal jejunal vein (PDJV) that branched from the superior mesenteric vein (SMV) dorsal side and drained the IPDVs. This study aimed to clarify the usefulness of the right SMA approach using the PDJV preisolation method. METHODS: The PDJV was first isolated, and the IPDVs were divided along the PDJV on the right side of the SMA. Then, the IPDA was divided at the root without first separating the pancreatic head from the portal vein and the SMV. Overall, 21 patients underwent this approach, and the results were retrospectively compared with those of 21 patients who underwent the artery-first approach, which was performed on the left side of the SMA. Anatomical characteristics of the PDJV were evaluated using multidetector computed tomography for the two groups. RESULTS: Operative times and resection times were significantly lower for the PDJV preisolation group than for the conventional LPD group (489.3 vs. 541.7 min, respectively; p = 0.002). During anatomical evaluation, 41 patients (97.6%) had a PDJV that drained from the SMV dorsally and was in contact with the anterior aspect of the uncinate process. The PDJV was confirmed as the first jejunal vein in 31 patients (73.8%) and as the second jejunal vein in 10 patients (23.8%). CONCLUSIONS: This approach facilitates dissection of the IPDA on the right side of the SMA, thereby reducing operative times.


Assuntos
Pontos de Referência Anatômicos , Laparoscopia , Artéria Mesentérica Superior/anatomia & histologia , Pancreaticoduodenectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Tomografia Computadorizada Multidetectores , Duração da Cirurgia , Veias/anatomia & histologia , Veias/diagnóstico por imagem
19.
Exp Ther Med ; 14(1): 221-227, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28672918

RESUMO

Cancer cell engraftment in the target organ is necessary to establish metastasis. Clinically, lymph node metastasis of single cells has been confirmed using cytokeratin staining. In the current study, a LacZ-labeled cancer cell line was used to visualize intrahepatic metastasis of single cells or liver micrometastasis. KM12SM-lacZ stably expressing LacZ was prepared with a highly metastatic colon cancer cell line, KM12SM. KM12SM-lacZ was injected into the spleen of nude mice and following 1 week the spleen was excised. The liver was then examined for metastasis following 1, 2 or 3 weeks. Confirmation of liver metastasis was completed by observing the grade of metastasis. Grade-1 metastasis (DNA level), human DNA in liver tissue was detected; Grade-2 metastasis (metastasis of single cells), confirmed by X-gal staining; Grade-3 metastasis (histopathological micrometastasis), diagnosed by light microscopy and Grade-4 metastasis (typical metastasis), easily detected macroscopically or by hematoxylin and eosin staining. The Grade-1 metastasis detection rates 1, 2 and 3 weeks following splenectomy were 50, 100 and 100%, respectively. Grade-2 metastasis was not detected by microscopy. The Grade-3 metastasis detection rates for 1, 2 and 3 weeks were 75, 100 and 100%, respectively. Micrometastasis was observed in the portal vein lumen and wall. The Grade-4 metastasis detection rates were 50, 100 and 100% for 1, 2 and 3 weeks respectively. Cancer cells were present in vessels surrounding the main tumor. In conclusion, a specific number of cancer cell aggregates may be necessary to establish hematogenous metastasis.

20.
Cancer Chemother Pharmacol ; 79(5): 951-957, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28378027

RESUMO

PURPOSE: Chemoradiotherapy using intensity-modulated radiotherapy (IMRT) is expected to provide a powerful alternative to conventional chemotherapy with a low incidence of adverse events. This study evaluated the efficacy of intensity modulated radiotherapy in combination with gemcitabine and S-1 as neoadjuvant chemoradiotherapy (NACRT) for borderline-resectable pancreatic cancer with arterial involvement (BR-A). METHODS: A total of 27 patients with BR-A were enrolled in this study between February 2012 and September 2015. IMRT was administered at 50.4 Gy in 28 fractions with concurrent gemcitabine at a dose of 600 mg/m2 and S-1 at a dose of 60 mg. RESULTS: Only one patient (3.5%) experienced gastrointestinal adverse events at grade 3 or higher. Nineteen patients (70.3%) underwent resection, and R0 resection was achieved in 18 patients (94.7%). Thirteen patients (68.4%) developed distant metastasis at the initial site of recurrence after resection. Local recurrence developed in only one of these patients (7.7%). The median overall survival and 1-year survival rates were 22.4 months and 81.3%, respectively. CONCLUSIONS: Concurrent IMRT with gemcitabine and S-1 for patients is feasible as NACRT for BR-A with low gastrointestinal toxicity. IMRT can be employed as a standard radiotherapy to provide more effective NACRT with powerful chemotherapy drugs.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Artérias/patologia , Quimiorradioterapia/métodos , Terapia Neoadjuvante/métodos , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/terapia , Adulto , Idoso , Antimetabólitos Antineoplásicos/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/efeitos adversos , Quimiorradioterapia/efeitos adversos , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Combinação de Medicamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/efeitos adversos , Metástase Neoplásica , Recidiva Local de Neoplasia , Ácido Oxônico/administração & dosagem , Pancreatectomia , Neoplasias Pancreáticas/cirurgia , Estudos Prospectivos , Radioterapia de Intensidade Modulada , Taxa de Sobrevida , Tegafur/administração & dosagem , Tomografia Computadorizada por Raios X
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