Cancer-associated fibroblast senescence and its relation with tumour-infiltrating lymphocytes and PD-L1 expressions in intrahepatic cholangiocarcinoma.

BACKGROUND: Caveolin-1 (CAV1) in cancer-associated fibroblasts (CAFs) has pro- or anti-tumourigenic effect depending on the cancer type. However, its effect in intrahepatic carcinoma (ICC) remains unknown. Therefore, this study aimed to investigate the relationship between CAV1 in CAFs and tumour-infiltrating lymphocyte (TIL) numbers or PD-L1 levels in ICC patients. METHODS: Consecutive ICC patients (n = 158) were enrolled in this study. The levels of CAV1 in CAFs, CD8 + TILs, Foxp3+ TILs and PD-L1 in cancer cells were analysed using immunohistochemistry. Their association with the clinicopathological factors and prognosis were evaluated. The correlation between these factors was evaluated. RESULTS: CAV1 upregulation in CAFs was associated with a poor overall survival (OS) (P < 0.001) and recurrence-free survival (P = 0.008). Clinicopathological factors were associated with high CA19-9 levels (P < 0.001), advanced tumour stage (P = 0.046) and lymph node metastasis (P = 0.004). CAV1 level was positively correlated with Foxp3+ TIL numbers (P = 0.01). There were no significant correlations between CAV1 levels and CD8 + TIL numbers (P = 0.80) and PD-L1 levels (P = 0.97). An increased CD8 + TIL number and decreased Foxp3+ TIL number were associated with an increased OS. In multivariate analysis, positive CAV1 expression in CAFs (P = 0.013) and decreased CD8 + TIL numbers (P = 0.021) were independent poor prognostic factors. CONCLUSION: Cellular senescence, represented by CAV1 levels, may be a marker of CAFs and a prognostic indicator of ICC through Foxp3+ TIL regulation. CAV1 expression in CAFs can be a therapeutic target for ICC.

Prognostic significance of preoperative PNI and CA19-9 for pancreatic ductal adenocarcinoma: A multi-institutional retrospective study.

BACKGROUND: The aim of this study was to investigate the clinical value of nutritional and immunological prognostic scores as predictors of outcomes and to identify the most promising scoring system for patients with pancreatic ductal adenocarcinoma (PDAC) in a multi-institutional study. METHODS: Data were retrospectively collected for 589 patients who underwent surgical resection for PDAC. Prognostic analyses were performed for overall (OS) and recurrence-free survival (RFS) using tumor and patient-related factors, namely neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, Prognostic Nutritional Index (PNI), Glasgow Prognostic Score (GPS), modified GPS, C-reactive protein-to-albumin ratio, Controlling Nutritional Status score, and the Geriatric Nutritional Risk Index. RESULTS: Compared with PDAC patients with high PNI values (≥46), low PNI (<46) patients showed significantly worse overall survival (OS) (multivariate hazard ratio (HR), 1.432; 95% CI, 1.069-1.918; p = 0.0161) and RFS (multivariate HR, 1.339; 95% CI, 1.032-1.736; p = 0.0277). High carbohydrate antigen 19-9 (CA19-9) values (≥450) were significantly correlated with shorter OS (multivariate HR, 1.520; 95% CI, 1.261-2.080; p = 0.0002) and RFS (multivariate HR, 1.533; 95% CI, 1.199-1.961; p = 0.0007). Stratification according to PNI and CA19-9 was also significantly associated with OS and RFS (log rank, P < 0.0001). CONCLUSIONS: Our large cohort study showed that PNI and CA19-9 were associated with poor clinical outcomes in PDAC patients following surgical resection. Additionally, combining PNI with CA19-9 enabled further classification of patients according to their clinical outcomes.

Long-Term Outcome of Definitive Chemoradiotherapy and Induction Chemoradiotherapy Followed by Surgery for T4 Esophageal Cancer with Tracheobronchial Invasion.

BACKGROUND: T4 esophageal cancer (EC) that invades the trachea or bronchus often has poorer prognosis than other T4 ECs. We investigated the long-term results of definitive chemoradiotherapy (dCRT) or induction chemoradiotherapy followed by surgery (iCRT-S) in patients with T4 EC with tracheobronchial invasion (TBI). PATIENTS AND METHODS: From 2003 to 2013, 71 patients with T4 EC with TBI were treated in our institution; 58 underwent dCRT, and 13 underwent iCRT-S. The long-term results associated with survival were retrospectively analyzed, and prognostic factors were examined by univariable and multivariable analysis. RESULTS: The 1-, 2-, and 5-year overall survival for all patients with T4 EC with TBI treated by dCRT or iCRT-S was 57, 29, and 19%, respectively. Multivariable analysis revealed that clinical lymph node (LN) metastasis and the treatment period were significant prognostic factors. Clinical LN positivity had significantly poorer prognosis than LN negativity. The treatment outcome in the later period was significantly better than that in the earlier period. In particular, the outcome after dCRT revealed significantly better prognosis in the later compared with the earlier period, whereas the outcome after iCRT-S did not show such a difference. With respect to treatment modality, no significant difference in survival was observed between dCRT and iCRT-S. CONCLUSIONS: Clinical LN negativity and later treatment period were significantly good prognostic factors for T4 EC with TBI. The recent improvements in dCRT outcomes may help to achieve survival comparable to that of iCRT-S.

Prognostic Significance of Preoperative Controlling Nutritional Status (CONUT) Score in Patients Undergoing Hepatic Resection for Hepatocellular Carcinoma: A Multi-institutional Study.

BACKGROUND: The Controlling Nutritional Status (CONUT) score is an objective tool that is widely used to assess the nutritional status in patients, including those with cancer. The relationship between the CONUT score and prognosis in patients who have undergone hepatic resection has not been evaluated in a multi-institutional study. METHODS: Data were retrospectively collected for 2461 consecutive patients with hepatocellular carcinoma (HCC) who had undergone hepatic resection with curative intent at 13 institutions between January 2004 and December 2015. Patients were assigned to two groups: preoperative CONUT scores ≤ 3 (low CONUT score) and ≥ 4 (high CONUT score). Clinicopathological characteristics, surgical outcomes, and long-term survival were compared using propensity score matching analysis. RESULTS: Of the 2461 patients, 540 (21.9%) had high (≥ 4) and 1921 (78.1%) had low (≤ 3) preoperative CONUT scores. Overall, a high CONUT score was significantly associated with older age, female sex, low body mass index, low serum albumin, high serum total bilirubin, low lymphocyte count, low serum cholesterol, shorter prothrombin time, higher indocyanine green retention test at 15 min, Child-Pugh B (vs. A), liver cirrhosis, minor resection, shorter operation time, massive blood loss, blood transfusion, and postoperative complications. After propensity score matching, a higher CONUT score was significantly associated with poor overall survival (OS) and recurrence-free survival (RFS) using multivariate analysis. CONCLUSIONS: This retrospective, multi-institutional analysis showed that, in patients who undergo curative hepatectomy for HCC, the preoperative CONUT score is predictive of worse OS and RFS, even after propensity score matching analysis.

S-1 Adjuvant Chemotherapy Earlier After Surgery Clinically Correlates with Prognostic Factors for Advanced Gastric Cancer.

BACKGROUND: S-1 adjuvant chemotherapy is commonly administered postoperatively for stage II and III advanced gastric cancer. METHODS: This study included 113 patients treated with S-1 adjuvant chemotherapy after surgery for stage II and III advanced gastric cancer. These patients were divided into 4 groups: group A (n = 63), who had a longer duration (≥6 months) and earlier S-1 administration (≤6 weeks) after surgery; group B (n = 16), who had a longer and later S-1 administration (>6 weeks) after surgery; group C (n = 27), who had a shorter duration (<6 months) and earlier S-1 administration after surgery; and group D (n = 7), who had a shorter and later S-1 administration after surgery. RESULTS: The recurrence rates in groups A, B, C, and D were 15.7, 43.8, 44.4, and 57.1 %, respectively (A vs. B, p < 0.05, A vs. C and D, p < 0.01). The survival time of group A was significantly longer than that of other groups (p < 0.005). In addition, the survival time of patients with severe complications was significantly shorter than that of patients with non-severe complications (p < 0.05). An earlier S-1 administration after surgery was the only independent prognostic factor in the multivariate analysis. CONCLUSIONS: The prognosis of advanced gastric cancer was significantly related to the start of S-1 adjuvant treatment within 6 weeks after surgery.

Hepatic resection of hepatocellular carcinoma after proton beam therapy: A case report.

Despite the widespread use of proton beam therapy (PBT) as locoregional therapy, there is currently a lack of histological evidence about the therapeutic effect of PBT for hepatocellular carcinoma (HCC). We present a case of hepatectomy and histological examination of HCC initially treated by PBT. A 76-year-old man with chronic hepatitis C underwent routine ultrasound surveillance, which revealed a 22-mm HCC in segment 4 of the liver. His hepatic reserve was adequate for surgical resection of the tumor; however, he chose to undergo PBT because of his cardiac disease. The patient received 66 Gy in 10 fractions with no toxicity exceeding grade 1. Six months after completion of PBT, contrast computed tomography showed that the tumor had increased in size to 27 mm, and the marginal part of the tumor, but not the central region, was enhanced. Additionally, two new hypervascular nodules were present in segments 5 and 6. The patient underwent surgical treatment 7 months after PBT. The operation and postoperative clinical course were uneventful. Nine months later, however, computed tomography demonstrated new, small, enhanced nodules in the remnant liver (segments 3, 5 and 6) and sacrum. In conclusion, PBT is a valuable treatment for HCC; however, it is difficult to evaluate therapeutic effect of HCC during the early post-irradiation period and provide an alternative treatment if PBT is not effective, especially in HCC cases with good liver function.

Effect of sustained virological response to interferon therapy for hepatitis C to the hepatectomy for primary hepatocellular carcinoma.

BACKGROUND/AIMS: Interferon (IFN) therapy improves the prognosis of the patients with HCV-related hepatocellular carcinoma (HCC). However, the effects of IFN therapy for hepatectomy (Hx) for primary HCC have not been established. Several published reports investigating the effects of IFN therapy on survival and tumor recurrence after curative resection of HCC have been inconclusive. METHODOLOGY: Subjects included 470 patients who underwent Hx for HCV related primary HCC. One hundred and fifty nine patients received IFN therapy past or postoperatively of the first Hx. Seventy-four of those patients attained a sustained viral response (SVR group). The other 396 patients, including 85 were no responders (NR) and 311 patients who had not received IFN therapy (non-IFN) were classified as the control group. RESULTS: Overall survival (SVR group vs. control group: 5-yr, 93.2 vs. 61.9%; p<0.0001) and disease-free survival (SVR group vs. control group: 5-yr, 56.0 vs. 27.4%; p<0.0001) rates were significantly different. By multivariate analysis, NR/non-IFN was the independent risk factor for overall survival (p=0.0002) and disease-free survival (p=0.0053) after Hx. CONCLUSIONS: SVR achieved past or postoperatively to the Hx of HCV-related HCC significantly inhibits recurrence and consequently improves patient survival after Hx for HCC.

Role of resection of the primary pancreatic neuroendocrine tumor in the multidisciplinary treatment of patients with unresectable synchronous liver metastases: a case series.

CONTEXT: Liver metastases have often existed in patients who have pancreatic neuroendocrine tumors (pNETs) at the time of diagnosis. In the management of patients of pNETs with unresectable liver metastases, the clinical efficacy of surgery to primary pancreatic tumor has been controversial. We presented four patients who were treated with resection of primary pancreatic tumor, trans-arterial hepatic treatment and systemic therapies. We reviewed literatures and discussed about role of resection of primary pancreatic tumor in the multidisciplinary treatment. METHODS: We retrieved medical records of patients who had been histopathologically diagnosed as pNETs at our institution between April 2000 and March 2006, and found 4 patients who had pNETs with unresectable synchronous liver metastases and no extrahepatic metastases. All patients received resection of primary tumor. Patients' demographics, pathology, treatment, short- and long-term outcome were examined. RESULTS: In short-term outcome analysis, delayed gastric emptying was developed in one patient who received pancreaticoduodenectomy. There were no other significant postoperative complications. As for long-term outcome, two patients who received distal pancreatectomy, sequential trans-arterial treatments and systemic therapies could survive for long time relatively. They died 92 and 73 months after the first treatment, respectively. One patient who received distal pancreatectomy and trans-arterial treatment died from unrelated disease 14 months after the first treatment. Another patient who received preoperative trans-arterial treatments and pancreaticoduodenectomy rejected postoperative trans-arterial treatment, was treated with systemic therapies and died 37 months after the initial treatment. CONCLUSIONS: Resection of primary pNETs would be considered as an optional treatment for the selected patients who had unresectable synchronous liver metastases in the process of the multidisciplinary approach.

Significant prognostic factors in patients with Stage IV gastric cancer with special reference to the curability of surgery.

PURPOSES: The purpose of this study was to determine an effective treatment strategy for patients with Stage IV gastric cancer. METHODS: We analyzed the significant prognostic factors in 74 patients who underwent surgery between 1989 and 2005, and were finally determined to have Stage IV gastric cancer. These patients were classified as curability A (n = 0), B (n = 29) and C (n = 45) according to the criteria outlined by Japanese Gastric cancer society. Anti-tumor drugs were used after surgery in some cases. There were 32 patients who received either no treatment or an oral anti-tumor drug, and 42 patients who received new chemotherapeutic regimens. RESULTS: According to a univariate analysis, the postoperative mean survival times were significantly different; tumor size ≤ 12 cm, a tumor without lymphatic involvement, more than D2 lymphadenectomy, and classification as curability B were favorable prognostic factors. The multivariate analysis revealed that tumor size, lymphadenectomy and curability were independent prognostic factors. In curability B patients, venous involvement was an independent prognostic factor. In curability C patients, both the tumor size and postoperative chemotherapy affected their prognosis. CONCLUSIONS: In patients with curable Stage IV gastric cancer, at least a D2 gastrectomy to reduce the absolute volume of tumor cells, followed by adjuvant chemotherapy, may be essential to improve their prognosis. In incurable cases, aggressive new chemotherapeutic regimens should be the treatment of choice for the prolongation of survival.

Differential expression of insulin-like growth factor 1 in human primary liver cancer.

Insulin-like Growth Factor 1 (IGF-1) antigen was immunohistochemically examined in 28 patients of the primary hepatocellular carcinoma with hepatectomy. IGF-1 was expressed in 93% (26/28) of the primary lesion and 100% (28/28) of the normal liver. Compared with expression in normal liver, decreased expressions in primary lesions were noted in 36% (10/28) for IGF-1. Histological examination revealed that there were significant correlations between patients with decreased expressions of IGF-1 in primary lesions and poor differentiated hepatocellular carcinoma, and portal vein infiltration. These results indicate that expression of IGF-1 has the relationship with the differentiation in human primary hepatocellular carcinoma.

The effect of overweight status on the short-term and 20-y outcomes after hepatic resection in patients with hepatocellular carcinoma.

BACKGROUND: We aimed to evaluate the impact of body mass index (BMI) on the short- and long-term outcomes of hepatic resection in patients with hepatocellular carcinoma (HCC). METHODS: We performed 371 hepatic resections in HCC patients whom we categorized into two groups based on BMI: BMI ≥ 25 (n = 77) and BMI <25 (n = 294). We compared surgical outcomes between groups. RESULTS: The incidence of postoperative complications in the BMI ≥ 25 group was comparable to those in the BMI <25 group. However, patients in the BMI <25 group showed a significantly worse long-term prognosis than those in the BMI ≥ 25 group (P < 0.01). The results of multivariate analyses showed that BMI <25 was an independent and prognostic indicator of long-term outcome after hepatic resection in HCC patients. CONCLUSIONS: A BMI ≥ 25 is not a risk factor for mortality or postoperative complications, and is considered to provide a better long-term prognosis (>20 y) than a BMI <25 in patients with HCC after hepatic resection. Further studies are needed to determine whether these results apply to other patient populations outside Japan where BMI ≥ 30 is more prevalent.

Prognostic effects of oral anti-cancer drugs as adjuvant chemotherapy for 2 years after gastric cancer surgery.

PURPOSE: We conducted this retrospective study to evaluate the effectiveness of giving oral anti-cancer drugs for 2 years as postoperative adjuvant chemotherapy to gastric cancer patients. METHODS: The subjects were 76 patients with stage II and III gastric cancer, who underwent curative surgery between 1989 and 2008. We divided the 20 years chronologically into the UFT term (1989-2003) and the S-1 term (2004-2008). The patients from each term were then divided into three groups according to the length of drug administration; namely, the surgery alone group, the 1-year group, and the 2-year group. RESULTS: The survival time of the 2-year group was better than that of the surgery alone group, not only in the UFT term, but also in the S-1 term (P = 0.0224). Longer relapse-free survival was evident in the S-1 term, especially for the 2-year group (P = 0.0110). A multivariate analysis showed both the stage of the cancer and 2 years of postoperative adjuvant chemotherapy to be independent factors predictive of prolonged survival (P = 0.0040 and P = 0.0022, respectively). CONCLUSIONS: The 2-year administration of oral anti-cancer drugs as postoperative adjuvant chemotherapy might improve the outcome of stage II, III gastric cancer patients. Randomized control trials are warranted to prove the effectiveness of this 2-year regimen.

Efficacy of surgical microwave therapy in patients with unresectable hepatocellular carcinoma.

BACKGROUND: We aimed to evaluate the efficacy and long-term outcome in surgical microwave therapy (MW) for patients with unresectable hepatocellular carcinoma (HCC). METHODS: An institutional review board approved and single-institutional study of surgical MW of unresectable HCC was conducted from May 2003 to December 2010. The median follow-up period was 19 months (range 1-77 months). RESULTS: A total of 60 patients underwent 143 surgical MW for unresectable HCC. Of these, 15 patients had initial HCC and 45 had recurrent HCC. The median tumor size of HCC was 1.95 cm (range 0.8-3.3 cm). The median numbers of nodules that underwent surgical MW were 2 (range 1-9). Multinodular type was found in 33 patients (55%). Morbidity was 18.3%, and there was zero mortality. Also, 3 patients (5%) had incomplete MW. Of the 60 patients, 39 (65%) had recurrence, and 7 (11.6%) had local recurrence. The 1- and 3-year recurrence-free survival rates of the patients who underwent surgical MW for initial HCC were 55.1 and 36.7%, respectively, and those for recurrent HCC were 41.6% and 8.8%, respectively. A tumor size ≥ 2.0 cm and multiple nodules were selected as independent and significant indicators for recurrence of the disease. The 1-, 3-, and 5-year overall survival rates after the surgical MW procedure were 93.9, 53.8, and 43.1%, respectively. A level of des-gamma carboxyprothrombin (DCP) was an independent and significant indicator for overall survival. CONCLUSIONS: Surgical MW is an effective method for treating initial or recurrent unresectable HCC, and it can be undergone safely.

The prognostic significance of chemotherapy for stage IV gastric cancer patients: a single-institution experience.

PURPOSE: The significance of aggressive chemotherapy for stage IV gastric carcinoma was retrospectively examined. METHODS: This study analyzed 94 stage IV gastric cancer patients who underwent surgery with or without subsequent chemotherapeutic treatment. There were 29 potentially curative patients classified as Curability B and 65 noncurative patients classified as Curability C. These patients were divided into three groups chronologically according to the primary type of drugs administered as the 1st (1989-1998), the 2nd (1999-2002), and the 3rd term (2003-2005). RESULTS: There was no significant difference in the survival time among the three groups (n = 94). The survival time of the patients classified as Curability C (n = 65) in the 3rd-term group (n = 17) was longer than that of the other two groups (P < 0.05). Similarly, the survival time in patients who were given new drugs and regimens (n = 22) was longer than that in those who were not (n = 43) in Curability C (P < 0.05). A multivariate analysis proved that the administrations of new drugs and regimens were independent factors for the prolongation of survival times for patients undergoing noncurative surgery (P < 0.01). CONCLUSIONS: These findings suggested that the administration of new anticancer drugs might bring about a favorable outcome for stage IV gastric cancer patients, especially in those with evidence of a residual tumor.

Using the E-PASS scoring system to estimate the risk of emergency abdominal surgery in patients with acute gastrointestinal disease.

PURPOSE: The Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system, which quantifies a patient's reserve and surgical stress, is used to predict morbidity and mortality in patients before elective gastrointestinal surgery. We conducted this study to clarify whether the E-PASS scoring system is useful for assessing the risks of emergency abdominal surgery. METHODS: The subjects of this retrospective study were 51 patients who underwent emergency gastrointestinal surgery at a public general hospital. The main outcomes were the E-PASS scores and the postoperative course, defined by mortality and morbidity. RESULTS: Postoperative complications developed in 15 of the 51 patients (29.4%). The E-PASS score was significantly higher in the patients with postoperative complications than in those without (0.61 ± 0.31 vs 0.20 ± 0.35, respectively; n = 36). The morbidity rates were significantly lower in the patients with a value less than 0.5 than in those with a value more than 0.5 (17.1% and 56.3%, respectively; P < 0.01). There were 7 operative deaths among the 16 patients with a high score, versus none among the 9 patients with a low score (P < 0.01). Three patients underwent laparoscopic-assisted bowel resection with a good postoperative course, with scores of less than 0.5. CONCLUSIONS: The E-PASS scoring system is useful for surgical decision making and evaluating whether patients will tolerate emergency gastrointestinal surgery. Minimally invasive therapy would assist in lowering the risk of complications.

Trends in the treatment outcomes for advanced colorectal cancer: an analysis at a single community hospital in Japan.

PURPOSE: To evaluate the trends in the treatment outcomes for patients with colorectal cancer in Japan. METHODS: We performed a retrospective analysis of patients undergoing surgery for primary colorectal cancer during a 16-year period (Group A [1992-2000, n = 258]; Group B [2001-2008, n = 258]) at Fukuoka City Hospital. Because no significant differences were found in the survival rates in stage 0, I, II, and III patients between the two groups, we concentrated on examining stage IV patients. RESULTS: The 3-year survival rate for stage IV patients in Group B (n = 26) was significantly higher than that in Group A (n = 31) (34.9% vs 3.9%, P < 0.05). The rate of curative resection for advanced liver metastases in Group B patients was also significantly higher than that of Group A patients (50.0% vs 13.3%, P < 0.05). As a result, the 2-year survival rate for the disease-free patients in Group B was significantly higher than that for the non-disease-free patients in Group B (46.0% vs 21.0%, P < 0.05). Group B had a greater proportion of patients receiving l-leucovorin/5-fluorouracil than Group A (8 patients vs none, P < 0.05). CONCLUSIONS: Recent advances in surgical innovations and the utilization of new chemotherapeutic agents may have led to significant improvements in the treatment outcomes for advanced colorectal cancer in Japan.

Laparoscopic splenectomy may be a superior supportive intervention for cirrhotic patients with hypersplenism.

BACKGROUND AND AIMS: To evaluate and compare laparoscopic splenectomy and partial splenic embolization as supportive intervention for cirrhotic patients with hypersplenism to overcome peripheral cytopenia before the initiation of and during interferon therapy or anticancer therapy for hepatocellular carcinoma. METHODS: Between December 2000 and April 2008, 43 Japanese cirrhotic patients with hypersplenism underwent either laparoscopic splenectomy or partial splenic embolization as a supportive intervention to facilitate the initiation and completion of either interferon therapy or anticancer therapy for hepatocellular carcinoma. We reviewed the peri- and post-intervention outcomes and details of the subsequent planned main therapies. For interferon therapy, the rate of completion, the rate of treatment cessation and virological responses were evaluated. Anti-cancer therapies for hepatocellular carcinoma included liver resection, ablation therapy, intra-arterial chemotherapy, and transarterial chemoembolization. RESULTS: All patients tolerated the operations well with no significant complications. The platelet count was significantly higher in the laparoscopic splenectomy group than in the partial splenic embolization group at 1 and 2 weeks after the intervention. Interferon therapy was stopped in two patients in the partial splenic embolization group due to recurrent thrombocytopenia whereas all patients in the laparoscopic splenectomy group completed interferon therapy. The planned anticancer therapies were performed in all patients, and were completed in all patients without any problems or major complications. CONCLUSION: Laparoscopic splenectomy may be superior to partial splenic embolization as a supportive intervention for cirrhotic patients with hypersplenism. Future prospective, randomized controlled patient studies are required to confirm these findings.

An assessment of surgery for portal hypertensive patients performed at a single community hospital.

PURPOSE: The outcomes of surgery for portal hypertensive patients at a single community hospital in the last two decades were retrospectively examined. METHODS: From June 1989 to March 2008, 13 of 848 (1.5%) portal hypertensive patients admitted and treated at the community hospital underwent surgery. The types of surgery performed were a distal splenorenal shunt for 2 patients, gastric devascularization and splenectomy for 8, laparoscopic gastric devascularization and splenectomy for 1, distal gastrectomy for 1, and splenectomy alone for 1. This study reviewed the postoperative records of the endoscopic findings and additional treatments, and the perioperative records. RESULTS: No patient had bleeding from esophagogastric varices during the 75-month mean follow-up period after surgery. Five patients had one or two series of endoscopic treatment for recurrent likely-to-bleed esophageal varices. One patient needed interventional radiology for recurrent gastric varices. No patients died due to upper gastrointestinal bleeding. The survival rates were 87.5% after 5 years and 46.9% after 10 years. CONCLUSIONS: Surgery for portal hypertensive patients performed at a single community hospital is still safe and effective, and has been adequately incorporated into the late treatment strategy for portal hypertensive patients.

Technical standardization of laparoscopic splenectomy harmonized with hand-assisted laparoscopic surgery for patients with liver cirrhosis and hypersplenism.

BACKGROUND/PURPOSE: The aims of this study were to standardize the techniques of laparoscopic splenectomy (LS) to improve safety in liver cirrhosis patients with portal hypertension. METHODS: From 1993 to 2008, 265 cirrhotic patients underwent LS. Child-Pugh class was A in 112 patients, B in 124, and C in 29. Since January 2005, we have adopted the standardized LS including the following three points: hand-assisted laparoscopic surgery (HALS) should be performed in patients with splenomegaly (> or =1,000 mL), perisplenic collateral vessels, or Child-Pugh score 9 or more; complete division and sufficient elevation of the upper pole of the spleen should be performed before the splenic hilar division; and when surgeons feel the division of the upper pole of the spleen is too difficult, conversion to HALS should be performed. RESULTS: There were no deaths related to LS in this study. After the standardization, conversion to open surgery significantly reduced from 11 (10.3%) of 106 to 3 (1.9%) of 159 patients (P < 0.05). The average operation time and blood loss significantly reduced from 259 to 234 min (P < 0.01) and from 506 to 171 g (P < 0.01), respectively. CONCLUSIONS: With the technical standardization, LS becomes a feasible and safe approach in the setting of liver cirrhosis and portal hypertension.