Long-term outcomes of single-incision laparoscopic colectomy for right-sided colon cancer utilising a craniocaudal approach.

INTRODUCTION: This study aimed to evaluate the short- and long-term outcomes of single-incision laparoscopic colectomy (SILC) for right-sided colon cancer (CC) using a craniocaudal approach. PATIENTS AND METHODS: The data of patients who underwent SILC for right-sided CC at our hospital between January 2013 and December 2022 were retrospectively collected. Surgery was performed using a craniocaudal approach. Short- and long-term operative outcomes were analysed. RESULTS: In total, 269 patients (127 men, 142 women; median age 74 years) underwent SILC for right-sided CC. The cases included ileocaecal resection (n = 138) and right hemicolectomy (n = 131). The median operative time was 154 min, and the median operative blood loss was 0 ml. Twenty-seven cases (10.0%) required an additional laparoscopic trocar, and 9 (3.3%) were converted to open surgery. The Clavien-Dindo classification Grade III post-operative complications were detected in 7 (2.6%) cases. SILC was performed by 25 surgeons, including inexperienced surgeons, with a median age of 34 years. The 5-year cancer-specific survival (CSS) was 96.1% (95% confidence interval [CI] 91.3%-98.2%), and CSS per pathological disease stage was 100% for Stages 0-I and II and 86.2% (95% CI 71.3%-93.7%) for Stage III. The 5-year recurrence-free survival (RFS) was 90.6% (95% CI 85.7%-93.9%), and RFS per pathological disease stage was 100% for Stage 0-I, 91.7% (95% CI 80.5%-96.6%) for Stage II and 76.1% (95% CI 63.0%-85.1%) for Stage III. CONCLUSIONS: SILC for right-sided CC can be safely performed with a craniocaudal approach, with reasonable short- and long-term outcomes.

[Hyperammonemic encephalopathy after treatment with modified FOLFOX6 regimen for recurrent gastric cancer:a case report].

A 64-year-old female received modified FOLFOX6 therapy with continuous administration of a high concentration of 5-fluorouracil (5-FU) for recurrence of peritoneal dissemination after total gastrectomy. Twenty-nine hours after the administration, there was the sudden onset of altered consciousness and hepatic dysfunction accompanied by hyperammonemia. The consciousness and hepatic function improved the following day after treatment with branched-chain amino acid formulation, lactulose, fresh frozen plasma, and continuous hemodiafiltration. Thus, the diagnosis was 5-FU-induced hyperammonemia. Improvement of dehydration and renal dysfunction would be important for avoiding the risk of developing the side effects. Because recurrent gastric cancer is often a progressive condition, post-treatment might be promptly transferred to the other posterior regimen without 5-FU as required.

Surgical resection of solid gallbladder adenocarcinoma presenting as a large mass: report of a case.

This report describes a case of a patient with a large solid gallbladder adenocarcinoma that was completely resected through aggressive surgery. The patient was a 57-year-old woman who had been diagnosed with advanced gallbladder cancer, had no indications for surgical resection and was scheduled to undergo systemic chemotherapy. She presented to our hospital for a second opinion. At the time of assessment, her tumor was large but was well-localized and had not invaded into the surrounding tissues, indicating that surgical resection was a reasonable option. Subsequently, the tumor was completely extracted via right hepatectomy with en bloc resection of the caudate lobe and extrahepatic bile duct. Histopathologically, the tumor was a solid adenocarcinoma. Although there are relatively few reports in the literature regarding solid gallbladder adenocarcinoma, well-localized growth appears to be a characteristic feature. On the basis of a tumor's progression behavior, aggressive surgical treatment might be indicated even when the tumor has grown to a considerable size.

Post-operative depletion of platelet count is associated with anastomotic insufficiency following intrahepatic cholangiojejunostomy: a case-control study from the results of 220 cases of intrahepatic cholangiojejunostomy.

BACKGROUND: Post-operative anastomotic insufficiency following major hepato-biliary surgery has significant impacts on the post-operative course. Recent reports have revealed that platelets play an important role in liver regeneration and wound healing. From these experimental and clinical results on platelet function, we hypothesized that post-operative platelet depletion (to <10 × 104/µL) would be associated with delayed liver regeneration as well as anastomotic insufficiency of intrahepatic cholangiojejunostomy. However, little information is available regarding correlations between platelet count and these complications. The purposes of the present study were, firstly, to evaluate the incidence of anastomotic insufficiency following intrahepatic cholangiojejunostomy and, secondly, to evaluate whether platelet depletion represents a risk factor for anastomotic insufficiency in intrahepatic cholangiojejunostomy. METHODS: Participants in this study comprised 220 consecutive patients who underwent intrahepatic cholangiojejunostomy following hepato-biliary resection for biliary malignancies between September 1998 and December 2010. Anastomotic insufficiency was confirmed by cholangiographic demonstration of leakage from the anastomosis using contrast medium introduced via a biliary drainage tube or prophylactic drain placed during surgery. RESULTS: Anastomotic insufficiency of the intrahepatic cholangiojejunostomy occurred in 13 of 220 patients (6%). Thirteen of the 220 patients, including one with anastomotic insufficiency, died during the study. Uni- and multivariate analyses both revealed that platelet depletion on post-operative day 1 (<10 × 104/µL) correlated with anastomotic insufficiency. CONCLUSION: Post-operative platelet depletion was closely associated with anastomotic insufficiency following intrahepatic cholangiojejunostomy. This correlation has been established, but the underlying mechanisms have not.

Portal vein resection using the no-touch technique with a hepatectomy for hilar cholangiocarcinoma.

OBJECTIVES: To assess the safety and feasibility and discuss the oncological impact of a portal vein resection using the no-touch technique with a hepatectomy for locally advanced hilar cholangiocarcinoma. PATIENTS AND METHODS: From 2005 to March 2009, 49 patients with hilar cholangiocarcinoma underwent a major right-sided hepatectomy with curative intent. Portal vein resection was performed using the no-touch technique in 36 patients (PVR group) but the portal vein was not resected in the other 13 patients (NR group). Peri-operative data and histological findings were compared between the two groups. Moreover, tumour recurrence and survival rates after surgery were calculated and compared for each group. RESULTS: Although the tumours of the patients in the PVR group were more locally advanced, the residual tumour status and tumour recurrence rate were similar and there was no significant difference in long-term survival between the two groups: 5-year survival rates in the PVR and NR groups were 59% and 51%, respectively (P = 0.353). In-hospital mortality was encountered in 2 of the 49 patients. CONCLUSION: A portal vein resection using the no-touch technique with a right-sided hepatectomy had a positive impact on survival and is feasible in terms of long-term outcomes with acceptable mortality.

Novel aspects of preoperative chemoradiation therapy improving anti-tumor immunity in pancreatic cancer.

Pancreatic cancer is an aggressive cancer with poor prognosis. Little is known about the immune response in the tumor microenvironment after chemotherapy for initially unresectable tumor. The purpose of this study was to investigate the immunological effects of chemoradiation therapy in the tumor microenvironment of pancreatic adenocarcinoma. Seventeen patients with pancreatic adenocarcinoma with and without preoperative chemoradiation therapy were retrospectively analyzed using immunohistochemical methods for HLA class I heavy chain, CD4(+), CD8(+), CD45RO(+) and Foxp3(+) T cell infiltrations. Seven of the 17 study patients received preoperative chemoradiation therapy. There were no statistically significant differences in the number of CD4(+) and CD8(+) T cell infiltrations in the tumor microenvironment. However, the number of Foxp3(+) T cell infiltrations was significantly lower in the neoadjuvant chemoradiation therapy group. The HLA class I expression status was the same between the two groups. In conclusion, preoperative chemoradiation therapy in pancreatic adenocarcinoma is useful for reducing regulatory T cell levels in combination with its direct cytotoxic effects.

Modified duodenum-preserving pancreas head resection for low-grade malignant lesion in the pancreatic head.

BACKGROUND/OBJECTIVES: Our institution has utilized a duodenum-preserving pancreas head resection (DPPHR) procedure for management of low-grade malignant lesions within the head of the pancreas, but this has resulted in a higher rate of postoperative complications, including pancreatic fistula and ischemic bile duct injury. To avoid these complications we recently modified DPPHR to resect all the parenchyma around the pancreatic head and to preserve the epicholedochal plexus around the bile duct. The goal of this study was to investigate outcomes with postoperative complications and disease control following this modified procedure. METHODS: Twenty-one consecutive patients underwent DPPHR between 1994 and 2011. Patients were retrospectively classified into one of two groups: the conventional DPPHR group (cDPPHR) or the modified DPPHR group (mDPPHR). Perioperative factors and postoperative complications were compared between these two groups. RESULTS: The median age of the 21 patients was 61 (23-77) years, and the median follow-up period was 51 months. Intra-operational blood loss was significantly smaller and duration of hospital stay was significantly shorter in the mDPPHR group than in the cDPPHR group, respectively. The rate of pancreatic fistula was markedly lower in the mDPPHR group (2/13; 15%) than in the cDPPHR group (7/8; 88%) (P = 0.0022). For neoplastic lesions, the surgical margin was negative in all cases, and local recurrence has not occurred in either group. CONCLUSIONS: For selected patients, modified DPPHR may provide clinical benefits in terms of less complications associated with shorter hospital stay.

Operative and perioperative management experience for hepatobiliary malignancies following ERCP-related pancreatitis.

BACKGROUND/AIMS: There have been few papers on how to treat hepatobiliary malignancies after ERCP-related pancreatitis focusing on the timing of the operation and postoperative complications. The aim of this study was to clarify the relationship among the time after the pancreatitis, the complexity of the operation, and the characteristic postoperative complications. METHODOLOGY: The clinicopathological characteristics of five patients with hepatobiliary malignancies who had a prior history of ERCP-related pancreatitis were analyzed. RESULTS: The five patients included two with extrahepatic bile duct carcinomas, two with ampulla of Vater carcinomas, and one with intrahepatic hilar cholangiocarcinoma. The median time to the operation from pancreatitis was 31 (16-116) days. The median operation time and blood loss were 661 (576-924) min and 3695 (2730-7240) mL, respectively. Various postoperative complications were seen in all cases including acute respiratory distress syndrome and infection of peripancreatic necrosis. The postoperative mortality rate was 0%, with a morbidity rate of 100%. R0 operations were performed in all five cases. CONCLUSIONS: Surgery for hepatobiliary malignancies after ERCP-related pancreatitis appears to have a high morbidity rate. The surgery must strike a balance between curability of the malignancy and safety with respect to the frequent postoperative complications.

Surgical strategy for liver metastases of neuroendocrine tumors.

BACKGROUND/AIMS: Little information is available about the long-term prognosis after hepatectomy for liver metastases of neuroendocrine tumors (NETs). To clarify the prognosis for liver metastases of NETs after hepatectomy and to identify a practical and useful surgical indication for hepatic metastases of NETs. METHODOLOGY: Twenty-four patients with NET were divided into 2 groups: the nHM group (patients without hepatic metastasis, n=13) and the HM group (patients with hepatic metastasis or recurrences, n=11). Hepatectomy was indicated for metastases or disease recurrences in the liver if R0 resection was expected to be achievable. Patient clinicopathological features, mode of recurrences and treatment for them were evaluated retrospectively. RESULTS: The median follow-up period for the 24 patients was 34 months (range 7-69) and the disease specific survival rate was 82% at 5 years. DSS at 5 years did not differ between patients with and without hepatic recurrence (91% vs. 75% respectively, p=0.6144), even though the histological grade and the MIB-1 index were higher in the HM group. CONCLUSIONS: Patient prognosis was acceptable following our policy of hepatectomy for NET liver metastases. Survival could be improved by intensive multimodal treatment.

Multidisciplinary treatment strategy for advanced pancreatic neuroendocrine tumors- a single center experience.

BACKGROUND/AIMS: Pancreatic neuroendocrine tumors (PNETs) are rare neoplasms. Little is known about the mode of recurrence and long term prognosis after resection. We aimed to evaluate the surgical indication, especially for the patients with concomitant multiple liver metastases or extreme local invasions. METHODOLOGY: The overall survival (OS) and the disease free survival (DFS) were statistically analyzed for twenty one patients with PNETs who underwent surgical intervention in our institute. The patients were divided into 2 groups, G1 NET (grade 1 neuroendocrine tumor: n=11) and G2 NET (grade 2 neuroendocrine tumor: n=10), according to WHO 2010 classification. The radical operation was indicated if curative resection were expected to be achievable. Otherwise,alternative multi-disciplinary treatments were introduced especially for the hepatic metastasis or repeated recurrences. RESULTS: Median follow-up period was 37 months (range 7-69). OS was 100% at 3 years and 86% at 5 years. DFS was 62% at 3 years and 39% at 5 years. Disease recurrence developed more frequently in G2 NET, compared to G1 NET. However, there was statistically no difference for the OS between these two groups. CONCLUSIONS: Appropriate radical operation with multi-disciplinary treatments could contribute to the patients' survival in the treatment strategy of PNETs.

Application of a novel surgical difficulty grading system during laparoscopic cholecystectomy.

BACKGROUND: Prevention of bile duct injury and vasculo-biliary injury while performing laparoscopic cholecystectomy (LC) is an unsolved problem. Clarifying the surgical difficulty using intraoperative findings can greatly contribute to the pursuit of best practices for acute cholecystitis. In this study, multiple evaluators assessed surgical difficulty items in unedited videos and then constructed a proposed surgical difficulty grading. METHODS: We previously assembled a library of typical video clips of the intraoperative findings for all LC surgical difficulty items in acute cholecystitis. Fifty-one experts on LC assessed unedited surgical videos. Inter-rater agreement was assessed by Fleiss's κ and Gwet's agreement coefficient (AC). RESULTS: Except for one item ("edematous change"), κ or AC exceeded 0.5, so the typical videos were judged to be applicable. The conceivable surgical difficulty gradings were analyzed. According to the assessment of difficulty factors, we created a surgical difficulty grading system (agreement probability = 0.923, κ = 0.712, 90% CI: 0.587-0.837; AC2  = 0.870, 90% CI: 0.768-0.972). CONCLUSION: The previously published video clip library and our novel surgical difficulty grading system should serve as a universal objective tool to assess surgical difficulty in LC.

Distal pancreatectomy and portal vein resection without vascular reconstruction for endocrine tumors with massive intraportal growth: report of a case.

Pancreatic endocrine tumors (PETs) are relatively rare. Owing to their slow growing characteristics, an aggressive surgical approach has been considered to improve patients' survival. A case of PET with portal vein (PV) thrombus, successfully treated by distal pancreatectomy with concomitant PV resection and removal of PV tumor thrombus, preserving collateral pathways, is reported.

Extensively spreading intraepithelial bile duct carcinoma causing multiple bile duct strictures: report of three cases.

Extensive intraepithelial spread of bile duct carcinoma is a common feature, seen in approximately 18% of all cases. However, this spread is rarely accompanied by bile duct strictures. We herein describe three cases of bile duct carcinoma with multiple bile duct strictures due to extensive intraepithelial spread. In all three cases, the spread of intraepithelial cancer extended into the epithelium of the peribiliary glands along the intrahepatic bile ducts with marked fibrosis on histopathological examination. It is speculated that peribiliary gland involvement by superficially spreading bile duct cancer and subsequent obstructive glandular inflammation with fibrosis might cause intrahepatic bile duct strictures even without interstitial cancer invasion.

Postoperative bowel function and nutritional status following distal pancreatectomy with en-bloc celiac axis resection.

BACKGROUND/AIMS: Distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) is routinely accompanied by complete resection of the bilateral celiac ganglions and the circumferential plexus of the superior mesenteric artery. The postoperative condition including bowel movement, nutritional status, and tolerance to adjuvant chemotherapy has never been studied. METHODS: 40 patients who underwent DP-CAR were enrolled in this study. Postoperative bowel function was estimated by the requirement of anti-diarrheal agents. Changes of nutritional parameters including body weight and laboratory data for 1 year after surgery were evaluated. RESULTS: 15 (38%) patients needed no anti-diarrheal agent after a median follow-up period of 39 months. The other patients were well controlled for their bowel movement with anti-diarrheal drugs. 13 patients who received adjuvant chemotherapy tolerated it well despite hematologic toxicity in 7 patients who received gemcitabine. Postoperative body weight was significantly decreased and reached a plateau value at postoperative month 3. The values of laboratory data indicating nutritional status were significantly lower at 1 month after surgery and recovered between 3 and 12 months. CONCLUSION: The patients who underwent DP-CAR scarcely suffered from intractable diarrhea and could achieve a feasible nutritional status after surgery to be able to receive adjuvant chemotherapy.

Colonic varices treated with embolization after pancreatoduodenectomy with portal vein resection: a case report.

BACKGROUND: Pancreatoduodenectomy with resection of the portal vein or superior mesenteric vein confluence has been safely performed in patients with pancreatic head cancer associated with infiltration of the portal vein or superior mesenteric vein. In recent years, left-sided portal hypertension, a late postoperative complication, has received focus owing to increased long-term survival with advances in chemotherapy. Left-sided hypertension may sometimes cause fatal gastrointestinal bleeding because of the rupture of gastrointestinal varices. Here, we present a case of colonic varices caused by left-sided portal hypertension after pancreatoduodenectomy with portal vein resection. CASE PRESENTATION: A 69-year-old man diagnosed with pancreatic head cancer was referred to our department for surgery after undergoing chemotherapy with nine courses of gemcitabine and nab-paclitaxel. Computed tomography showed a mass 25 mm in diameter and in contact with the portal vein. He had undergone subtotal stomach-preserving pancreatoduodenectomy with portal vein resection. Four centimeters of the portal vein had been resected, and end-to-end anastomosis was performed without splenic vein reconstruction. We had to completely resect the right colic vein, accessary right colic vein, and middle colic vein due to tumor invasion. The pathological diagnosis was ypT3, ypN1a, ypM0, and ypStageIIB, and he was administered TS-1 as postoperative adjuvant chemotherapy. Seven months after therapeutic radical surgery, he presented with melena with progressive anemia. Computed tomography revealed transverse colonic varices. He was offered interventional radiology. Trans-splenic arterial splenic venography showed that transverse colonic varices had developed as collateral circulation of the splenic vein and inferior mesenteric vein system. An embolic substance was injected into the transverse colonic varices, which halted the progression of the anemia caused by melena. Fifteen months after therapeutic radical surgery, local recurrence of the tumor occurred; he died 28 months after the surgery. CONCLUSIONS: When subtotal stomach-preserving pancreatoduodenectomy with portal vein resection is performed without splenic vein reconstruction, colonic varices may result from left-sided portal hypertension. Interventional radiology is an effective treatment for gastrointestinal bleeding due to colonic varices, but it is important to be observant for colonic necrosis and new varices.

Portal vein tumor thrombus from colorectal cancer with no definite metastatic nodules in liver parenchyma.

Portal vein tumor thrombus (PVTT) in hepatocellular carcinoma (HCC) is a common entity. In colorectal liver metastasis, microscopic tumor invasion into the intrahepatic portal vein is also usually observed, but the incidence of macroscopic tumor thrombus in the first branch and trunk of the portal vein is rare. Most reported cases of PVTT from colorectal cancer had concomitant metastatic nodules in liver parenchyma, and the PVTT was continuous with the liver nodule, like PVTT in HCC. We present a case of PVTT from colorectal cancer with no definite metastatic nodules in liver parenchyma. A 58-year old man underwent laparoscopic high anterior resection for rectosigmoid carcinoma accompanied by bulky tumor thrombus in the branch of the inferior mesenteric vein. Six months later, he received left lobectomy and left caudate resection for liver metastasis. The resected specimen demonstrated there was no metastatic nodule in liver parenchyma and that the left portal system was filled with the tumor thrombus. The patient is alive with no sign of recurrence 66 months after hepatectomy. Even if there is a macroscopic PVTT from colorectal cancer, a better prognosis may be expected when the tumor can be completely resected en-bloc by anatomic hepatectomy including PVTT.

A rare case of localized IgG4-related sclerosing cholecystitis mimicking gallbladder cancer.

Objective: IgG4-related sclerosing cholecystitis is generally associated with IgG4-related sclerosing cholangitis and presents with diffuse, circumferential thickening of the gallbladder wall. We report a rare case of localized IgG4-related sclerosing cholecystitis without IgG4-related sclerosing cholangitis, which was difficult to differentiate from gallbladder cancer preoperatively. Patient: A 56-year-old man with suspected IgG4-related disease or gallbladder cancer was admitted to our ward. The serum IgG4 level was elevated at 721 mg/dL. Computed tomography (CT) demonstrated focal wall thickening of the gallbladder fundus. Drip infusion cholecystocholangiography with CT revealed no dilation, stenosis, or border irregularity of the bile duct. Results: For diagnostic and treatment purposes, cholecystectomy with wedge resection of the gallbladder bed was performed. The pathological diagnosis was IgG4-related sclerosing cholecystitis. Conclusion: It is difficult to differentiate IgG4-related sclerosing cholecystitis from gallbladder cancer in cases involving localized thickening of the gallbladder wall. In similar cases, surgical resection with cancer in mind might be performed based on present clinical knowledge.

Oncocytic Type Intraductal Papillary Mucinous Neoplasm of the Pancreas with Unusually Low Mucin Production Mimicking Intraductal Tubulopapillary Neoplasm: A Report of a Case Diagnosed by a Preoperative Endoscopic Biopsy.

We herein report the case of a 78-year-old woman with an intraductal tumor with scant mucin production in a moderately dilated main pancreatic duct that resembled an intraductal tubulopapillary neoplasm (ITPN) on imaging. An endoscopic transpapillary forceps biopsy enabled an accurate preoperative diagnosis of the tumor as an oncocytic type intraductal papillary mucinous neoplasm (IPMN) of the pancreas microscopically showing papillary growth consisting of oncocytic cells with a typical mucin expression profile, although with few intraepithelial lumina containing mucin. This is the first case of an oncocytic type IPMN mimicking an ITPN that was able to be diagnosed preoperatively.

Exocrine function following the whipple operation as assessed by stool elastase.

What impact does pancreaticoduodenectomy (PD) have on exocrine function? Does the pancreatic anastomosis remain patent? When stool elastase became available for testing in November 2001, we began preoperative assessment and then increasingly employed postoperative measurements. From December 2001 until March 2006, 182 patients underwent PD by the same surgeon. Preoperative stool elastase was measured in 138 (76%) patients and was repeated postoperatively at 3 +/- 1 month, 12 +/- 2 months, and 24 +/- 3 months. At the same time periods, an abdominal CT scan was used to assess patency of the pancreatic anastomosis as implied by pancreatic duct dilation in the remnant (dilation = duct >3 mm or, if duct dilated preoperatively, then duct that failed to decrease in size). All cases were reconstructed with duct-to-mucosa pancreaticojejunostomy. Stool elastase was expressed as normal (>200 microg/gram stool), moderately reduced (100-200 microg/gram), or severely reduced (<100 microg/gram). Preoperative stool elastase values were "normal" in 78% (pancreatic cancer 32% normal vs. all other groups >78%; P < or = 0.001). As compared with preoperative values, the percent of cases with reduced elastase levels at 3 months, 1 year, and 2 years postoperatively was 48%, 73%, and 50%, respectively. The CT scans at the time of the 69 stool elastase measurements after PD showed pancreatic duct dilation in the pancreatic remnant in 9 of 69 (9%) stools but was not more frequent in the group with decreased elastase. Based on cases elastase, one third of patients about to have PD will have exocrine insufficiency, an observation most common among the patients with pancreatic cancer (68%). Stool elastase levels are further depressed in the majority of cases after PD from parenchymal loss because we could not implicate an occluded pancreatic anastomosis. These results suggest that, after PD, exocrine supplementation should be given to all patients with pancreatic cancer, especially those with impending adjuvant therapy. To further improve the long-term results after PD, each surgeon should assess the effect of their own type of pancreaticoenteric technique on exocrine function.

Advances in the surgical treatment of hilar cholangiocarcinoma.

With the improvement of perioperative management and surgical techniques as well as the accumulation of knowledge on the oncobiological behavior of bile duct carcinoma, the long-term prognosis of hilar cholangiocarcinoma has been improving. In this article, the authors review the recent developments in surgical strategies for hilar cholangiocarcinoma, focusing on diagnosis for characteristic disease extension, perioperative management to reduce postoperative morbidity and mortality, surgical techniques for extended curative resection and postoperative adjuvant therapy.