Introducing the coaxial method of catheter port implantation for hepatic arterial infusion chemotherapy.

BACKGROUND: Hepatic arterial infusion chemotherapy (HAIC) is an effective method of treating patients with liver metastasis. However, in patients who have tortuous hepatic arteries, the procedure is extremely difficult with currently available methods. We have hence devised a method that is applicable in technically difficult circumstances called the coaxial method of cannulation. METHODS AND RESULTS: When compared to the conventional method of cannulation for HAIC, the coaxial method does not involve catheter exchange. This process is often associated with the flimsy micro-guide wire dislodging out of the target artery, particularly if the patient has a torturous or stenosed artery. In the coaxial method, both the anti-coagulated indwelling and coaxial catheters are placed in the artery together, with the coaxial catheter inside the indwelling catheter. The proximal ends of the catheter unit are attached to a connecting pipe, which subsequently connects to the implantable port. Our results show no differences in the cumulative patency rates of the hepatic artery between coaxial and conventional methods of HAIC. CONCLUSION: It is important to continually devise new methods to make HAIC technically less demanding. The coaxial method is free from catheter exchange, and therefore allows easier cannulation of difficult arteries.

Laparoscopic hepatectomy for liver tumors: proposals for standardization.

BACKGROUND/PURPOSE: We draw on our experience with laparoscopic hepatectomy (LH) to present recommendations for standardization of LH for the treatment of liver tumors. METHODS: At our center, 90 LHs were performed from April 1993 to January 2008. These were divided equally into early cases and late cases, and short-term postoperative results were compared. Forty-nine of the LH procedures were total-laparoscopic procedures, 16 were hand-assisted procedures, and 25 were laparoscopy-assisted procedures. The tumors were malignant in 76 cases and benign in 14 cases. RESULTS: Among late cases, the numbers of malignant tumors and tumors located in the posterosuperior region of the liver (Segments VII, VIII, and IVb) were significantly higher than among early cases; however, operative blood loss and postoperative hospital stay were significantly lower in the late cases (158.9 +/- 213.4 vs. 377.6 +/- 421.2 cc, P = 0.007; and 8.7 +/- 3.6 vs. 15.3 +/- 8.7 days, P = 0.0001, respectively). No operative deaths occurred in either group. CONCLUSIONS: Although LH does have a steep learning curve, we believe that it can be standardized and provide a less invasive surgical option--with no reduction in disease curability--for the treatment of liver tumors in selected patients.

Fourteen-years of disease-free survival in a patient with advanced gallbladder carcinoma after radical resection: a case report.

We describe a case of advanced gallbladder carcinoma (GBC) with extensive local invasion that has had 14-years of disease-free survival after complete resection. A 53-year-old woman was referred to our hospital with right hypochondriac pain and constipation. A preoperative diagnosis of advanced GBC with invasion into the liver bed, the abdominal wall, the duodenum, the common bile duct and the hepatic flexure of the colon were made. It was performed an extensive en bloc resection of the GBC, which included a cholecystectomy, resection of the associated liver bed, pancreatoduodenectomy, right hemicolectomy and resection of the anterior abdominal wall. On histopathology, the resected specimen showed a well-differentiated adenocarcinoma and the 56 resected lymph nodes showed no evidence of metastasis. Twelve-years after the above procedure, a laparotomy was performed for ileus; however, no macroscopic evidence of cancer recurrence was found in the peritoneal cavity.

[Regression of metastatic hepatic cancer from gastric cancer by polysaccharide K and UFT administration--a case report].

Various treatments for hepatic metastasis of gastric cancer have been attempted, but problems remain with respect to long-term effectiveness and recurrence. Case reports have indicated the tumor regression effect of polysaccharide K(PSK)combined with chemotherapy, and meta-analysis has shown that PSK combined with chemotherapy improves the prognosis compared to chemotherapy alone. However, marked improvement of disease following PSK administration is rarely reported. We report a case of hepatic metastasis of gastric cancer in which low-dose UFT and PSK therapy resulted in regression of metastatic hepatic lesions and improvement of tumor markers. A 78-year-old man had synchronous hepatic metastasis of gastric cancer. Gastrectomy and microwave coagulation therapy using Microtase were conducted, followed by postoperative adjuvant chemotherapy with UFT 300 mg/day. Recurrences of metastatic hepatic lesion and new hepatic lesion were observed 6 months after surgery. Addition of PSK to UFT chemotherapy was selected as the treatment for recurrences, resulting in disappearance of the hepatic lesions and normalization of tumor markers. The patient is alive without recurrence at this writing, 38 months after surgery.

Long-term follow-up of a pouching operation after pancreaticoduodenectomy using a double-jejunal pouch.

A 63-year old male was referred with intraductal papillary adenocarcinoma of the pancreas. The patient had been treated previously with a distal gastrectomy for duodenal ulceration. This surgery left the patient with esophagitis, residual gastritis, and decreased appetite. A modification of the Imanaga reconstructive method using a double-jejunal pouch was performed for the pancreatic carcinoma. This method allows a better quality of life by not only preventing reflux esophagitis and residual gastritis but also increasing a food volume. Here we illustrate the usefulness of a pancreaticoduodenectomy using the pouching operation.

[A case of gastric cancer with synchronous hepatic metastases which enforced the intra hepatic arterial chemotherapy showed a reduction of both tumors].

This is a case report of the intrahepatic arterial chemotherapy showing an effective reduction of tumors without an operation. The patient was a 68-year-old female. Instead of having an operation to gastric cancer with synchronous hepatic metastases, an intrahepatic arterial embolization of MMC and CPT-11 with DSM was enforced in the right-and-left hepatic arteries, and intrahepatic arterial infusions of 5-FU and CDDP were enforced after that. After intrahepatic infusion, the tumor size and marker of the gastric cancer and synchronous hepatic metastases decreased, and it was diagnosed as partial response (PR). Since the tumor marker showed an increase after thirteen times of the intrahepatic arterial infusions of 5-FU and CDDP, intrahepatic arterial embolization of CPT-11 and MMC with DSM was performed again and the intrahepatic arterial infusions of 5-FU and CDDP were enforced fourteen times after that. Although the tumor marker showed a small range of fluctuation, PR was kept observed and the patient has been stable for fifteen months since the chemotherapy began. She continuously received the combination chemotherapy as an outpatient.

[Transarterial chemoembolization with irinotecan (CPT-11) and degradable starch microspheres (DSM) in patients with liver metastases from colorectal cancer].

We report 27 cases of liver metastases treated with transarterial chemoembolization (TACE) with CPT-11, DSM, and mitomycin C (CPT-DSM therapy). In the 27 patients with liver metastases from colorectal cancer, CPT-DSM therapy was performed 47 times. All of these patients were a contra indication of hepatectomy. We compared a tumor marker before and after the treatment, and measured a serum level of SN-38, which is an active substance of CPT-11 and resolved from CPT-11. Although the level of CPT-11 was wearing off after CPT-DSM therapy, the peak of SN-38 level delayed 1 hour after the infusion. The CEA and CA19-9 levels were decreased to 54.2% and to 45.1% of the level before the treatment, respectively. Nine of the partial response and stable disease patients underwent surgery. The response rate was 59%. A 3-year survival rate was 20%. These results suggest that CPT-DSM therapy is one of the most effective anticancer agents. This TACE can be a feasible therapy for colorectal liver metastases as the first-line therapy.

[Case report of a liver metastasis from rectal cancer achieving complete response (CR) by a combination of intra-hepatic arterial infusion of irinotecan (CPT-11) with degradable starch microspheres (DSM) and weekly high-dose intra-hepatic arterial chemotherapy with 5-FU].

A 67-year-old woman, who was diagnosed with rectal cancer and liver metastasis, underwent a low anterior resection of the rectum in May 2004. Two months later, the level of tumor markers increased and a CT scan revealed a 45 x 35 mm liver metastasis in the S(8) segment. She was referred to our hospital for treatment of the liver tumor. Intra-hepatic arterial infusion of irinotecan (CPT-11) and mitomycin C (MMC) with degradable starch microspheres (DSM) was given in July 2004. Following this, a 34-week course of weekly high-dose intra-hepatic arterial 5-FU infusion (5-FU 1,000 mg/m(2)) was performed. In April 2005, the size of the liver metastasis decreased, and the level of serum tumor marker normalized. A CT and echo scan revealed a calcified tumor, and therefore all chemotherapy was stopped. She was followed in the outpatient clinic, with no evidence of recurrence for 12 months. This case suggests that the use of intra-hepatic arterial infusion of CPT-11 and MMC with DSM is useful for the treatment of liver metastases in colorectal cancer.

Gastrointestinal stromal tumor mimicking arteriovenous malformation of the jejunum.

There have been case reports of small intestinal gastrointestinal stromal tumors (GISTs) complicated with arteriovenous malformation (AVM) and angiodysplasia and exhibiting intense tumor staining. Herein we report a GIST of the small intestine that showed tumor staining and early venous return on imaging studies, and so the patient was suspected to have AVM. A 62-year-old male presented with intermittent pain in the left abdominal region. Contrast-enhanced computed tomography revealed a 15-mm-long spindle-shaped mass showing intense tumor staining and early venous return through the jejunal vein. In the arterial phase, the attenuation value of the tumor was 250 Hounsfield units. Color Doppler ultrasonography simultaneously delineated vessels extending from the serosal side and turbulent signals showing a mosaic pattern in the tumor. On angiography, intense staining was observed in the peripheral part of the second branch of the jejunal artery. Although these findings suggested AVM, the tumor was diagnosed as a GIST based on pathological examination of the resected specimens. In this case, no AVM or change in vascular density was noted despite the careful examination of pathological specimens, and the cause of the tumor staining remained unknown.

Angiogenesis-related factors are molecular targets for diagnosis and treatment of patients with esophageal carcinoma.

Angiogenesis plays an essential role in the growth and metastasis of esophageal carcinoma. Vascular endothelial growth factor, thymidine phosphorylase, fibroblast growth factor, midkine, and hepatocyte growth factor have been reported to be vital molecules for tumor angiogenesis. Polymorphisms in gene encoding angiogenic factors or their receptors may alter protein expression and/or activity. Increased angiogenic-factor expression and increased serum levels of these molecules were found to be associated with poor treatment response and poor prognosis. We reviewed the clinicopathological significance of angiogenesis-related molecules in patients with esophageal carcinoma. Antiangiogenic molecular-treatment strategies are also discussed.

Use of an opened umbilical vein patch for the reconstruction of the injured biliary tract.

BACKGROUND/PURPOSE: When iatrogenic biliary tract injury occurs, there is the risk of complications such as bile leak and biliary stricture, and hepaticojejunostomy is the conventional procedure used for injury repair. However, this procedure can be complicated by retrograde biliary tract infection and the procedure can destroy the normal anatomical structure. METHODS: We report here a method of end-to-end biliary tract reconstruction that uses an opened umbilical vein (OUV) patch and two stents to reduce bile leakage and biliary stricture formation following injury to the common bile duct or right main bile duct. The postoperative courses of four patients are reviewed. RESULTS: In two of the patients, there was a small amount of postoperative bile drainage (for 3 days in the first patient and 2 days in the second patient). Of the two stents, the first stent was removed 1 month postoperatively, and the second stent at 2 to 3 months postoperatively. Three patients have returned to normal activity without symptoms after 44, 62, and 93 months, respectively. One patient died of a liver tumor recurrence in the fifth postoperative month, without a biliary problem. CONCLUSIONS: An OUV patch for end-to-end biliary reconstruction reduced the volume and duration of bile leakage. Further research is needed to accurately evaluate the stenting period so as to reduce its duration.

Laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein.

Herein, we report the successful performance of a laparoscopy-assisted spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein for a patient with pancreatic cystadenoma, as a minimally invasive procedure with the preservation of function. The laparoscopy-assisted distal pancreatectomy procedure involved detaching the spleen and the distal pancreas from the retroperitoneum by a hand-assisted procedure, removing them from the peritoneal cavity through a small incision, and detaching the distal pancreas by ligating and transecting the short gastric artery and vein and the branches of the splenic artery and vein, while the spleen and main splenic artery and vein were preserved under direct view. The pancreatic parenchyma was transected with a stapling device (TL-30), and continuous suturing was added to the resected margin. The patient's postoperative course was uneventful; the patient started to eat and walk on postoperative day 2 and was discharged on day 8. It is considered that the combination of hand-assisted and laparoscopy-assisted distal pancreatectomy, with conservation of the splenic artery and vein, is a minimally invasive and clinically useful technique for treating tumors of cystic disease of the pancreas with low-grade malignant potential, or benign solitary neuroendocrine tumors.