Usefulness of Hem-o-lok® clips to ligate the gastroduodenal artery in pancreatoduodenectomy.

BACKGROUND/PURPOSE: Post-pancreatectomy hemorrhage (PPH) is a fatal complication of pancreatoduodenectomy. When complicated by a pancreatic fistula, pancreatic juice contacting the artery may form a pseudoaneurysm and cause arterial bleeding. We used Hem-o-lok® clips to prevent damage to the outer wall of the gastroduodenal artery (GDA). This study evaluated the usefulness of using Hem-o-lok® clips to ligate the GDA stump to prevent PPH. METHODS: Overall, 468 patients who underwent PD at our hospital were included. Before July 2020, we ligated the GDA stump using the knot-tying method, which involves double ligation. After July 2020, the GDA stump was double clipped using a 10-mm Hem-o-lok® clip to the residual side without tension on the GDA. Propensity score matching was used to compare cases of pancreatic fistulas that underwent clipping vs. knot-tying. RESULTS: Propensity score matching resulted in 37 patients in each group. PPH occurred in 12 (16.4%) and 4 (6.9%) patients in the knot-tying and clipping groups, respectively. PPH from the GDA stump occurred in eight (11.0%) and one (1.7%) patient in the knot tying and clipping groups, respectively (P = 0.044). CONCLUSIONS: Hem-o-lok® clips are safe to apply on the GDA stump during pancreatoduodenectomy to prevent PPH.

Efficacy and Safety of the Combination of Nano-Liposomal Irinotecan and 5-Fluorouracil/L-Leucovorin in Unresectable Advanced Pancreatic Cancer: A Real-World Study.

INTRODUCTION: This retrospective study investigated the efficacy and safety of nano-liposomal irinotecan (nal-IRI) plus 5-fluorouracil/L-leucovorin (5-FU/l-LV) treatment in the second-line or later setting for advanced pancreatic cancer under real-world conditions. METHODS: Between June 2020 and September 2021, a total of 44 patients with unresectable advanced pancreatic cancer treated with nal-IRI + 5-FU/l-LV in our affiliated hospitals were included. The prognosis, predictive factors (including systemic inflammation-based prognostic indicators), and adverse events were investigated. RESULTS: The median age was 68 (interquartile range 62-73) years old, and 22 patients (50.0%) were male. Concerning tumor factors, 9 patients (20.5%) had local advanced disease and 35 patients (79.5%) had metastases. Twenty-five of the 44 patients were receiving second-line treatment, and 19 were receiving third-line or later treatment. The median overall survival (OS) and progression-free survival were 9.0 (range, 0.7-15.4) months and 4.4 (range, 0.6-15.4) months, respectively. The overall response rate was 5.3%. The disease control rate was 44.7%. Patients with a neutrophil-to-lymphocyte ratio of ≥2.7 had a significant risk of a poor OS (HR = 0.275, p = 0.017). Adverse events were manageable, although gastrointestinal symptoms and neutropenia were observed. The most common grade ≥3 adverse event was neutropenia, which was reported in 20% of patients. CONCLUSIONS: Nal-IRI + 5-FU/l-LV therapy was considered to be a useful regimen as second-line or later treatment for unresectable advanced pancreatic cancer, even in clinical practice.

A case of resected anaplastic carcinoma of the pancreas producing granulocyte-colony stimulating factor with literature review.

BACKGROUND: Granulocyte colony-stimulating factor (G-CSF)-producing tumors have been reported in various organs, and the prognosis of patients with G-CSF-producing pancreatic cancers is particularly dismal. In this report, we present a case of G-CSF-producing anaplastic carcinoma of the pancreas (ACP), characterized by early postoperative recurrence and rapid, uncontrolled growth. CASE PRESENTATION: A 74-year-old man presented to our hospital with complaints of abdominal fullness and pain after eating. On admission, it was observed that the peripheral leukocyte counts and serum G-CSF levels were significantly elevated (23,770/µL and 251 pg/mL, respectively). Computed tomography of the abdomen revealed a pancreatic head tumor involving the superior mesenteric vein. Pathologically, ultrasound-guided fine-needle aspiration confirmed ACP. Subsequently, we performed a subtotal stomach-preserving pancreaticoduodenectomy with portal vein reconstruction and partial transverse colon resection. On postoperative day (POD) 7, the leukocyte count decreased from 21,180/µL to 8490/µL; moreover, computed tomography revealed liver metastasis. Therefore, mFOLFILINOX chemotherapy was initiated on POD 30. However, the tumor exhibited rapid progression, and the patient died on POD 45. CONCLUSIONS: G-CSF-producing ACP is rare, and the prognosis of patients is extremely poor. Basic research is required to develop effective drugs against G-CSF-producing tumors, and large-scale studies using national databases are needed to develop multidisciplinary treatment methods.

Primary duodenal carcinoma suspected to arise from ectopic gastric mucosa: a case report.

BACKGROUND: Ectopic gastric mucosa mainly occurs in the duodenal bulb, and its etiology is thought to be congenital straying of gastric tissues. Primary duodenal carcinoma is a rare disease; however, reports of carcinoma arising from ectopic gastric mucosa are extremely rare. We report a case of primary duodenal carcinoma suspected to arise from ectopic gastric mucosa, which discovered as a result of duodenal stenosis. CASE PRESENTATION: The patient was a 71-year-old man with persistent weight loss and white stools. Enhanced computed tomography showed stenosis of the third portion of the duodenum and main pancreatic duct dilatation. Upper gastrointestinal endoscopy revealed irregularity of the duodenal mucosa from the anorectal side of the papilla of Vater to the stenosis of the third portion. No malignant cells were found by biopsies from the duodenal mucosa. Endoscopic ultrasonography did not detect the tumor in the pancreatic head. The possibility of a pancreatic tumor could not be ruled out based on findings of main pancreatic duct dilatation in the pancreatic head, and the patient had long-term poor oral intake because of duodenal stenosis; thus, surgical treatment was planned. Intraoperative findings showed palpable induration of the third portion of the duodenum and white nodules on the serosal surface. This was diagnosed as primary duodenal carcinoma, and pylorus-preserving pancreatoduodenectomy was performed. Histopathological diagnosis revealed ectopic gastric mucosa in the papilla of Vater and well-differentiated tubular adenocarcinoma invaded the normal duodenal submucosa and extended to the duodenal serosa. No mass lesion was detected in the pancreas, and an intraductal papillary mucinous neoplasm was observed in the branch pancreatic duct. The main pancreatic duct stricture was caused by the duodenal carcinoma invasion. CONCLUSIONS: This case of primary duodenal carcinoma was suspected to arise from ectopic gastric mucosa and review the relevant literature.

Successful Treatment of Pancreatic Fistula Following Surgery for Congenital Biliary Dilatation with Endoscopic Ultrasound-Guided Transduodenal Drainage.

Despite improvements in surgical techniques and perioperative management, postoperative pancreatic fistula (PF) is often difficult to treat and can be fatal due to various complications without effective drainage. Here, we report a case of PF following surgery for congenital biliary dilatation (CBD) successfully managed by endoscopic ultrasound (EUS)-guided transduodenal drainage. A 55-year-old woman underwent extrahepatic bile duct resection, including the gallbladder, and biliary tract reconstruction for CBD. On the 10th postoperative day (POD), computed tomography (CT) showed fluid retention observed from the upper edge of the pancreatic head to the surface of the right lobe of the liver. First, percutaneous fine-needle aspiration was performed on the fluid retention in the lateral part of the liver on the 11th POD. The amylase level in the drainage was high (30,156 U/L), and we diagnosed it as PF. Percutaneous drainage was difficult for fluid retention on the cut surface of the pancreas; thus, drainage under EUS guidance was decided. On the 13th POD, EUS was performed, a scan of the duodenal bulb revealed fluid retention with debris inside, and approximately 20-mL fluid was aspirated (amylase: 139,200 U/L). Although the inflammatory response temporarily improved, it recurred, so we decided to perform continuous drainage. On the 21st POD, EUS was performed again; a 19-G needle was used; a 0.025-in angle-type Jagwire was advanced into the fluid retention and expanded using a 7-Fr dilator; and then, a 6-Fr endoscopic nasoabscess drain (ENAD) tube was placed. On the 29th POD, CT showed that the fluid retention on the upper edge of the head of the pancreas had shrunk to a thickness of approximately 20 mm. On the 30th POD, the patient started eating. The ENAD tube was removed on the 38th POD. The patient was discharged from the hospital on the 45th POD without any symptoms. EUS-guided transduodenal drainage is an effective treatment option for postoperative PF following surgery for CBD.

Clinical outcomes of double endoscopic intralumenal surgery for early gastric cancer.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a safe, efficacious, and minimally invasive technique for superficial gastrointestinal neoplasms. However, the procedure is long, complex, and associated with higher complication rates. To overcome such limitations, the authors devised a double endoscopic intralumenal operation (DEILO) and assessed its efficacy and safety for superficial gastric neoplasms. METHODS: The DEILO procedure was performed for 31 gastric cancers. This novel technique is characterized by the use of two endoscopes, one for lifting lesions and the other for cutting them, inserted into the stomach simultaneously. RESULTS: The DEILO technique was performed successfully, and en bloc resection was achieved for 29 (93.5%) of 31 patients. Histologically, curative resection was achieved for 26 lesions (83.8%). The mean operating time for DEILO was 34 min (range, 20-107 min). Two patients experienced postoperative hemorrhage, which was controlled endoscopically. Perforation occurred in two cases (6.4%), both of which were successfully treated nonsurgically. CONCLUSION: The DEILO procedure appears to shorten the operating time for ESD, with comparable efficacy and complication rates.

Successful treatment of enterocutaneous fistula after esophagectomy with scopolamine ointment and negative pressure wound therapy: a case report.

BACKGROUND: Despite improved surgical techniques and perioperative management, anastomotic leakage (AL) after esophageal cancer surgery remains a potential complication. In most cases, spontaneous healing upon proper drainage is observed, but sometimes, AL results in intractable enterocutaneous fistulas. We here report a case of intractable enterocutaneous fistula caused by post-esophagectomy AL and successfully treated by scopolamine ointment and negative pressure wound therapy (NPWT). CASE PRESENTATION: A 77-year-old man underwent thoracoscopic subtotal esophagectomy with 3-field lymph node dissection, followed by gastric tube reconstruction through the posterior mediastinal route. On the 6th postoperative day, AL was identified, forming an enterocutaneous fistula. Initially, conservative treatment was performed, but the fistula failed to close. We hypothesized that the substantial amount of exudate might be hampering fistula closure. Scopolamine ointment was used to reduce the amount of fluid. NPWT was also initiated to promote wound healing. Approximately 3 weeks after the beginning of the treatment, the fistula closed; oral intake became possible, and the patient was discharged from the hospital without any symptoms. CONCLUSIONS: The combination of scopolamine ointment and NPWT may be regarded as one effective treatment option for intractable enterocutaneous fistula due to AL after esophagectomy.

Laparoscopically assisted total gastrectomy with lymph node dissection for upper and middle gastric cancer.

BACKGROUND: In recent years, laparoscopic gastrectomy has been applied for the treatment of gastric cancer in Japan and Western countries. This report describes the short- and long-term results for patients with gastric cancer who underwent laparoscopically assisted total gastrectomy (LATG) with lymph node dissection. METHODS: From September 1999 to December 2007, 20 patients underwent LATG, and 18 underwent conventional open total gastrectomy (OTG) for upper and middle gastric cancer. The indications for LATG included depth of tumor invasion limited to the mucosa or submucosa and absence of lymph node metastases in preoperative examinations. The LATG and OTG procedures for gastric cancer were compared in terms of pathologic findings, operative outcome, complications, and survival. RESULTS: No significant difference was found between LATG and OTG in terms of operation time (254 vs 248 min.), number of lymph nodes (26 vs 35), complication rate (25% vs 17%), or 5-year cumulative survival rate (95% vs 90.9%). Differences between LATG and OTG were found with regard to blood loss (299 vs 758 g) and postoperative hospitalization (19 vs 29 days). CONCLUSION: For properly selected patients, laparoscopically assisted total gastrectomy can be a curative and minimally invasive treatment for early gastric cancer.

Sentinel lymph node mapping with technetium-99m colloidal rhenium sulfide in patients with gastric carcinoma.

BACKGROUND: The objective of this study was to determine, with the use of technetium-99m colloidal rhenium sulfide, whether the concept of sentinel lymph nodes (SLNs) is applicable to gastric cancers. METHODS: Fifty-nine gastric cancer patients underwent radical gastrectomy and SLN mapping with an intraoperative hand-held gamma probe. After surgery, each transected lymph node was measured for radioisotope (RI) activities by a well-type scintillation counter. RESULTS: SLNs were detectable in 57 (96%) of 59 patients. The sensitivity, specificity, and diagnostic accuracy were calculated to be 83.3%, 100%, and 92.9%, respectively. Sensitivity was 100% in the T1 group, 91.6% in the T2 group, and 62.5% in the T3 group. When RI activities were measured with a well-type scintillation counter, every metastatic non-SLN was found to be situated in the same lymphatic basin as the SLNs. CONCLUSION: The SLN concept is applicable to patients with early gastric cancer (T1). SLN mapping is suitable for identifying the lymphatic basin in cases of gastric cancer.

Neuroendocrine tumor of the ampulla of Vater with distant cystic lymph node metastasis: a case report.

BACKGROUND: Neuroendocrine tumors (NETs) of the ampulla of Vater are rare and difficult to diagnose. We report a rare case of a small NET of the ampulla of Vater with metastasis to distant lymph nodes. CASE PRESENTATION: The patient was a 54-year-old man complaining of epigastric pain and melena. Upper gastrointestinal endoscopy revealed a bulging papilla with active bleeding, which was diagnosed as a well-differentiated NET of the ampulla of Vater. An approximately 10-mm hypervascular tumor at the ampulla of Vater and a 41-mm cyst adjacent to the wall of the jejunum were revealed by abdominal computed tomography. We performed pylorus-preserving pancreaticoduodenectomy with lymph node dissection. Macroscopic examination revealed a 9-mm tumor of the ampulla of Vater and a 52-mm cyst adjacent to the wall of the jejunum. Histological examination revealed that the cyst was a lymph node metastasis. The final diagnosis was non-functional NET G1 of the ampulla of Vater, designated T1N1M0 stage IIIB. Postoperatively, the patient underwent no treatment and has had no recurrence for 4 years. CONCLUSIONS: This case demonstrates that sporadic NETs of Vater's papilla have aggressive metastatic potential even with a small primary lesion, and radical resection with lymphadenectomy is recommended for all cases.

Laparoscopic assisted distal gastrectomy for early gastric cancer: Five years' experience.

BACKGROUND: Laparoscopic assisted gastrectomy is being reported increasingly as the treatment of choice for early gastric cancer. However, no reports concerning the prognosis of patients who have undergone laparoscopic assisted distal gastrectomy (LADG) for early gastric cancer or data comparing the results to those obtained after open gastric surgery are yet available. METHODS: A retrospective study was performed comparing laparoscopic assisted and open distal gastrectomies for early gastric cancer. Eighty-nine patients who underwent LADG were compared to 60 who underwent conventional open distal gastrectomy (DG) in terms of pathologic findings, operative outcome, complications, and survival. RESULTS: There were no significant differences between LADG and DG in operation time (209 vs 200 minutes), complication rate (9% vs 18%), and 5-year survival rate (98% vs 95%). There were differences between LADG and DG with regard to blood loss (237 vs 412 mL), number of lymph nodes (19 vs 25), postoperative stay (17 vs 25 days), and the duration of epidural analgesia (2 vs 4 days) ( P < .05 each). CONCLUSIONS: For properly selected patients, LADG can be a curative and minimally invasive treatment for early gastric cancer.

Gastrointestinal stromal tumor of the stomach: report of a case.

We report herein a case of a 65-year-old woman who had a gastrointestinal stromal tumor (GIST) of the stomach. Preoperative endoscopic and X-ray examinations showed a spherical submucosal tumor in the gastric fornix. We resected the tumor by laparoscopic surgery, because it was detected by computed tomography (CT) and positron emission tomography (PET), and they did not detect distant metastasis. Postoperative histologic examination revealed that the tumor was composed of spindle-shaped cells with elongated nuclei and showed little mitosis. Almost all of the cells showed immunoreactivity for c-kit, CD34, vimentin and but did not show alpha-smooth muscle actin (SMA), S-100, or desmin. The Ki-67 labeling index was 0.8%. The tumor did not show differentiation toward smooth muscle or neural cells. Pathological findings showed this tumor was probably benign. In such cases, careful follow-up is needed to detect liver metastasis and local recurrence.

Postoperative functional evaluation of jejunal interposition with or without a pouch after a total gastrectomy for gastric cancer.

BACKGROUND: The objective of this study was to compare the motility of a gastric substitute after jejunal interposition without a pouch and jejunal interposition with a pouch and to evaluate the relationship of both methods with nutritional outcome. METHODS: Twelve patients with gastric cancer treated by total gastrectomy and reconstruction with jejunal interposition without a pouch (J-I) and 14 patients treated by total gastrectomy and reconstruction with jejunal interposition with a pouch (J-P) were investigated in regard to the motor activity of the interposed jejunum and changes in body weight and dietary intake. RESULTS: Phase III of the interposed jejunum without a pouch was observed over a 3-month follow-up, but phase III of the interposed jejunum with a pouch was not observed in any patient within 3 months of surgery. In the fed state, the motor activity of the interposed jejunum without a pouch increased significantly in patients within 12 months of follow-up, but in the interposed jejunum with a pouch, it did not. The amount of food consumed by the J-I group was significantly greater than that consumed by the J-P group. CONCLUSIONS: This study demonstrates that the interposed jejunum with a pouch shows marked disturbances from the motor pattern of a normal jejunum during the fasting and fed states. These motor abnormalities may be responsible for insufficient food intake of the J-P group.

Relationship between clinicopathological features and mucin phenotypes of advanced gastric adenocarcinoma.

AIM: To investigate a relationship between the clinicopathological features and mucin phenotypes in advanced gastric adenocarcinoma (AGA). METHODS: Immunohistochemical staining was performed to determine the mucin phenotypes in 38 patients with differentiated adenocarcinomas (DACs), 9 with signet-ring cell carcinomas (SIGs), and 48 with other diffuse-type adenocarcinomas (non-SIGs) of AGA. The mucin phenotypes were classified into 4 types: gastric (G), gastrointestinal (GI), intestinal, and unclassified. RESULTS: The G-related mucin phenotypes were highly expressed in all the histological subtypes of AGA. The expression of the GI phenotype in SIG patients was lower than that in DAC patients (P = 0.02), and this phenotype was observed in 56% of the non-SIG patients in the intramucosal layer. Among non-SIG cases, the expression of the GI phenotype was significantly higher in patients with extended adenocarcinomas and those with positive rates of lymph node metastasis. There was no difference between the expressions of the G and other GI phenotypes factors. Among DAC and non-SIG patients, there were no differences between the survival rates of the corresponding patient groups. CONCLUSION: The GI phenotype might possess more invasive characteristics than the G phenotype in non-SIG. Neither of the phenotypes indicated a poor prognosis of DAC and non-SIG.

Feasibility study of postoperative intraperitoneal hyperthermochemotherapy by radiofrequency capacitive heating system for advanced gastric cancer with peritoneal seeding.

BACKGROUND: Gastric carcinoma patients with peritoneal dissemination have an extremely poor prognosis. Attempting to improve regional control and decrease the risk of complications related to hyperthermic chemotherapy, we applied a new treatment modality using a combination of gastrectomy with postoperative intraperitoneal hyperthermo-chemotherapy (PIHC) using Thermotron RF-8. The purpose of this study was to evaluate the feasibility of PIHC in advanced gastric carcinoma patients with peritoneal seeding. PATIENTS AND METHODS: Between March 2002 and April 2006, 20 gastric carcinoma patients with peritoneal dissemination were allocated to two groups in the patient's selection. The PIHC group (10 patients) received a 60-min PIHC with a cisplatin dose of 80 mg/m2 two weeks after surgery, and the control group (10 patients) received surgery alone. Thermotron RF-8 is a heating device that can raise temperatures in both superficial and deep-seated tumours using 8 MHz radiofrequency electromagnetic waves as a source of heat. RESULTS: No patients in either group had life-threatening complications. The most frequent nonhaematologic toxicity (grade 3) was nausea. The one-, two-, and three-year cumulative survival rates for the PIHC group were 60%, 48%, and 36%, respectively, whereas those for the control group were 40%, 10%, and 0%, respectively. The survival rates for the PIHC group were significantly higher than those for the control group. CONCLUSION: Although this study was conducted non-randomly with a small number of patients, the PIHC group had a higher survival rate and better prognosis compared with the control group.