Surgical Laparotomy for Repeated Delayed Arterial Hemorrhage after Pancreaticoduodenectomy

Postpancreatectomy hemorrhage is one of the major life-threatening complications of pancreatic surgery. Radiological intervention is used as a first-line approach for the initial treatment of late arterial hemorrhage. However, rehemorrhage has a high risk for mortality, and it is undecided which urgent intervention provides optimal management for rehemorrhage. We experienced a successful surgical laparotomy for the repeated delayed arterial hemorrhage caused by a pancreaticoduodenectomy (PD) for chronic pancreatitis. A 57-year-old man had undergone PD with pancreaticogastrostomy for tumor-forming pancreatitis with possible pancreatic cancer. A delayed massive hemorrhage from the drain developed 11 days after surgery. Although angiography was done, the bleeding site was not clearly detected. Therefore, urgent surgical laparotomy was performed. Arterial bleeding was detected from the stump of the gastroduodenal artery. Surgical ligation, using the suture technique, was performed for hemostasis, and a closed drain was placed in the area due to drainage of pancreatic juice and an abscess. However, rehemorrhage from the drain developed 7 days after the initial hemorrhage. Relaparotomy was performed immediately. The surgical ligation and compression hemostasis with absorbable hemostatic cotton was done. After relaparotomy for rehemorrhage, there was no hemorrhage or fatal hepatic failure. He left our hospital 64 days after initial surgery. Surgical laparotomy is one of the feasible procedures for hemostasis of a massive arterial hemorrhage. Proper blood vessel ligation is necessary for reliable hemostasis and proper drainage of pancreatic juice and abscesses to prevent hemorrhage.

Effects of Enteral Immunonutrition in Esophageal Cancer

Background

Immunonutrition (IN) significantly reduces the incidence of postoperative infectious complications and the length of hospitalization in patients undergoing major elective surgery for gastrointestinal malignances. However, the clinical benefit of IN in patients who have undergone esophagectomy for esophageal cancer is unclear. Moreover, the effect of enteral IN in patients during preoperative adjuvant chemoradiotherapy and in patients treated with concurrent chemoradiotherapy for advanced esophageal cancer is unknown.

Summary

This review analyzes the evidence supporting the enteral administration of IN in patients who have undergone esophagectomy and/or chemoradiotherapy for esophageal cancer. Twelve trials that evaluated IN exclusively in patients who underwent esophagectomy were published between January 1980 and August 2017. Two trials concerning IN during chemoradiotherapy for esophageal cancer were identified in the same period. However, the evidence is insufficient to recommend enteral IN in patients who have undergone esophagectomy and/or chemoradiotherapy for esophageal cancer.

Key Message

Further evidence from well-designed randomized controlled trials is required to verify the clinical benefits of enteral IN in patients undergoing esophagectomy and/or chemoradiotherapy for esophageal cancer.

Practical Implications

Resolvins, which are generated from EPA, are novel anti-inflammatory lipid mediators and may play a key role in the resolution of acute inflammation when IN is supplemented with EPA in patients undergoing severely stressful operations.

Utility of Inflammatory Marker- and Nutritional Status-based Prognostic Factors for Predicting the Prognosis of Stage IV Gastric Cancer Patients Undergoing Non-curative Surgery

BACKGROUND/AIM

The present study aimed to compare the utility of various inflammatory marker- and nutritional status-based prognostic factors, including many previous established prognostic factors, for predicting the prognosis of stage IV gastric cancer patients undergoing non-curative surgery.

PATIENTS AND METHODS

A total of 33 patients with stage IV gastric cancer who had undergone palliative gastrectomy and gastrojejunostomy were included in the study. Univariate and multivariate analyses were performed to evaluate the relationships between the mGPS, PNI, NLR, PLR, the CONUT, various clinicopathological factors and cancer-specific survival (CS).

RESULTS

Among patients who received non-curative surgery, univariate analysis of CS identified the following significant risk factors: chemotherapy, mGPS and NLR, and multivariate analysis revealed that the mGPS was independently associated with CS.

CONCLUSION

The mGPS was a more useful prognostic factor than the PNI, NLR, PLR and CONUT in patients undergoing non-curative surgery for stage IV gastric cancer.

[Report of a Successful Case of Combined Modality Therapy for a Patient with Local Recurrence of Rectal Cancer]

A 67-year-old man underwent abdominoperinealresection for rectalcancer (Rb, tub2>muc, A, N1, H0, P0, M0, Cy1, Stage III a). We administered mFOLFOX6 as adjuvant chemotherapy for 6 months. Twenty-seven months after surgery, his serum tumor marker level was increased, and local recurrence in the left rear of the prostate was detected by pelvic CT. The patient selected radiation(50 Gy/25 Fr), after rejecting resection for the local recurrence. After radiation, we performed chemotherapy combined with bevacizumab. Seventeen months from the start of chemotherapy, 47 months after surgery, chemotherapy was stopped because his tumor maker levels normalized and pelvic CT revealed a partial response. At present, his progression-free survival is 7 months after completion of chemotherapy. We conclude that combined modality therapy is an option for a patient with locally recurrent rectal cancer.

[Primary Tumor Resection in Incurable Stage IV Colorectal Cancer]

The influence of primary tumor resection on the prognosis of patients with incurable Stage IV colorectal cancer is unclear. We retrospectively analyzed 30 patients with incurable Stage IV colorectal cancer who underwent primary tumor resection. Postoperative complications occurred in 13 patients(43.3%)classified as grades greater than Clavien-Dindo classification II . There was no mortality. Median duration of hospital stay after surgery was 23 days. Fourteen patients(46.7%)underwent chemotherapy after surgery, of which 12 were administered molecular targeted therapy. The median number of chemotherapy regimens was 2(range, 1 to 3). The median time between start and end of chemotherapy was 11.8 months. The median survival time(MST)of all patients was 16.9 months. The MST of patients treated with chemotherapy combined with molecular targeted therapy(60.6 months)was significantly longer than those who did not undergo chemotherapy(10.9 months). Chemotherapy combined with molecular targeted therapy contributes to survival after primary tumor resection in patients with incurable Stage IV colorectal cancer.

Adenocarcinoma arising from heterotopic pancreas at the third portion of the duodenum

A 62-year-old Japanese man presented to our hospital with a history of weight loss of 6 kg in 4 mo. Imaging examinations revealed a tumor located on the third portion of the duodenum with stenosis. We suspected duodenal carcinoma and performed pancreas-preserving segmental duodenectomy. Adenocarcinoma arising from a heterotopic pancreas at the third portion of the duodenum was finally diagnosed by immunohistochemical staining. Malignant transformation in the duodenum arising from a heterotopic pancreas is extremely rare; to our knowledge, only 13 cases have been reported worldwide, including the present case. The most common location of malignancy is the proximal duodenum at the first and descending portion. Herein, we describe the first case of adenocarcinoma arising from a heterotopic pancreas, which was located in the third portion of the duodenum, with a review of the literature.

Glasgow prognostic score is a useful predictive factor of outcome after palliative gastrectomy for stage IV gastric cancer

BACKGROUND/AIM

The Glasgow prognostic score (GPS) is a predictor of outcome for several cancer types. The present study examined the significance of modified GPS (mGPS) in the prognosis of patients undergoing palliative surgery for stage IV gastric cancer.

PATIENTS AND METHODS

A total of 42 patients with stage IV gastric cancer treated with palliative gastrectomy and gastrojejunostomy were included in the study. Univariate and multivariate analyses were performed to evaluate the relationship between clinicopathological factors and cancer-specific survival (CS).

RESULTS

Among patients who underwent palliative surgery including gastrectomy and gastrojejunostomy, univariate analysis of CS identified the following significant risk factors: surgical treatment, chemotherapy and mGPS, and multivariate analysis revealed that mGPS was independently-associated with CS. In particular, among patients who underwent palliative gastrectomy, mGPS was shown to be the strongest independent predictive factor for CS.

CONCLUSION

The mGPS was an independent predictive factor for survival in patients who underwent palliative surgery for stage IV incurable gastric cancer, especially for those who underwent palliative gastrectomy.

Simultaneous laparoscopic Nissen fundoplication and percutaneous endoscopic gastrostomy to treat an elderly patient with a large paraesophageal hernia: a case report

Laparoscopic Nissen fundoplication (LNF) and gastrostomy are often performed in children with gastroesophageal reflux disease. With a population that is increasingly aging, the number of elderly patients with paraesophageal hernia who have a nutritional disorder due to dysphagia has increased. In these patients with feeding difficulties, LNF and percutaneous endoscopic gastrostomy (PEG) are effective procedures for providing nutritional support. Here, we describe the case of an 82-year-old woman with paraesophageal hernia and certain comorbidities. She was receiving enteral feeding through a nasogastric tube, which was discontinued because aspiration pneumonia occurred. Therefore, LNF and crural repair without mesh placement were performed. The PEG tube was placed using the Ponsky pull technique under direct visualization with a laparoscope and gastroscope. The patient's nutritional status improved after she received enteral nutrition through the PEG tube. Thus, LNF and PEG may be useful techniques for nutritional support in elderly patients with a large paraesophageal hernia.

Gastric Cancer Arising from an Upside-Down Stomach through a Paraesophageal Hiatal Hernia

We report the rare case of an elderly patient with an advanced gastric cancer arising from an upside-down stomach through a paraesophageal hiatal hernia (PEH). An 82-year-old man presented with appetite loss and anemia. Upper gastrointestinal endoscopy revealed a type 1 tumor located in the middle body of the stomach. An upper gastrointestinal series and computed tomography showed organoaxial rotation of the stomach, which was located in the mediastinum, through a PEH, indicating an upside-down stomach. The preoperative diagnosis was gastric cancer arising from an upside-down stomach through a PEH. The patient underwent total gastrectomy with lymph node dissection and closure of the hernial orifice. Although a large PEH is a chronic disorder, gastric malignancies should be considered in patients with PEH manifested as an upside-down stomach due to its anatomical characteristics, and careful preoperative diagnosis is mandatory.

Pancreaticogastrostomy in patients with considerably dilated pancreatic ducts

BACKGROUND/AIMS

Patency of pancreaticogastrostomy (PG) is one of the most important factors affecting the function of the remnant pancreas and quality of life. We evaluated the early postoperative changes in pancreatic duct dilation after pancreaticoduodenectomy (PD) and PG with duct-to-mucosa anastomosis in patients with remarkably dilated pancreatic ducts.

METHODOLOGY

We retrospectively analyzed 26 patients who had remarkably dilated pancreatic ducts (diameter, ≥7 mm) and who underwent PD followed by PG. They were divided into 2 groups on the basis of the endoscopic findings of the anastomotic orifice of PG: Group A, clear pancreatic duct orifice with pancreatic juice output; and Group B, unclear pancreatic duct orifice with pancreatic juice output.

RESULTS

The mean diameter of the duct of the remnant pancreas after the surgery was smaller in Group A than in Group B. With regards to postoperative pancreatic exocrine function, there was no significant difference between the 2 groups.

CONCLUSIONS

Invagination with duct-to-mucosa anastomosis is a useful technique to prevent pancreatic leakage; however, it is difficult to prevent inflammation and fibrosis around the anastomotic site of PG, and this can lead to anastomotic stricture in patients with a remarkably dilated pancreatic duct (diameter ≥7 mm).

Chemotherapy for liver metastasis originating from colorectal cancer with portal vein tumor thrombosis: a case report

The patient was a male in his 70s with a history of chronic renal failure and dilated cardiomyopathy. In January 2011, he underwent abdominoperineal resection of the rectum, right hepatic lobectomy, and resection of a portal vein tumor thrombus with a diagnosis of rectal cancer and metastatic liver cancer accompanied by portal vein tumor thrombosis. Although 5-fluorouracil + l-leucovorin therapy (RPMI regimen) was carried out as postoperative adjuvant chemotherapy, the tumor marker (CEA and VA19-9) levels increased 8 months after surgery. Since the functions of major organs were impaired, UFT^® + UZEL^® therapy was started. The tumor marker levels decreased temporarily, but increased again 12 months after surgery, and so intravenous instillation of panitumumab was initiated. Nine administrations have been performed to date, with no increase in tumor marker levels or exacerbation of the condition. Also, no grade 2 or severer adverse event has been noted according to CTCAE v.4.0. The experience with this patient suggests the possibility that exacerbation of the condition of patients with liver metastasis of colorectal cancer accompanied by portal vein tumor thrombosis with abnormalities in the functions of major organs can be controlled temporarily by the administration of panitumumab alone.

Horizontal vs. vertical incision on the anterior gastric wall in pancreaticogastrostomy

BACKGROUND/AIMS

Pancreaticogastrostomy during pancreaticoduodenectomy is associated with a very low rate of anastomotic leakage. However, gastric peristalsis is disturbed by pancreaticogastrostomy, which stabilizes the posterior stomach at that point leading to delayed gastric emptying. We evaluated which anterior gastrostomy, i.e. horizontal or vertical incision on the anterior gastric wall, is better for maintaining peristaltic movement of the anterior stomach to prevent delayed gastric emptying after pancreaticogastrostomy.

METHODOLOGY

We retrospectively studied 50 patients who underwent subtotal stomach-preserving pancreaticoduodenectomy with pancreaticogastrostomy. These patients were divided into 2 groups depending on the type of anterior gastrostomy: horizontal incision (H group) and vertical incision (V group).

RESULTS

The observed grade of delayed gastric emptying was lower in the V group than in the H group; however, the difference was not significant.

CONCLUSIONS

We conclude that a vertical incision on the anterior gastric wall is preferable for preventing delayed gastric emptying after a pancreaticogastrostomy.

Killian-jamieson diverticula presenting synchronously with thyroid adenoma

Killian-Jamieson diverticulum is a rare hypopharyngeal diverticulum, less commonly encountered compared with Zenker's diverticulum. These hypopharyngeal diverticula that cause dysphagia often mimic a thyroid tumor incidentally detected on neck ultrasonography. However, to our knowledge, Killian-Jamieson diverticula complicated by a thyroid tumor have not been previously described. We experienced a rare case of bilateral Killian-Jamieson diverticula synchronously complicated by a thyroid adenoma in a 74-year-old woman who became aware of dysphagia and a tumor in the left side of her neck. Pharyngoesophagography revealed bilateral diverticula protruding from the lateral wall of the esophagopharyngeal junction, but the appearance of the cricopharyngeal bar representing the cricopharyngeus muscle above the diverticula had become unclear because the thyroid tumor was pressing on the diverticula and the cervical esophagus. However, the diverticula were diagnosed as Killian-Jamieson diverticula because cervical computed tomography showed bilateral diverticula arising from the cervical esophagus just below the level of the cricoid cartilage, and operative finding showed that the diverticula were located above the upper esophageal longitudinal muscle. Radiographic imaging is useful for diagnosis as cause of dysphagia and cervical tumor.

Minimal incision based on measurement of the to-be-resected specimen in laparoscopic hepatectomy

Recent technological improvements in laparoscopic devices have significantly extended the surgeon's ability to perform laparoscopic liver surgery safely. Hand-assisted laparoscopy has been proposed in order to achieve greater safety and accessibility in laparoscopic liver surgery. Moreover, in order to expand the indications of minimally invasive liver resection and improve its safety, the "hybrid procedure" or "laparoscopy-assisted resection" has been proposed. Hand-assisted laparoscopic liver resection consists of the placement of a gas-tight port through an 8cm incision that enables a hand to be introduced into the abdomen. The "hybrid procedure" is performed through an 8-12cm midline or subcostal incision. Such a minimal abdominal incision is preferred not only for cosmetic reasons but also for obtaining adequate surgical margin. We performed laparoscopic liver resection via a minimal incision that was based on the measurement of the to-be-resected specimen intraoperatively by ultrasonography. Here, we have described our procedure and evaluated its efficacy.

Diffuse Peritonitis due to Perforated Gastric Ectopic Pancreas

Ectopic pancreas is frequently found in the gastrointestinal tract. Lesions comprise well-developed and normally organized pancreatic tissue outside the pancreas, without anatomic or vascular connections with the true pancreas. Most patients with ectopic pancreas are asymptomatic or exhibit nonspecific symptoms. A 68-year-old Japanese woman had been experiencing intermittent pain in the right upper abdomen. Suddenly, the abdominal pain changed to intense pain in the right flank of the abdomen 2 days later. On initial medical examination, the abdomen exhibited rebound tenderness and distension. The results of laboratory tests revealed increased inflammatory reaction. Abdominal computed tomography showed free air and ascites on the surface of the liver and elevated levels of adipose tissue around the antrum and pylorus of the stomach. Perforation of the upper gastrointestinal tract was diagnosed and we performed urgent surgery. The site of perforation, whose size was 25 mm, was the lesser curvature of the antrum of the stomach. Since it was not possible to perform omentopexy, we performed extensive gastric resection. The reconstruction was a Billroth II operation. Microscopic analysis revealed pancreatic tissue within the ulceration, showing islets of Langerhans, acini, and ducts; the lesion was diagnosed as type I using Heinrich's criteria. The postoperative course was uneventful. The patient was discharged on day 13 and remains clinically healthy. Gastric perforation due to ectopic pancreas has been reported in 2 cases, including our patient, and is extremely rare. Once gastric perforation has been diagnosed, the presence of ectopic pancreas might be considered.

Cholecystitis or cholestasis after total gastrectomy and esophagectomy

BACKGROUND/AIMS

Increased incidences of gallbladder disorders after esophagectomy and gastrectomy have been reported. Moreover, several researchers have reported increased incidences of gallbladder diseases in patients receiving long-term total parenteral nutrition. We studied the incidence of cholecystitis or cholestasis and determined its relationship with total parenteral nutrition; further, we compared the incidence after esophagectomy and after total gastrectomy.

METHODOLOGY

We retrospectively studied 109 patients who underwent total gastrectomy or esophagectomy. These patients were divided into 2 groups, those who underwent total gastrectomy (TG group) and those who underwent esophagectomy (E group).

RESULTS

The 2 groups did not significantly differ with respect to the mean duration of perioperative administration of total parenteral nutrition and the incidence rate of cholecystitis or cholestasis after esophagectomy.

CONCLUSIONS

Postoperative hyperbilirubinemia after esophagectomy may not contribute to the development of gallbladder complications. We suggest that parenteral modalities such as tube feeding be initiated immediately after surgery for preventing gallbladder complications after esophagectomy. Further, a short duration of administration of total parenteral nutrition and immediate postoperative initiation of oral feeding may prevent gallbladder complications after esophagectomy and total gastrectomy.

[A case of intussusception due to sigmoid colon cancer during mFOLFOX6 therapy]

We experienced a rare case of intussusception due to sigmoid colon cancer during chemotherapy. A-62-year-old female was started on mFOLFOX6 due to sigmoid colon cancer and hepatic metastases(stage IV). After 2 courses, she had abdominal pain and bloody stool. Abdominal ultrasonography showed a target sign, and abdominal CT showed edema of the mucosa of the sigmoid colon and invagination. She was diagnosed with intussusception due to sigmoid colon cancer, and underwent a bloodless reduction. However, because it was unavailable, we performed an emergency operation. The sigmoid colon invaginated 10 cm to the anal side. We then performed sigmoidectomy and lymphadenectomy(D2). The histopathological diagnosis was mucinous carcinoma, stage I. There was no report of intussusception with the chemotherapy. It is important to consider the intussusception of colon cancer even during chemotherapy.

Mesh vs. non-mesh repair for inguinal hernias in emergency operations

BACKGROUND/AIMS

Prosthetic repair has become the gold standard for elective management of inguinal hernias; however, its use in the setting of acute incarceration is still limited for fear of prosthetic-related complications, mainly infection. Thus, in this study. we conducted a comparative investigation of the outcomes of prosthetic repair vs. tissue repair in the management of incarcerated inguinal hernias.

METHODOLOGY

We retrospectively analyzed 62 patients who underwent emergency operations for incarceration of an inguinal hernia. These patients were divided into 2 groups based on the surgical procedure used: a mesh repair group (M group) and a non-mesh repair group (N group).

RESULTS

There were no significant differences between the 2 groups with respect to postoperative complications and the mean period of post-operative hospitalization.

CONCLUSIONS

Contrary to traditional belief, the use of a prosthetic mesh in the emergency setting is not contra-indicated. Its usage for the repair of incarcerated inguinal hernias appears to be safe and acceptable. However, when perforation of the intestine occurs due to incarceration of an inguinal hernia, prosthetic repair using hernioplasty should not be performed because of the high risk of infection.

Duodenal switch operation for juxtapapillary duodenal diverticula

BACKGROUND/AIMS

Since the first case of juxtapapillary diverticlum reported by Lemmel, several reports have demonstrated an association between periampullary diverticulum and gallstone disease. Thus, we compared the efficiency of the duodenal switch operation and choledchojejunostomy for patients who underwent surgery for cholangitis with juxtapapillary duodenal diverticula.

METHODOLOGY

We retrospectively studied 17 patients who had cholangitis associated with juxtapapillary duodenal diverticula. These patients were divided into 2 groups on the basis of the operative procedure: the duodenal switch operation group (DS group) and the choledochojejunostomy group (CJ group).

RESULTS

The mean operative time and blood loss were significantly lesser in the DS group than in the CJ group (p<0.0001 and p<0.0005, respectively); however, the duration of nasogastric suction requirement and time after which oral ingestion of solid diet could be safely resumed after surgery were significantly longer in the DS group than in the CJ group (p<0.0001 and p<0.0001, respectively). Gallstone formation after the surgery did not occur in both groups.

CONCLUSIONS

Duodenal switch operation is useful and less invasive for cholangitis associated with juxtapapillary duodenal diverticula and for preventing cholangitis for a long period after the operation; however, gastric stasis still remains a problem with this procedure.

Delayed gastric emptying after pancreaticoduodenectomy in diabetes mellitus

INTRODUCTION

Delayed gastric emptying (DGE) is one of the most troublesome complications of pancreaticoduodenectomy (PD). Diabetes mellitus (DM) is one of the risk factors for pancreatic cancer. Moreover, several studies have shown that diabetic patients tend to have a high incidence of upper gastrointestinal symptoms such as nausea, vomiting and DGE. Here, we compared the influence of DM on the incidence of DGE after PD.

METHODS

We retrospectively analysed 67 cases of PD with pancreaticogastrostomy. These patients were categorized into the following two groups: the DM group included patients with DM, and the NDM group included patients without DM. The incidence of DGE was determined and compared between the two groups.

RESULTS

In the DM group, 76.5%, 5.9% and 17.6% of the subjects developed classes A, B and C DGE, respectively; the corresponding values in the NDM group were 58%, 22%, and 20%. The incidence of DGE did not differ between the two groups (P < 0.2771).

CONCLUSIONS

DM does not accelerate DGE in patients who have undergone PD. Preoperative DM does not appear to play a key role in post-operative DGE after PD.

Anterior vs. posterior mediastinal routes in colon interposition after esophagectomy

BACKGROUND/AIMS

Colon interposition is the most commonly used method of esophageal reconstruction when the stomach cannot be used; however, this method may cause surgical complications such as anastomotic leakage and sepsis due to colon necrosis. Therefore, many surgeons use a retrosternal or subcutaneous route because it is easier to manage the subcutaneous drainage when anastomotic leakage occurs. However, some researchers have reported that the posterior mediastinal route provides better long-term functional outcomes after surgery than the anterior mediastinal route. Thus, in this study, we compared these reconstruction routes used for colon interposition, with or without the supercharge technique, in patients with a history of distal gastrectomy, who have undergone colon interposition after esophagectomy.

METHODOLOGY

We retrospectively studied 30 patients who underwent esophagectomy with colon interposition. These patients were divided into 2 groups based on the reconstruction route: the anterior mediastinal or subcutaneous route (A group), or the posterior mediastinal route (R group).

RESULTS

Anastomotic leakages were observed in 4 patients (26.7%) in the A group and in 1 patient (6.7%) in the R group.

CONCLUSIONS

Ischemia is not always the result of arterial failure, but may also originate from venous blood flow impairment due to injury or distortion of veins.

Spleen enlargement after distal gastrectomy in patients without hepatitis

BACKGROUND/AIMS

Platelet count-to-spleen diameter ratio is reported to be the best non-invasive predictor of esophageal varices in cirrhotic patients. However, spleen enlargement is frequently detected during follow-up of patients after gastrectomy. Thus, we studied the relationship of the platelet count-to-spleen diameter ratio with the development of esophageal varices after distal gastrectomy in patients without liver cirrhosis or hepatitis.

METHODOLOGY

We retrospectively studied 64 patients who underwent distal gastrectomy. Their platelet counts, spleen diameters and platelet count-to-spleen diameter ratios were correlated with the occurrence rate of esophageal varices after the surgery.

RESULTS

Esophageal varices were not detected during the first 6 months after surgery; however, esophageal varices were detected in 2 patients (3%) at 12 months after surgery and their mean platelet count-to-spleen diameter ratio was 2,628 ± 409.

CONCLUSIONS

The platelet count-to-spleen diameter ratio is a useful parameter for non-invasive prediction of esophageal varices after distal gastrectomy. In addition, we suggest that the occurrence rate of esophageal varices increases beyond 6 months after distal gastrectomy and when the platelet count-to-spleen diameter ratio is less than approximately 2600 and thus, endoscopy should be performed to determine the presence of esophageal varices.

Antecolic and retrocolic route on delayed gastric emptying after MSSPPD

BACKGROUND/AIMS

Previously, we developed a modified subtotal stomach-preserving pancreaticoduodenectomy for preventing delayed gastric emptying and achieved a decrease in the incidence of delayed gastric emptying. In this study, we compared the antecolic and retrocolic routes to determine which reconstruction route is better for decreasing the incidence of delayed gastric emptying in modified subtotal stomachpreserving pancreaticoduodenectomy.

METHODOLOGY

We retrospectively analyzed 42 patients who underwent modified subtotal stomach-preserving pancreaticoduodenectomy with pancreaticogastrostomy. The patients were divided into 2 groups based on type of reconstruction: the antecolic reconstruction group and the retrocolic reconstruction group. The incidence of delayed gastric emptying was determined and compared between the 2 groups.

RESULTS

The mean time during nasogastric suction and before initiation of a diet after surgery was shorter in the retrocolic reconstruction group (without significant difference); however, the mean time before oral ingestion of solid food could be safely resumed was significantly shorter in the retrocolic reconstruction group (9.7±1.2 days) than in the antecolic reconstruction group AC group (11.4±3.0 days; p<0.0112).

CONCLUSIONS

We consider retrocolic reconstruction preferable to antecolic reconstruction for preventing delayed gastric emptying in patients who have undergone modified subtotal-stomach-preserving pancreaticoduodenectomy with pancreaticogastrostomy.

Thrombocytosis following splenectomy: with or without additional organ resection

BACKGROUND/AIMS

Splenectomy is one of the main causes of reactive thrombocytosis. In most cases, thrombocytosis found incidentally is harmless and resolves spontaneously; however, extreme thrombocytosis may result in thrombotic events such as acute myocardial infarction, mesenteric vein thrombosis and pulmonary embolism. Thus, there are no clear indications for determining which patients with reactive thrombocytosis require treatment. In this study, we evaluated reactive thrombocytosis that developed after splenectomy with or without additional organ resection.

METHODOLOGY

We retrospectively studied 70 patients who underwent splenectomy. These patients were divided into 2 groups: the only splenectomy group (group A) and the splenectomy with additional organ resection group (group B).

RESULTS

Both the platelet count at 1 week and 1 month after the operation (p<0.01 and p<0.001, respectively) and the incidence rate of thrombocytosis at 1 week and 1 month (p<0.4089 and p<0.0007, respectively) were significantly higher in group A than in group B. All patients in both groups recovered from thrombocytosis without any platelet reduction therapy and there was no postoperative thrombosis.

CONCLUSIONS

Splenectomy often results in reactive thrombocytosis; however, platelet reduction therapy is not required for treating postsplenectomy reactive thrombocytosis.

Jejunal scarf-covering method in pancreaticojejunostomy after total gastrectomy

Pancreatic fistula is the most serious postoperative complication after pancreaticoduodenectomy, and it leads to intra-abdominal abscess, sepsis, hemorrhage and high mortality. To prevent pancreatic fistula, wrapping of skeletonized vessels and the anastomotic site of the pancreaticoenterostomy using the round ligament, greater omentum, or both has been evaluated. However, the round ligament and greater omentum have already been resected in patients who have previously undergone total gastrectomy, making them unavailable in pancreaticoduodenectomy. Therefore, we developed a procedure for wrapping the anastomotic site of the pancreaticojejunostomy using the jejunum, namely the 'jejunal scarf-covering method' as a novel technique to prevent pancreatic fistula following pancreaticoduodenectomy in patients who have previously undergone total gastrectomy.

Gastric marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy due to delayed gastric emptying and Helicobacter pylori infection

BACKGROUND/AIMS

Marginal ulceration and delayed gastric emptying are considerable problems after pancreaticoduodenectomy. Helicobacter pylori (HP) are well known to be associated with gastritis, gastric ulcer and gastric cancer. Thus, we studied the relationship between marginal ulceration and delayed gastric emptying in the early postoperative period after pancreaticoduodenectomy with pancreaticogastrostomy.

METHODOLOGY

We retrospectively studied 58 patients who underwent pancreaticoduodenectomy with pancreaticogastrostomy. On the basis of the grade of delayed gastric emptying, these patients were divided into 2 groups-WS group; without/with slight delayed gastric emptying and MS group; moderate/severe delayed gastric emptying.

RESULTS

Two patients (3.4%) developed postoperative marginal ulcer, these 2 patients had no HP infection; moreover, they belonged to the MS group. Five patients in the WS group were infected with HP; although, postoperative marginal ulceration did not develop in these 5 patients.

CONCLUSIONS

Delayed gastric emptying might be a stronger promoting factor of postoperative marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy rather than HP infection and prevention of delayed gastric emptying is important to reduce the occurrence rate of postoperative marginal ulcer. Our modified subtotal stomach-preserving pancreaticoduodenectomy is a useful procedure for preventing delayed gastric emptying and postoperative marginal ulcer after pancreaticoduodenectomy with pancreaticogastrostomy.

Open pancreatic stenting with duct-to-mucosa anastomosis for pancreatic-duct obstruction after pancreaticoduodenectomy with pancreaticogastrostomy

Pancreatic-duct dilatation is frequently observed in the patients who have undergone pancreaticoduodenectomy (PD). Pancreaticodigestive anastomotic stricture may occasionally develop after PD. Stenosis of the pancreaticoenterostomy induces obstructive chronic pancreatitis, which occurs due to primary stenosis or obstruction of the main pancreatic duct and causes in inflammation of the distal pancreas. The patency of the pancreaticoenterostomy is one of the most important factors affecting the functioning of the remnant pancreas and the quality of life. Endoscopic dilatation is one of the treatment options for stenosis of pancreaticogastrostomy (PG). However, the failure of endoscopic dilatation necessitates surgical approaches. We have described our technique of open pancreatic stenting with a duct-to-mucosa anastomosis for a case which the stenosis of PG could not be resolved by endoscopic dilatation. This technique dose not require re-resected PG or side-to-side pancreaticojejunostomy: the risk of anastomotic leakage is quite low and the procedure is minimally invasive.

Advantages of jejunal pouch in Roux-en-Y reconstruction

BACKGROUND/AIMS

To improve the quality of life of patients after total gastrectomy, various pouch-reconstruction techniques have been developed. However, pouch reconstruction is technically challenging and remains controversial. We therefore, determined the efficacy of the addition of a jejunal pouch to Roux-en-Y reconstruction after total gastrectomy.

METHODOLOGY

We retrospectively studied 68 gastric cancer patients who had undergone total gastrectomy with simple Rouxen- Y reconstruction (RY group) or with Roux-en-Y reconstruction and jejunal pouch (JP group).

RESULTS

Six months after discharge from the hospital, the mean total serum albumin level was significantly lower in the RY group than in the JP group, but the mean weight loss and incidence of reflux esophagitis did not differ between the 2 groups.

CONCLUSIONS

The addition a jejuna pouch to Roux-en-Y reconstruction provides better reservoir function, but does not influence the incidence of reflux esophagitis. The construction of new fundus-like jejunal plication and the smooth passage of food from the esophagus to the jejunum prevent reflux esophagitis after total gastrectomy.

Primary vs. secondary anastomosis for superior mesenteric arterial occlusion

BACKGROUND/AIMS

Superior mesenteric arterial occlusion (SMAO) often requires massive bowel resection. We compared primary anastomosis with open abdominal surgery and secondary anastomosis after enterostomy creation for the management of SMAO.

METHODOLOGY

We retrospectively studied 27 patients who underwent massive bowel resection for SMAO; the patients were divided into 2 groups depending on the operative procedure: primary anastomosis with open abdominal surgery (P group) and secondary anastomosis after enterostomy creation (S group).

RESULTS

The mean duration from the initial operation to final operation (closure of open abdomen or closure of enterostomy) was significantly shorter in the P group (4.6±0.9 days) than in the S group (26.8±9.4 days) (p<0.0001). No disease recurrence was observed in either group; however, 2 patients died of multiple organ failure in the S group.

CONCLUSIONS

Primary anastomosis with open abdominal surgery is useful for patients with low acute physiology and chronic health evaluation (APACHE) II scores and secondary anastomosis should be performed in patients with high APACHE II scores. Further, it is important to perform timely enterostomy closure on the basis of precise examination of blood flow in the remnant bowel to avoid deterioration in the patients' quality of life.

Hand-assisted laparoscopic hepatectomy for primary clear cell hepatocellular carcinoma of the liver

We report a case of primary clear cell hepatocellular carcinoma of the liver (PCCCL) for which we performed hand-assisted laparoscopic hepatectomy. A 71-year-old female with hepatitis C infection and diabetes mellitus was admitted to our department for a hepatic tumor with gallstone. Abdominal computed tomography revealed a tumor 25 mm in diameter on the surface in segment 5 of the liver. The imaging results suggested small hepatocellular carcinoma located on the surface in segment 5 of the liver, and we performed laparoscopic surgery aiming at a minimally invasive procedure. We performed laparoscopic cholecystectomy and hand-assisted laparoscopic hepatectomy. Histopathological findings showed moderately differentiated hepatocellular carcinoma, and as the proportion of clear cells was 75%, the tumor was diagnosed as PCCCL. This is the first report of hand-assisted laparoscopic hepatectomy for PCCCL. Laparoscopic hepatectomy is a useful minimally invasive surgical procedure when the tumor is located on the surface of the liver.

Percutaneous drainage in conservative therapy for perforated gastroduodenal ulcers

BACKGROUND/AIMS

The management of peptic ulcers has dramatically changed and the incidence of elective surgery for gastroduodenal peptic ulcers has markedly decreased; hence, the incidence of emergency surgery for perforated peptic ulcers has slightly increased. In select cases, conservative therapy can be used as an alternative for treating perforated gastroduodenal ulcers. In this study, we evaluated the efficacy of percutaneous abdominal drainage for the conservative treatment of perforated gastroduodenal ulcers.

METHODOLOGY

We retrospectively studied 51 patients who had undergone conservative therapy for perforated gastroduodenal ulcers. These patients were divided into 2 groups on the basis of the initial treatment with conservative therapy with or without percutaneous drainage: group PD included patients who had undergone percutaneous drainage and group NPD, patients who had undergone non-percutaneous drainage.

RESULTS

In the PD group, 14.3% (n=3) of the patients did not respond to conservative therapy, while this value was 43.3% (n=13) in the NPD group. The 2 groups differed significantly with respect to conversion from conservative therapy to surgery (p<0.0352).

CONCLUSIONS

Conservative therapy for perforated gastroduodenal ulcers should be performed only in the case of patients meeting the required criteria; its combination with percutaneous intraperitoneal drainage is effective as initial conservative therapy.

Cholecystitis, cholelithiasis and hyperbilirubinemia after esophagectomy

BACKGROUND/AIMS

A high incidence of hyperbilirubinemia and an increased incidence of gallbladder disorders after esophagectomy have been reported. Moreover, several studies have documented an increased incidence of gallbladder disease in patients receiving long-term total parenteral nutrition. We studied the incidence of cholecystitis and cholestasis and hyperbilirubinemia associated with total parenteral nutrition after esophagectomy.

METHODOLOGY

We retrospectively studied 42 patients who underwent esophagectomy. These patients were divided into 2 groups: the hyperbilirubinemia group and the non-hyperbilirubinemia group. The incidence of cholecystitis or cholestasis after the surgery was compared between the 2 groups.

RESULTS

The mean total serum bilirubin level of the hyperbilirubinemia group (2.40±0.35mg/dL) was significantly higher than that of the non-hyperbilirubinemia group (1.20±0.34mg/dL; p<0.0001). No significant differences were observed between the 2 groups with respect to the mean duration for which total parenteral nutrition was required around the time of the operation (i.e. pre- and postoperatively) and the incidence rate of cholecystitis or cholestasis after esophagectomy.

CONCLUSIONS

Hyperbilirubinemia after esophagectomy was frequently observed; however, it may not contribute to gallbladder problems. We suggest that parenteral modalities such as tube feeding should be initiated soon after surgery to prevent gallbladder problems after esophagectomy.

Omental packing with continuous suction drainage following abdominoperineal resection

BACKGROUND/AIMS

Primary closure of the perineum along with drainage after abdominoperineal resection for lower rectal cancer is a widely accepted procedure but is associated with non-healing of the perineal wound a major complication. We evaluated the efficacy of omental packing and continuous suction drainage after abdominoperineal resection.

METHODOLOGY

We retrospectively studied 45 patients with adenocarcinoma of the lower rectum who underwent abdominoperineal resection, either without omental packing (NOP group) or with omental packing and continuous suction drainage (OPCD group). A pedicled omentum supplied by the epiploic arcade was conducted and drawn down through the perineal wound, over the small intestine and into the pelvis. Drains were placed on both sides of the pelvis through the perineal wall and continuous suction was performed.

RESULTS

Perineal wound infection was significantly more frequent in the NOP group (32%) than in the OPCD group (5%). Ileus was not observed in the OPCD group. The duration of hospitalization was shorter in the OPCD group (17.8±4.2 days) than in the NOP group (21.0±9.1 days).

CONCLUSIONS

Omental packing with continuous suction is useful to prevent non-healing of the perineal wound after abdominoperineal resection for lower rectal cancer.

Administration of bisphosphonates for malignant hepatic tumor with hypercalcemia

BACKGROUND/AIMS

Hypercalcemia is a paraneoplastic syndrome that is a serious condition requiring urgent treatment. We administered alendronate to hypercalcemia patients with advanced cancer with metastasized liver tumors or hepatocellular carcinoma (HCC) and then evaluated the mechanism and anticancer function of this compound.

METHODOLOGY

We retrospectively studied 17 patients with hypercalcemia associated with metastatic liver tumor or HCC. Alendronate (10mg) was administered via the intravenous route for patients with metastatic liver tumor (n=12) and via the hepatic artery for patients with HCC (n=5).

RESULTS

Intravenous administration of alendronate resulted in decrease in serum calcium levels in all patients. The serum levels of tumor markers also decreased in 66.7% (8/12) of these patients. After intra-arterial alendronate administration, the serum calcium and parathyroid hormone-related protein levels decreased in all the patients. The serum levels of tumor markers such as AFP and PIVKA-II were decreased in 80% (4/5) of these patients. Electron microscopic examination of the resected hepatic tumor revealed an increase in the vascularization and formation of apoptotic vesicles in the vascular endothelial cells.

CONCLUSIONS

Alendronate is effective not only for controlling hypercalcemia but also for directly enhancing the apoptosis of HCC cells.

Laparoscopic cystogastrostomy via the posterior approach for pancreatic pseudocyst drainage

BACKGROUND/AIMS

The treatment of pancreatic pseudocysts is still being debated. Laparoscopic treatment of pancreatic pseudocysts enables definitive drainage with faster recovery. Moreover, the best drainage technique for pseudocysts located adjacent to the posterior gastric wall is pseudocystgastrostomy. Although, drainage via the anterior approach has been frequently reported, reports on the posterior approach are rare. Here, we evaluated the efficacy of the posterior approach technique for pancreatic pseudocyst drainage.

METHODOLOGY

We retrospectively studied 28 patients who underwent cystogastrostomy for pancreatic pseudocysts: they were divided into the conventional cystogastrostomy group (CCG group) and the laparoscopic cystogastrostomy via the posterior approach group (LCGP group).

RESULTS

The mean operative time was significantly shorter, blood loss was significantly reduced, and the duration of hospitalization after surgery was significantly shorter in the LCGP group than in the CCG group. Recurrence was observed in 1 patient (5.6%) in the CGP group; it was an asymptomatic recurrence that did not require additional treatment. In contrast, there was no recurrence in the LCGP group patients.

CONCLUSIONS

We think that our technique of performing laparoscopic cystogastrosotmy via the posterior approach is easy and feasible for pancreatic pseudocyst drainage.

Laparoscopic transhiatal approach for cardiac cancer with lower esophageal invasion for patients with compromised respiratory function

BACKGROUND/AIMS

The thoracoabdominal approach with extended abdominal incision and a left thoracotomy is the traditional approach for the treatment of cardiac cancer with lower esophageal invasion. However, this procedure entails high morbidity and mortality. We evaluated the effectiveness of the laparoscopic transhiatal approach without a thoracotmy.

METHODOLOGY

We retrospectively analyzed the data obtained from 40 patients who underwent total gastrectomy with lower esophagectomy for cardiac cancer with lower esophageal invasion. These patients were divided into 2 groups: patients who underwent surgery via the conventional thoracoabdominal approach with extended abdominal incision and a left thoracotomy group (CTA group) and patients who underwent surgery via the laparoscopic transhiatal approach without a thoracotomy group (LTH group).

RESULTS

All the LTH group patients were successfully treated without a thoracotomy. The 1- second forced expiratory volume was significantly lower in LTH group than in CTA group. No difference was observed between the groups with respect to the mean length of resected esophagus. The LTH group patients did not develop postoperative pneumonia.

CONCLUSIONS

The laparoscopic transhiatal approach is safe and feasible for the resection of gastric cardiac cancer with lower esophageal invasion in patients with compromised respiratory function.

Common bile duct dilatation after cholecystectomy: open versus laparoscopic procedure

BACKGROUND/AIMS

Cholecystectomy as a factor causing common bile duct (CBD) dilatation has been debated. The aim of this study was to investigate CBD dilatation after cholecystectomy in patients with a preoperative CBD diameter of <6mm.

METHODOLOGY

We retrospectively analyzed the cases of 101 patients who underwent cholecystectomy. These patients were divided into 2 groups, the open cholecystectomy group (OC group) and the laparoscopic cholecystectomy group (LC group).

RESULTS

The postoperative mean CBD diameter was 5.80±0.49mm in the OC group and 5.75±0.47mm in the LC group; the diameters were not significantly different between the 2 groups (p<0.6699). With regard to the change in body weight after surgery, in the OC group 71.1%, patients gained weight, 20% showed no change and 8.9% lost weight; the corresponding numbers in the LC group were 75%, 23.2% and 1.8% patients, respectively. Thus, there were no significant differences in terms of weight changes between the 2 groups (p<0.6607, p<0.6973 and p<0.1690, respectively).

CONCLUSIONS

For patients with preoperative CBD diameters of <6mm no compensatory dilatation occurs after open or laparoscopic cholecystectomy.

Technical considerations in laparoscopic staging for advanced gastric cancer

BACKGROUND/AIMS

Staging laparoscopy is useful for increasing the accuracy of preoperative tumor staging. Diagnostic laparoscopy has therefore been introduced to prevent unnecessary laparotomy in patients with unresectable cancers. However, the technique of laparoscopic observation remains controversial. In this study, we determined the efficacy of hand-assisted laparoscopic staging.

METHODOLOGY

We retrospectively studied 44 patients who underwent conventional (LS group) or hand-assisted laparoscopic staging (HALS group).

RESULTS

The T factors of the TNM staging system was accurately determined in 95% of the patients in the HALS group and 58.3% of the patients in the LS group (p<0.0060). A total of 33.3% tumors in the LS group and 10% in the HALS group were judged to be unresectable. The overall mean survival was longer in the HALS group (20.3±12.2 months) than in the LS group (15.8±11.9 months).

CONCLUSIONS

Laparoscopic diagnosis and staging of advanced gastric cancer are reliable. Moreover hand-assisted laparoscopic staging enables the accurate assessment of tumor resectability.

Pancreatic duct patency after pancreaticoduodenectomy for dilated pancreatic ducts

BACKGROUND/AIMS

It is important to prevent pancreatic leakage and maintain pancreatic duct patency after pancreaticoduodenectomy (PD). We used an implantation method and a pancreatic stent in pancreaticogastrostomy (PG) and achieved good results without pancreatic leakage; however, PG strictures were observed in some cases. Using a pancreatic stent, we evaluated the early postoperative changes in the remnant pancreatic duct diameter in patients with a mildly dilated pancreatic duct.

METHODOLOGY

We retrospectively analyzed 46 patients with a mildly dilated pancreatic duct (diameter 4-7mm) who underwent PD with PG. They were divided into 2 groups on the basis of the surgical treatment they received for pancreatic stump: Group C included patients who underwent complete ligation of the pancreatic duct with a pancreatic stent (complete external drainage of the pancreatic juice), and Group I included patients who underwent pancreatic duct-to-mucosa anastomosis with a pancreatic stent (incomplete external drainage of the pancreatic juice).

RESULTS

The postoperative mean diameter of the remnant pancreatic duct was significantly smaller in Group I (6.22±0.81mm) than in Group C (6.80±1.10mm) (p<0.0466).

CONCLUSIONS

To prevent pancreatic leakage and maintain pancreatic duct patency, duct-to-mucosa anastomosis with a pancreatic stent is useful for patients with a dilated pancreatic duct.

Palliative enteric bypass for malignant gastric outflow obstruction after pancreaticoduodenectomy in early recurrent pancreatic cancer

BACKGROUND/AIMS

Recurrent pancreatic cancer has a poor prognosis and there are no established therapeutic strategies. We retrospectively studied patients who underwent palliative surgery for recurrent disease with gastric outlet obstruction (GOO) after an initial pancreaticoduodenectomy (PD) for pancreatic cancer.

METHODOLOGY

We retrospectively studied 4 patients who had undergone a bypass operation, including a modified Devine gastrojejunostomy with vertical stomach reconstruction (MDVSR) for GOO to ensure a direct dietary route to the jejunum, thereby, enabling the gastric contents to easily reach the jejunum.

RESULTS

MDVSR was performed in 4 patients, and in addition to the bypass, 1 patient underwent a jejunojejunostomy, and 1 patient an ileocolostomy. The median operative time and blood loss were 123min (range, 95-150 min) and 164mL (range, 115-235 mL). After the second surgery, 2 of 4 patients received chemotherapy (1 patient: gemcitabine + S1, 1 patient: gemcitabine alone). The remaining 2 patients did not receive chemotherapy. The mean survival after the second operation was 145 days (range, 34-386 days).

CONCLUSIONS

Palliative surgery including MDVSR is useful to improve a patient's nutritional state and it is more effective than chemotherapy for treating recurrent disease with GOO after a PD for pancreatic cancer.

A new surgical technique of transduodenal pancreatic juice drainage prevents pancreatic fistula following distal pancreatectomy

Although, a variety of techniques have been described to reduce the risk of postoperative pancreatic fistula, there is no consensus on appropriate technique for closure of the pancreatic remnant after distal pancreatectomy. We developed a new surgical technique, transduodenal pancreatic juice drainage, for preventing postoperative pancreatic fistula. The procedure involves a transduodenal approach. A pancreatic stent was inserted into the main pancreatic duct from the papilla of Vater to its the distal side, and continuous suction drainage was performed. The pancreatic parenchyma was divided using a knife, and the main pancreatic duct was ligated. The cut surface of the remaining pancreas was closed by hand suturing. This procedure was performed on 10 patients, and none of them developed clinical postoperative pancreatic fistula. We consider our transduodenal pancreatic juice drainage technique to be an effective procedure for preventing postoperative pancreatic fistula in patients who have undergone distal pancreatectomy.

Modified duval procedure for small-duct chronic pancreatitis without head dominance

BACKGROUND/AIMS

In the case of small-duct chronic pancreatitis, surgery for pain relief is broadly divided into resection and drainage procedures. These procedures should be selected according to the location of dominant lesion, diameter of the pancreatic duct and extent of the disease. The appropriate procedure for the treatment of small-duct chronic pancreatitis, especially small-duct chronic pancreatitis without head dominance, remains controversial. We developed the modified Duval procedure for the treatment of small-duct chronic pancreatitis without head dominance and determined the efficacy of this procedure.

METHODOLOGY

We retrospectively studied 14 patients who underwent surgical drainage with or without pancreatic resection for chronic pancreatitis with small pancreatic duct (<7mm) without head dominance. These patients were divided into 2 groups; the modified Puestow procedure group and the modified Duval procedure group.

RESULTS

No complications occurred in the modified Duval group. In the modified Puestow procedure group, complete and partial pain relief were observed in 62.5%, and 37.5% of patients respectively. In contrast, complete pain relief was observed in all the patients in the modified Duval procedure group.

CONCLUSIONS

Our modified Duval procedure is useful and should be considered the appropriate surgical technique for the treatment of small-duct chronic pancreatitis without head dominance.

Delayed gastric emptying accelerates pancreatic anastomotic stricture formation after pancreaticogastrostomy for soft pancreas

BACKGROUND/AIMS

Pancreatic duct dilatation induced anastomotic stenosis of the pancreatic duct is frequently observed in patients who have undergone pancreaticoduodenectomy (PD) with pancreaticogastrostomy (PG). Patency of the pancreaticoenteric anastomosis is one of the most important factors affecting the function of the remnant pancreas and quality of life. Anastomotic stenosis after PG is observed in some patients after approximately 1 to 2 postoperative weeks and is attributed to acute inflammation and fibrosis around the anastomosis. We therefore evaluated the early postoperative changes in remnant pancreatic duct diameter after PG in patients with soft pancreas in terms of delayed gastric emptying (DGE).

METHODOLOGY

We retrospectively studied 42 patients with soft pancreas who underwent PD with PG. They were divided into 2 groups depending on the grade of DGE; without or slightly DGE group (WS group) and moderate or severe DGE group (MS group).

RESULTS

The mean diameter of the pancreatic duct of the remnant pancreas was significantly smaller in the WS group than in the MS group.

CONCLUSIONS

DGE accelerates pancreatic anastomotic stricture development after PG in patients having soft pancreas with a pancreatic duct with a small diameter. Hence, to maintain the pancreatic duct patency, preventing DGE is important.

Early implantation of Denver shunt

BACKGROUND/AIMS

The Denver peritoneovenous shunt is useful in the resolution of refractory ascites, because it alleviates symptoms and allows effective palliation. However, this shunt did not prolong the life expectancy of patients with decompensated liver cirrhosis. Therefore, when deciding whether or not to implant a Denver shunt, it is important to determine the condition of the patient with refractory ascites. Here, we determined the appropriate time for Denver shunt implantation.

METHODOLOGY

We retrospectively studied 21 patients who underwent Denver shunt implantation for hepatic failure-related ascites. The patients were divided into PC and WPC groups depending on whether or not paracentesis was performed before implantation of the Denver shunt, respectively.

RESULTS

The mean interval from hospital admission to Denver shunt implantation was significantly shorter in the WPC group (9.0±2.2 days) than in the PC group (25.9±5.9 days) (p<0.0001). The mean survival time was significantly longer in the WPC group (8.4±2.5 months) (p<0.0071) than in the PC group (5.6±1.7 months).

CONCLUSIONS

Early implantation of a Denver shunt should be considered for the treatment of ascites that is resistant to conservative medical therapy.

Double stents: airway stenting after esophageal-stent implantation for esophageal cancer

BACKGROUND/AIMS

Esophageal stenting with self-expandable metallic stents can effectively relieve malignant esophageal strictures in patients in whom chemoradiotherapy has failed. However, airway stenosis can sometimes occur after esophageal stenting. This study aims to evaluate the efficacy of double stents (combined esophageal and airway stents) in patients with recurrent and unresectable esophageal carcinoma in whom definitive chemoradiotherapy has failed.

METHODOLOGY

We retrospectively studied 35 patients who underwent esophageal stenting for recurrent esophageal carcinoma after failure of chemoradiotherapy. These patients were divided into 2 groups; the E group, consisting of patients who underwent esophageal stenting alone and the D group, consisting of patients who required airway stenting after esophageal stenting due to airway compression. Bronchoscopy was performed before esophageal stenting in all patients.

RESULTS

In all 5 patients developed airway stenosis after esophageal stenting. With regard to the bronchoscopic findings before esophageal stenting, the incidence of category-2b findings was significantly higher in the D group than in the E group. Mean survival was 60 days (range 24-102 days).

CONCLUSIONS

Accurate bronchoscopic examination with special attention to compression of the airway should be performed before esophageal stenting in patients in whom the bronchoscopic findings are classified as category 2b or higher.

Multiple Gastric Carcinomas Associated with Potter Type III Cystic Disease

We report a case of multiple gastric carcinomas associated with Potter type III cystic disease of the liver, mesenterium and kidney. A 65-year-old man with chronic renal failure due to polycystic kidneys and under hemodialysis treatment 3 times a week for 2 years was admitted to our hospital because of anemia. He stated that his sister had suffered from polycystic kidney disease. Gastrointestinal fiberscopy showed two lesions in the lesser curvature in the lower portion of the stomach, and histopathological analysis of the gastric tumor biopsies revealed that one of the tumors was a papillary adenocarcinoma and the other a poorly differentiated adenocarcinoma. Helicobacter pylori infection was not detected in the stomach mucosa. Abdominal computed tomography scan revealed polycystic lesions in the liver, mesenterium and both kidneys. These imaging findings and family history suggested that the patient suffered from multiple gastric carcinomas associated with Potter type III cystic disease of the liver, mesenterium and kidney. Reports on the association of malignant neoplasm with Potter type III cystic disease are extremely rare. Especially, no case of the association of gastric carcinoma with Potter type III cystic disease of the liver and kidney has been described previously. This is a first report of the association of gastric carcinoma with Potter type III cystic disease. We also review reports of other malignant neoplasms associated with polycystic disease.

Modified Cattell's reconstruction with pancreaticogastrostomy following pylorus-preserving pancreaticoduodenectomy for a patient with gastroptosis

Gastroptosis is a condition in which the stomach is enlarged and located in an abnormally low position, which impedes normal stomach function. A patient with gastroptosis has equivocal complaints such as nausea, stomach fullness and abdominal pain. Pylorus-preserving pancreaticoduodenectomy (PPPD) has a better outcome than the Whipple procedure in terms of operative mortality and morbidity, and postoperative nutritional state. However, delayed gastric emptying (DGE) is frequently observed after PPPD. If PPPD is performed for a patient with gastroptosis, the risk of postsurgical DGE may increase. Therefore, we have developed a modified Cattell's reconstruction with pancreaticogastrostomy (PG) after PPPD to prevent DGE in a patient with gastroptosis and adenocarcinoma of the ampulla of Vater.

Sutureless compression anastomosis with a biofragmentable anastomosis ring

BACKGROUND/AIMS

Many studies have reported the safety and effectiveness of biofragmentable anastomotic rings (BARs). However, these devices are not widely used, especially in Japan. Therefore, we considered the clinical benefits of BARs and the reasons for their unpopularity.

METHODOLOGY

We retrospectively examined 61 patients who underwent sigmoidectomy (34 patients) or high anterior resection (HAR) (27 patients). The patients were divided into 4 groups: sigmoidectomy and anastomosis with a BAR (SB group), sigmoidectomy and anastomosis with an end-to-end (EEA) stapler (SE group), HAR and anastomosis with a BAR (HARB group), and HAR and anastomosis with an EEA stapler (HARE group).

RESULTS

The time required for anastomosis was significantly lower in the HARE group than in the HARB group. The incidence of anastomotic stricture formation was significantly lower in the HARB group, however the duration of hospitalization after surgery was significantly longer in the HARB group rather than in the HARE group.

CONCLUSIONS

BARs are unpopular because of the long interval between surgery and the passage of the device in the feces, and because compared to BARs, staplers are easy to manipulate in the narrow pelvic space.