Safe approach to the splenic hilum by first mobilizing the pancreatic tail in laparoscopic splenectomy

INTRODUCTION

We employed a safe approach during laparoscopic splenectomy by first mobilizing the pancreatic tail and then dissecting the splenic vessels at the splenic hilum before mobilizing the spleen.

MATERIALS AND SURGICAL TECHNIQUE

Patients were placed in the lithotomy position, and only the upper body was twisted to the right side. Five trocars were placed. After the bursa omentalis was opened, an avascular layer was identified behind the pancreas. This avascular layer was bluntly dissected, and the pancreatic tail was isolated from the retroperitoneum. The tissue surrounding the splenic hilum was dissected by a handling tape that was placed around the pancreatic tail. Because the spleen remained connected to the retroperitoneum with the splenorenal ligament, a good operative view of the splenic hilum was obtained with proper extension. After sufficient space was secured between the pancreatic tail and the spleen, the splenic vessels were divided with a linear stapler. The spleen was detached in the final stage.

DISCUSSION

The current standardized procedure is highly recommended for a safe laparoscopic splenectomy.

[Neoadjuvant Chemotherapy Using S-1 for Pancreatic Cancer - Mid-Term Results]

BACKGROUND

Although surgical resection is the only curative strategy for pancreatic cancer, the prognosis of patients with pancreatic cancer remains poor. Recently, neoadjuvant treatment has been frequently employed as a promising treatment. Here, the mid-term results of neoadjuvant chemoradiotherapy(NACRT)using S-1, which has been performed in our hospital since 2008, are reported.

METHODS

Seventy-nine patients with resectable or borderline resectable pancreatic ductal adenocarcinoma, who had been intended to undergo NACRT treatment using S-1, were enrolled. The NACRT comprised radiotherapy( 1.8 Gy×28 days)and full-dose twice-daily oral S-1 given on the same days as the radiotherapy. The results of the NACRT and pancreatectomy and the patients' prognoses were evaluated.

RESULTS

Fifty-five patients(69.6%)underwent pancreatectomy, with no case of mortality. The curative resection rate was 94.5%. Postoperative adjuvant chemotherapy was administered in 46 patients(83.6%). The 3-year survival rates of all 79 patients and 55 pancreatectomy patients were 40.1% and 50.4%, respectively.

CONCLUSION

NACRT using S-1 was found to be feasible, and good mid-term outcomes were obtained. However, analysis of the long-term outcomes and comparisons with other novel anti-cancer drugs are still required.

The impact of the Japanese clinical guidelines on the clinical management of patients with acute cholecystitis

Background/purpose

The Japanese clinical guidelines for treating acute cholecystitis (AC), proposed in 2005, provide criteria not only for diagnosis, but also for management depending on the severity of the disease. The aim of this study was to assess how the Japanese guidelines for AC have impacted the clinical situation in Japan.

Methods

A postal questionnaire was sent to the councillors of the Japanese Society of Abdominal Emergency Medicine three times to ascertain the impact of the Japanese guidelines for AC. We surveyed 291 councillors one year before publication of the guidelines (2004), 279 councillors one year after publication (2006), and 191 councillors six years after publication (2011).

Results

The response rate was 72.5 % one year before publication of the guidelines, 51.9 % one year later and 69.1 % six years after publication.

Early cholecystectomy was used by 41.7 % of the respondents one year before publication, while 57.3 % of the respondents used this treatment one year after publication and 62.3 % of the respondents used it six years after publication. Laparoscopic cholecystectomy was used by 79.1 % of the respondents one year before the guidelines were published, while 87.3 % of the respondents used it one year after publication and 90 % of the respondents reported its use six years after publication.

Conclusions

The Japanese guidelines for AC are increasingly used and have changed the clinical management of patients with AC. The use of early and laparoscopic cholecystectomy for treating patients with AC has been increasingly adopted in Japan.

Drain selection reduces pancreatic fistulae risk: a propensity-score matched study

BACKGROUND/AIMS

Appropriate drainage management after pancreaticoduodenectomy (PD) is important to prevent and manage serious complications. This prospective study evaluated postoperative complications with either closed or open drainage placement after PD.

METHODOLOGY

The incidence of postoperative complications in patients of PD, assigned to 2 groups of closed- and open-drain systems based on assessment periods, were investigated using propensity scores matching (PSM) after accounting for potential covariates.

RESULTS

Baseline characteristics were comparable in both groups of patients [n = 100; open, 36; closed, 64). Pancreatic fistulae requiring clinical treatment, and wound infection, were found in 33.3% and 15.6%, and 22.2% and 0%, of patients in open- and closed-drainage groups, respectively. Drainage fluid culture showed exogenous infection (63.6% of bacteria) in the open-drain group which was absent in the closed-drainage group. PSM cohorts had 26 patients in either group. Following PSM, pancreatic fistulae requiring treatment were found in 12/26 (46.2%) and 3/26 (11.5%) of patients in the open- and closed-drain groups (RR, 0.25, 95% CI, 0.08-0.81), respectively. Intra-abdominal abscess (5/26 [19.2%]) and wound infection (7/26 [26.9%]) were found in the open-drain group only.

CONCLUSION

These results indicate postoperative retrograde infections may be prevented, and the incidence of pancreatic fistula reduced, with a closed drainage system.

Successful treatment of gallbladder dyskinesia by laparascopic cholecystectomy: Report of a case

A 75-year-old woman entered the hospital emergency room complaining of severe epigastric pain. She had experienced similar repeated abdominal pain for some time. Biliary tract dyskinesia was suspected based on the Roma III criteria. When drip infusion cholangiography-CT with egg yolk load was performed, the contraction rate of the gallbladder before and after applying the load was as low as 33.5%. Upon biliary tract scintigraphy, biliary excretion into the intestinal tract was found to be normal, but after the egg yolk load, the biliary excretion rate in the gallbladder decreased to 14.5%. Laparoscopic cholecystectomy was performed under a diagnosis of flaccid-type gallbladder dyskinesia. A few reports exist describing cases in which cholecystectomy was performed for gallbladder dyskinesia, so we are submitting this report with some bibliographic consideration.

AKT activation and telomerase reverse transcriptase expression are concurrently associated with prognosis of gastric cancer

AKT is a protein in the phosphatidylinositol-3 kinase (PI3K) pathway and associated with diverse pro-tumoral responses. Activation of the human telomere reverse transcriptase (hTERT) is one of AKT's tumorigenic effects. In this study, the significance of AKT phosphorylation and hTERT on prognosis of gastric cancer were examined. AKT activation by epidermal growth factor increased hTERT expression and telomerase activity. In contrast, AKT inactivation by inhibitors and knockdown decreased hTERT expression and telomerase activity in MKN28 gastric cancer cells. In 40 gastric cancer tissues, significant correlations were found among the levels of phosphorylated AKT (pAKT), hTERT expression, and telomer length. The pAKT levels or the levels of pAKT/hTERT were not associated with clinicopathological parameters, including stage and nodal metastasis. However, survival rates of the pAKT-high patients or the pAKT-high and hTERT-high patients were significantly poorer than those in other patients. These findings suggest that AKT and hTERT are good molecular targets for the treatment of gastric cancer.

Increased phosphorylation of AKT in high-risk gastric mucosa

To establish the role of oxidative stress and v-akt murine thymoma viral oncogene homolog (AKT) activation in gastric cancer development, we examined the levels of phosphorylated AKT (pAKT), inducible nitric oxide synthase (iNOS), nitrotyrosine (NT), and human telomerase reverse transcriptase (hTERT) by enzyme-linked immunosorbent assay in 73 non-cancerous gastric mucosa and 10 gastric carcinomas. We found that the levels of pAKT were associated with the levels of iNOS, NT, and hTERT. Gastric mucosa was classified into four categories: chronic gastritis without Helicobacter pylori (CG), chronic active gastritis with H. pylori (CAG), chronic metaplastic gastritis without H. pylori (CMG), and chronic gastritis with atypia without H. pylori (CGA). We found increasing levels of pAKT, iNOS, and NT in the order of CG, CAG, CMG, and CGA. hTERT was detected only in CGA. These findings suggest that oxidative stress might be associated with AKT activation and hTERT induction and that mucosa in CGA might confer a high-risk status for gastric carcinogenesis.

Significance of epithelial growth factor in the epithelial-mesenchymal transition of human gallbladder cancer cells

Five gallbladder cancer (GBC) cell lines were examined for morphological changes in collagen gel culture. GBh3 and HUCCT-1 cells formed tubules in response to treatment with epithelial growth factor (EGF) and hepatocyte growth factor (HGF), and showed high levels of expression of E-cadherin (ECD), and low levels of SNAIL, vimentin, transforming growth factor (TGF)-β, and nucleostemin (NS). In contrast, the GBd15 and FU-GBC-1 cell lines treated with EGF and HGF showed a scattering phenotype, and expressed low levels of ECD and high levels of SNAIL, vimentin, TGF-β, and NS. All cell lines expressed the EGF receptor, c-Met, EGF, and TGF-α, but not HGF. Transforming growth factor-β was upregulated by EGF. Knockdown of the EGF receptor abrogated both tubule formation and scattering, whereas KD of TGF-β abrogated only scattering. Knockdown of EGF induced nuclear translocation of β-catenin and Wnt-related NS induction in the scattering cell lines, but not in the tubule-forming cell lines, whereas KD of glycogen synthase kinase-3β in the tubule-forming cell lines resulted in the nuclear translocation of β-catenin and Wnt-related NS induction in response to EGF treatment. These results suggest that EGF enhances epithelial-mesenchymal transformation and acquisition of stemness in GBC cells with a scattering phenotype through the activity of β-catenin. Repression of ECD in scattering GBC cells induced the release of β-catenin from the cell adhesion complexes along the plasma membrane and its translocation to the nucleus to activate Wnt signaling, which upregulated NS.

The efficacy of diffusion-weighted imaging for the detection and evaluation of acute pancreatitis

BACKGROUND/AIMS

Diffusion-weighted imaging (DWI) is a new magnetic resonance imaging (MRI) technique that evaluates the random motion of water molecules in biological tissues. The clinical utility of DWI has been established for acute stroke and brain tumors. Recent technical advancements in MRI have enabled DWI for the body and several studies have revealed the efficacy of DWI for detecting various diseases. This study documents the efficacy of DWI for the evaluation of acute pancreatitis.

METHODOLOGY

MRI was performed with sequences including T1-weighted, T2-weighted, diffusion-weighted imaging, MR cholangiopancreatography (MRCP) and computed tomography (CT) examinations on 11 patients with mild acute pancreatitis. MRI examinations were performed using 1.5-T imager (Toshiba, Otawara, Japan). Two experienced radiologists evaluated the presence or absence of acute pancreatitis, complications and the cause of acute pancreatitis on the MRI and CT images.

RESULTS

There were no differences between the DWI and the CT images regarding their abilities to detect acute pancreatitis. However, DWI could detect acute pancreatitis more clearly than CT without enhancing material. The DWI findings were consistent with the clinical findings, the results of chemical analyses and the CT findings. Furthermore, DWI could detect pancreatic cancer causing acute pancreatitis and MR cholangiopancreatography (MRCP) could detect choledocholithiasis and pancreas divisum causing acute pancreatitis.

CONCLUSIONS

DWI can be a powerful tool for the evaluation and follow-up of acute pancreatitis.

The efficacy of diffusion-weighted imaging for the detection of colorectal cancer

BACKGROUND/AIMS

Diffusion-weighted imaging (DWI) is a new magnetic resonance (MR) imaging technique that evaluates the diffusion of water molecules. Its clinical usefulness in the acute stage of cerebral infraction has been established. Recent technical developments have enabled DWI for human body and the usefulness of DWI for detecting malignant tumors such as liver, kidney, ovary, and breast tumors has been reported. This study documents cases of colorectal cancer detected by DWI and discusses the efficacy of DWI for the evaluation of colorectal cancer.

METHODOLOGY

DWI, computed tomography (CT) and colonoscopy examinations were performed on 18 patients with colorectal cancer. MRI examinations were performed using a 1.5-T imager (Toshiba, Otawara, Japan). The signal intensity was measured in a series of DWI and the apparent diffusion coefficient (ADC) values were calculated in order to differentiate the cancers from normal tissues. Two experienced radiologists evaluated the depth of tumor invasion into the colorectal wall (tumor staging), the involvement of regional lymph nodes (nodal staging), and the presence or absence of metastasis (metastatic staging) on DWI and CT images according to the TNM classification system. TNM staging of each tumor was compared with the pathologic and surgical findings.

RESULTS

There were no differences between the DWI and the CT images regarding their abilities to detect early colorectal cancer. However, DWI could detect advanced colorectal cancer and liver metastasis more sensitivity, or accurately than CT with no enhancing material. In one patient who did not undergo a surgical resection, a follow up DWI showed peritoneal seeding and bone metastasis.

CONCLUSION

Although DWI has a difficulty to detect early colorectal cancer, DWI has the potential to be clinically effective for the evaluation of preoperative TNM staging and the postoperative follow-up of colorectal cancer.

Acute pancreatitis successfully diagnosed by diffusion-weighted imaging: A case report

Diffusion-weighted imaging (DWI) is an established diagnostic method of acute stroke. The latest advances in magnetic resonance imaging (MRI) technology have greatly expanded the utility of DWI in the examination of various organs. Recent studies have revealed the usefulness of DWI for imaging of the liver, kidney, ovary, and breast. We report a patient with acute pancreatitis detected by DWI and discussed the efficacy of DWI in diagnosing acute pancreatitis. A 50-year old man presented with a primary complaint of abdominal pain. We performed both DWI and computed tomography (CT) for this patient. The signal intensity in a series of DWI was measured and the apparent diffusion coefficient (ADC) values were calculated to differentiate inflammation from normal tissue. Two experienced radiologists evaluated the grade of acute pancreatitis by comparing the CT findings. Initially, the pancreas and multiple ascites around the pancreas produced a bright signal and ADC values were reduced on DWI. As the inflammation decreased, the bright signal faded to an iso-signal and the ADC values returned to their normal level. There was no difference in the abilities of DWI and CT images to detect acute pancreatitis. However, our case indicates that DWI can evaluate the manifestations of acute pancreatitis using no enhancement material and has the potential to replace CT as a primary diagnostic strategy for acute pancreatitis.

Usefulness of diffusion-weighted imaging (DWI) for the detection of pancreatic cancer: 4 case reports

The clinical utility of diffusion-weighted magnetic resonance imaging (DWI) was originally established for acute stroke; however, recent studies suggest that DWI may be more sensitive and specific for the detection and staging of malignant tumors than either computed tomography (CT) or ultrasonography (US). We herein present 4 cases of pancreatic cancer that were detected by DWI and subsequently discuss the efficacy of DWI for the diagnosis pancreatic cancer. We performed both DWI and dynamic CT examinations on 4 patients with pancreatic cancer. MR examinations were performed with a 1.5-T imager (Toshiba). We measured the signal intensity in a series of DWI images and calculated the apparent diffusion coefficient (ADC) values to differentiate the tumors from normal tissue, inflammation, or another lesion. Two radiologists analyzed the DWI and CT images, and the evaluation of the primary tumor (T), regional lymph nodes (N), and distant metastatic disease (M) was conducted according to the TMN classification system. There were no differences between the DWI and the CT images regarding their abilities to detect advanced pancreatic cancer. However, DWI displayed superior ability in detecting early stage tumors and evaluating the degree of tumor invasion. DWI has the potential to be clinically effective in the detection of early pancreatic cancer, and DWI can be a powerful tool for the evaluation of pancreatic cancer.

Diffusion-weighted imaging is a feasible method for screening colorectal cancer: report of a case

The liver is one of the most common sites for metastatic disease. It is sometimes difficult to detect the primary site. We describe herein the feasibility of diffusion-weighted imaging (DWI) for searching primary site of liver metastases. A 93-year-old male patient presented to us with the chief complaints of hematochezia. Ultrasonography (US) and computed tomography (CT) showed multiple masses in the liver. However, these examinations revealed no primary tumor. DWI showed bright signal mass in the rectum. Furthermore, the apparent diffusion coefficient (ADC) map in that area was depicted as a low ADC value. A histopathological analysis demonstrated the tumor to be moderately differentiated adenocarcinoma. We consider that DWI is a feasible method for screening colorectal cancer, especially for unknown primary site cancers.

The usefulness of diffusion-weighted imaging (DWI) for the detection of gastric cancer

BACKGROUND/AIMS

Diffusion-weighted imaging (DWI) is already utilized in the important clinical diagnosis of brain ischemia and also for differentiating brain abscesses from metastatic brain tumors. Recent technical developments make DWI of the body feasible. Several studies have revealed the usefulness of DWI for the diagnosis of liver, ovary, parotid gland, kidney, and breast tumors. We herein present cases of gastric cancer detected by DWI and discuss the efficacy of DWI for the diagnosis of gastric cancer.

METHODOLOGY

We performed DWI, enhanced computed tomography (CT) and endoscopic examinations on 15 patients with gastric cancer. MR examinations were performed using the 1.5-T imager (Toshiba). We measured the signal intensity in a series of DWI images and calculated the apparent diffusion coefficient (ADC) values in order to differentiate the tumors from normal tissues and inflammations. Two experienced radiologists evaluated the depth of tumor invasion into the gastric wall (tumor staging), the involvement of regional lymph nodes (nodal staging), and the presence or absence of metastasis (metastatic staging) on DWI and CT images according to the TMN classification system. TMN staging of each tumor was compared with the pathologic and surgical findings.

RESULTS

There were no differences between the DWI and the CT images regarding their abilities to detect advanced gastric cancer. However, DWI could detect peritoneal dissemination, liver metastasis, lymph nodes metastasis without any enhancement material more clearly than CT.

CONCLUSIONS

DWI is therefore considered to have the potential to be clinically effective for the evaluation of preoperative TMN staging of gastric cancer.

Color Doppler sonographic findings in splenic hamartoma

We present the gray-scale and color Doppler sonographic findings in a case of a splenic hamartoma in a 40-year-old man. Gray-scale sonograms showed a 2 x 2 cm, hypoechoic splenic mass that was homogeneous without evidence of cystic change or calcification. Color Doppler sonograms showed multiple radial blood-flow signals inside the mass, and spectral analysis confirmed arterial and venous flow. Arteriograms showed multiple small, hypervascular masses with fine tumor vessels and tumor stains within the spleen. Histologic analysis following a splenectomy showed dilated vessels and congestion consistent with the color Doppler sonographic findings.