Natural history of asymptomatic gallbladder stones in clinic without beds: A long-term prognosis over 10 years

BACKGROUND

Several studies have explored the long-term prognosis of patients with asymptomatic gallbladder stones. These reports were primarily conducted in facilities equipped with beds for addressing symptomatic cases.

AIM

To report the long-term prognosis of patients with asymptomatic gallbladder stones in clinics without bed facilities.

METHODS

We investigated the prognoses of 237 patients diagnosed with asymptomatic gallbladder stones in clinics without beds between March 2010 and October 2022. When symptoms developed, patients were transferred to hospitals where appropriate treatment was possible. We investigated the asymptomatic and survival periods during the follow-up.

RESULTS

Among the 237 patients, 214 (90.3%) remained asymptomatic, with a mean asymptomatic period of 3898.9279 ± 46.871 d (50-4111 d, 10.7 years on average). Biliary complications developed in 23 patients (9.7%), with a mean survival period of 4010.0285 ± 31.2788 d (53-4112 d, 10.9 years on average). No patient died of biliary complications.

CONCLUSION

The long-term prognosis of asymptomatic gallbladder stones in clinics without beds was favorable. When the condition became symptomatic, the patients were transferred to hospitals with beds that could address it; thus, no deaths related to biliary complications were reported. This finding suggests that follow-up care in clinics without beds is possible.

[Surgical Outcomes and Clinicopathological Analysis of Laparoscopic Distal Pancreatectomy]

SUBJECTS

We first reviewed surgical outcomes and pathological findings of 32 patients(laparoscopic group: LDP n=11, open group: ODP n=21)who underwent distal pancreatectomy for pancreatic cancer from January 2018 to October 2022. Then we reviewed long-term outcomes, and recurrence type for 20 patients(LDP: n=5, ODP: n=15)from January 2018 to February 2021.

RESULTS

LDP group had significantly longer operation time and less blood loss. There was no difference in length of hospital stay, postoperative complications, number of dissected lymph nodes, positive lymph node metastasis rate, and adjuvant chemotherapy rate. Because of high rate of pancreatic stump closure by hand sewing in ODP, postoperative pancreatic fistula rate was higher in ODP than in LDP. The 2-year relapse-free survival rate was 60% in LDP, 33% in ODP, and the 2-year overall survival rate was 60% in LDP, 71% in ODP, and there were no significant differences. As for the type of recurrence, in LDP group, 2 cases of distant metastases and no local recurrence was observed, and in ODP group, 6 cases each of local recurrences and distant metastases were observed.

CONCLUSION

LDP was not inferior to ODP in short and long- term outcomes, safety, curability, and local control ability.

Outcomes of lung metastasis from pancreatic cancer: A nationwide multicenter analysis

BACKGROUND

Although distant metastasis from pancreatic ductal adenocarcinoma (PDAC) has a dismal prognosis, some single center studies reported that lung metastasis has a favorable prognosis. The aim of this study is to evaluate the prognostic value of site-specific metastasis after pancreatectomy for PDAC, with a focus on lung metastasis.

METHODS

Data from 117 cases of lung metastasis after pancreatectomy were collected retrospectively from 23 institutions in Japan. To compare the sites of metastasis we also collected the data of 134 patients with liver only metastasis, 67 patients with peritoneal only metastasis and 121 patients with locoregional recurrence alone.

RESULTS

In patients with lung only metastasis, the median time from recurrence to death (RTD) was 23.1 months, which was better in comparison to other sites of recurrence. In lung metastasis group, the patients who underwent pulmonary resection had better long-term outcomes in comparison to those who did not. (RTD: 29.2 vs 15.2, P < .001). In the multivariate analysis, solitary metastasis (HR 5.03; 95% CI 1.195-21.144, P = .022) and postoperative chemotherapy (HR 14.089; 95% CI 1.729-114.77, P = .023) were identified as significant prognostic factors after lung resection.

CONCLUSIONS

Surgical resection is a favorable option for selected patients with a solitary lung metastasis and for whom adjuvant chemotherapy can be administrated.

[Laparoscopic Local Gastrectomy for Gastric Schwannoma and Extramurally Developed Gastric GIST]

Among gastric submucosal tumors, neurogenic tumors are considered to be rare diseases. We experienced a case of laparoscopic local gastrectomy of gastric schwannoma coexisting with extramurally developed gastric GIST found accidentally during surgery. A 61-year-old man was pointed out a gastric submucosal tumor with a diameter of 15 mm in a medical checkup. Endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)was performed, and immunostaining showed that c-kit(-), CD34(-), S-100(+), SMA(-), MIB-1<2%. Diagnosis was gastric schwannoma. We performed laparoscopic local gastrectomy. During the surgery another extramural nodule was accidentally found with a diameter of 8 mm at the anterior wall of the gastric body near lesser curvature. Immunostaining showed c-kit(+), CD34(+)and was diagnosed GIST. Because a gastric schwannoma coexisting with GIST is a rare case, we decided to report it by adding discussion with some literatures.

[A Case of Liver Metastasis 28 Years after Resection for Gastrointestinal Stromal Tumor of Duodenum]

A 69-year-old woman underwent a pancreaticoduodenectomy at the age of 41 years for a submucosal tumor of duodenum, which was diagnosed as leiomyoma at that time. Twenty eight years later, a liver tumor, which is 10 cm in a diameter, was identified on an abdominal ultrasonography. The left hepatectomy was undertaken. Immunohistochemical examination indicated that the tumor was positive for c-kit and diagnosed as a gastrointestinal stromal tumor(GIST). The pathological reexamination revealed the primary tumor was also positive for c-kit and diagnosed as GIST. Therefore, the liver tumor was considered as a metastasis of the duodenal GIST, which was resected 28 years earlier.

[A Case Report of R0 Resection after Chemotherapy for Locally Advanced Pancreatic Head Cancer with Ureter Invasion]

A 60-year-old woman was referred to our hospital due to pancreatic head cancer with right ureter invasion. We considered that it was difficult to achieve R0 resection for the patient by operation because of a wide range of retroperitoneal invasions involving the right ureter. She was treated with chemotherapy(gemcitabine plus nab-paclitaxel: GnP). GnP therapy was administered 3-weeks on/1-week off for 1 course. After 3 courses, we performed pancreaticoduodenectomy, right nephrectomy and partial transverse colectomy. We achieved R0 resection and considered the GnP therapy to be effective.

[Primary Small-Cell Carcinoma of the Digestive Tract-An Analysis of Six Cases]

INTRODUCTION

Primary small-cell carcinomas occur commonly in the lungs but rarely in the other organs. We studied the treatment outcomes in 6 cases of primary small-cell carcinoma of the digestive tract at our hospital.

PATIENTS

Six patients were diagnosed with small-cell carcinoma of the digestive tract histopathologically and treated at our hospital from September 2000 to December 2018.

RESULTS

The average age of the patients was 61.5 years(range: 40-80 years). Patients were 3 men and 3 women. The occurrence sites were the esophagus, stomach, and colon in 1, 2, and 3 patients, respectively. The patient with esophageal cancer underwent chemoradiotherapy without surgery. Other patients, except for 1 patient with colon cancer, underwent adjuvant chemotherapy after the surgery. Two of the 6 patients survived for over 5 years.

DISCUSSION

For small-cell carcinomas of the digestive tract with poor prognosis, long-term survival can be expected using multidisciplinary treatments depending on the case.

[A Case of Pancreatic Metastasis from Colon Cancer Successfully Treated with Capecitabine/Oxaliplatin plus Bevacizumab]

A 50-year-old man underwent low anterior resection for rectal cancer. The final diagnosis was rectal cancer of pT3N0M0, fStage Ⅱ. CT performed for examination of obstructive jaundice at 17 months after surgery revealed metastatic lesions of the pancreatic head and right lung. By core needle biopsies, the lesions were pathologically diagnosed as metachronous metastases of rectal cancer. Chemotherapy was carried out but was discontinued at 5 courses due to severe side effects. The pancreatic metastasis disappeared after 11 months. As the lung metastasis remained, a right upper lobectomy was performed 1 month later. The patient remains alive without recurrence 6 months after the partial lung resection.

[A Case of Jejunal Ectopic Pancreatic Cancer with Small Bowel Obstruction]

Were port a caseof an 82-year-old man who presented with vomiting. Computed tomography(CT)revealed a jejunum tumor and small bowel obstruction. Enteroscopy revealed a protruded lesion and biopsy indicated adenocarcinoma. PET-CT revealed nothing without jejunal tumor. Therefore, with a preoperative diagnosis of primary small bowel cancer, we performed operation. Surgery indicated peritoneal disseminations and a jejunal tumor 40 cm distal from the ligament of Treitz, and we performed small bowel partial resection. Pathological examination revealed adenocarcinoma originating from a Heinrich type I ectopic pancreas in the jejunum. Ectopic pancreatic cancer in the jejunum is rare, and we review case reports in the literature.

[A Case of Successful Curative Resection Following Downsizing Chemotherapy in Initially Unresectable Locally Advanced Gallbladder Carcinoma]

A 58-year-old woman was referred to our hospital with high fever and right upper abdominal pain. Abdominal computed tomography (CT) revealed a bulky tumor of the gallbladder with liver invasion, metastases to para-aortic lymph nodes, and extensive infiltration to Glisson's sheath. The tumor was initially considered to be unresectable locally advanced gallbladder carcinoma with inflammation, and she received 6 courses of chemotherapy with gemcitabine plus cisplatin. Subsequently, the inflammation was extinguished, and CT showed the main tumor shrunk and the Glisson's sheath infiltration disappeared; however, a liver metastasis existed in segment 5. Thus, S4a plus S5 hepatic segmentectomy with extrahepatic bile duct resection and regional and para-aortic lymphadenectomy was performed. The pathological diagnosis was pT3a, pN1, pM1 (Hep, LYM), fStage ⅣB. Curative resection was then performed. If selected according to their response to downsizing chemotherapy, conversion therapy might therefore be an effective multidisciplinary treatment for patients with initially unresectable locally advanced gallbladder carcinoma.

Sustained virologic response achieved after curative treatment of hepatitis C virus-related hepatocellular carcinoma as an independent prognostic factor

BACKGROUND AND AIM

Whether an antiviral interferon (IFN)-based therapy (IBT) after curative treatment of hepatocellular carcinoma (HCC) improves the prognosis in patients with hepatitis C virus (HCV)-related HCC remains to be elucidated.

METHODS

A total of 178 patients within the Milan criteria underwent curative treatment for HCV-related HCC. Both the time to beyond the Milan criteria (TTBMC) and overall survival (OS) were compared between the sustained virologic response (SVR) (IFN with SVR, n = 22), non-SVR (IFN without SVR, n = 19), and non-IBT (control, n = 82) groups using propensity score matching analysis. Prognostic factors to predict survival were also determined by the Cox proportional-hazards model.

RESULTS

TTBMC in the IFN with SVR group was significantly longer than those in the control and IFN without SVR groups (P < 0.001 and P = 0.006, respectively), although no significant difference existed between the IFN without SVR and control groups. Similarly, OS of the IFN with SVR group was significantly longer than that of the control and IFN without SVR groups (P < 0.001 and P = 0.029, respectively), although no significant difference existed between the IFN without SVR and control groups. The Cox proportional-hazards model identified SVR as an independent prognostic factor in these patients. The IFN with SVR group showed a 0.096-fold decrease in mortality risk compared with the control group (95% confidence intervals = 0.023-0.405; P = 0.001).

CONCLUSION

Elimination of HCV after curative treatment of patients with HCC within the Milan criteria inhibits recurrence and contributes to a preferential prognosis.

Clinical efficacy of Daikenchuto for gastrointestinal dysfunction following colon surgery: a randomized, double-blind, multicenter, placebo-controlled study (JFMC39-0902)

Objective

This exploratory trial was performed to determine whether Daikenchuto accelerates recovery of gastrointestinal function in patients undergoing open colectomy for colon cancer.

Methods

A total of 386 patients undergoing colectomy at 1 of the 51 clinical trial sites in Japan from January 2009 to June 2011 were registered for the study (JFMC39-0902). Patients received either placebo or Daikenchuto (15.0 g/day, t.i.d) between post-operative day 2 and post-operative day 8. Primary end-points included time to first bowel movement, frequency of bowel movement and stool form. The incidence of intestinal obstruction was evaluated post-operatively. The safety profile of Daikenchuto until post-operative day 8 was also evaluated.

Results

The results for 336 patients (Daikenchuto, n = 174; placebo, n = 162) were available for statistical analysis. The time to first bowel movement did not differ significantly between the two groups. All patients reported having diarrhea or soft stools immediately after surgery, and the time until stool normalization (50th percentile) in the Daikenchuto and placebo groups was 6 days and 7 days, respectively. The placebo group had a significantly greater number of hard stools at post-operative day 8 (P = 0.016), and bowel movement frequency continued to increase until post-operative day 8 as well. In contrast, bowel movement frequency in the Daikenchuto group increased until post-operative day 6, however decreased from post-operative day 7 and was significantly lower at post-operative day 8 compared with the placebo group (P = 0.024).

Conclusion

The moderate effects of Daikenchuto were observed ∼1 week after the operation. Although Daikenchuto had an effect on gastrointestinal function after open surgery in patients with colon cancer, this study did not show its clinical benefits adequately.

[A case of long-term survival after aggressive surgery for Stage IV gallbladder carcinoma]

A 67-year-old woman was referred to our hospital because of a gallbladder mass. Abdominal computed tomography revealed a protruding mass 34 mm in diameter in the body of the gallbladder with wall thickening and enhancement. Advanced gallbladder carcinoma was diagnosed by image analysis, with liver metastasis in segment 5 and lymph node metastasis in the hepatoduodenal ligament. Subsequently, S4a+S5 hepatic segmentectomy was performed with extrahepatic bile duct resection and regional lymphadenectomy. The final pathological diagnosis was pT2 pN1 pM1, Stage IV,according to the International Union against Cancer classification system. Curative resection was then performed. In addition, we performed adjuvant chemotherapy with 15 courses of 1,000 mg/m2 gemcitabine on days 1, 8, and 15 at every 28 days. At 5 years after the operation, the patient was alive and free of disease. Therefore, in cases of limited liver metastasis (within segments 4a and 5), aggressive surgery should be considered even for Stage IV gallbladder carcinoma. In such cases, long-term patient survival may be expected only when curative resection is achieved.

[A case of effective multidisciplinary treatment for advanced gallbladder carcinoma with distant lymph node metastases]

A 59-year-old woman with upper abdominal pain was diagnosed as having an advanced-stage gallbladder carcinoma with significant metastases in the para-aortic lymph nodes to the more distant right external iliac nodes by imaging studies. These findings suggested that the tumor was unresectable, and therefore, palliative cholecystectomy with lymph node biopsy was performed. Furthermore, we initiated chemoradiotherapy with linac radiotherapy( 50 Gy) and weekly gemcitabine (GEM 300 mg/body) for 6 weeks. Partial response (PR) was achieved after chemoradiotherapy. Subsequently, we initiated chemotherapy with GEM alone (1,000 mg/m2) on days 1, 8, and 15, every 28 days for 15 courses. Following disease progression, we initiated chemotherapy with S-1 alone( 80 mg/m2/day) on days 1-14, every 21 days for 9 courses, as second-line treatment. Two years later, following re-progression of the disease, we performed best supportive care with retrograde ureteral stenting for hydronephrosis and retrograde biliary stenting for obstructive jaundice. The patient survived for 35 months after palliative surgery. Moreover, she remained well and performed normal activities for 34 months. This experience indicates that, in patients with unresectable gallbladder carcinoma, multidisciplinary treatment could extend survival and improve the quality of life.

Randomized, controlled trial comparing S-1 with UFT/LV as adjuvant therapy for curatively resected stage III colorectal cancer (BCOG-CC02 study)

520

Background: Oral anticancer drug, UFT/LV, has recently been reported to improve both overall survival (OS) and relapse free survival (RFS) for patients with Stage III colorectal cancer in Japan. We conducted a randomized clinical trial to compare S-1 with UFT/LV for adjuvant therapy in patients with Stage III colorectal cancer. Methods: Patients with Stage III colorectal cancer (PS, 0 to 1; age, 20 to 80 years) were randomized to take either UFT / LV (28 days per 5 weeks) for 6 months. or S-1 (28 days per 6 weeks) for 12 months started within 6 weeks following curative resection. We investigated the correlations between disease- free survival (DFS) and tissue mRNA levels of 5-FU and folate metabolism-related enzymes. In addition, we investigated overall survival (OS) and safety. Results: Between April 2008 and August 2010, a total of 145 patients were registered from 22 centers. There were no clear intergroup differences in background factors. The patients who relapsed during protocol duration of treatment were excluded, the percentages of patients who took expected dosage of medicine were 67.1% (47/70) and 87.3% (62/71) in S-1 and UFT/LV groups, respectively. Grade3 to 4 myelosuppression(4%), bilirubin(3%) and diarrhea(8%) were occurred in S-1 group whereas, grade 3 liver dysfunction (5%) and diarrhea (5%) occurred in UFT/LV group, but all of them were reversible. The median follow-up period was 934 days, 3-years’ DFS in patients of S-1 and UFT/LV groups were 65.9% and 72.7%, respectively (p=0.88). In a univariate analysis, topoisomerase-1 (TOPO-1) mRNA level was shown as a factor of the recurrences. A poor-prognosis patient population was observed in the S-1 group such as with low gamma-glutamyl hydrolase (GGH) mRNA level. Conclusions: Oral anticancer drug, S-1 showed an equivalent effect for UFT/LV in Stage III colorectal cancer as adjuvant therapy. Tissue levels of mRNA of 5-FU/ folate metabolism-related enzymes were important parameters for postoperative prognosis in patients with stage III colorectal cancer who take oral 5-FU derivatives for adjuvant therapy. Clinical trial information: UMIN000001560.

Randomized, controlled trial comparing UFT with S-1 as adjuvant therapy for curatively resected stage III colorectal cancer

515

Background: Oral anticancer drug, UFT, has recently been reported to improve both overall survival (OS) and relapse-free survival (RFS) for patients with stage III colorectal cancer in Japan. We conducted a randomized clinical trial to compare S-1 with UFT for adjuvant therapy in patients with stage III colorectal cancer.

Methods: Patients with stage III colorectal cancer (PS, 0 to 1; age, 20 to 80 years) were randomized to take either UFT (400mg/m2/day, 5days per week) or S-1 (80mg/m2/day, 28days per 6weeks) for 1 year started within 6 weeks following curative resection. The primary endpoint was to investigate relations of relapse-free survival (RFS) and tissue mRNA levels of 5-FU metabolism-related enzymes. The secondary endpoint was over all survival (OS) and safety.

Results: Between July 2005 and February 2008, a total of 100 patients were registered from 21 centers. There were no clear intergroup differences in background factors. When patients who relapsed within 1 year postoperatively were excluded, the percentages of patients who took expected dosage of medicine were 73% (30/41) and 72% (33/46) in UFT and S-1 groups, respectively. Grade 3 liver dysfunction (4%) or diarrhea (4%) occurred in UFT group, whereas grade3 to 4 myelosuppression (4%), diarrhea (4%), stomatitis (2%) were observed in S-1 group, but all of them were reversible. With a median follow-up period of 1,250 days, OS in patients of UFT and S-1 groups were 86.6% and 95.9%, respectively (p=0.06). The number of patients who relapsed in rectal cancer was significantly higher in UFT group (11/25) than in S-1 group (4/21, p<0.01). In a multivariate analysis, dihydropyrimidine dehydrogenase (DPD) mRNA level was shown as a factor of the recurrences. And S-1 improved RFS in patients with rectum cancer with high orotate phosphoribosil transferase (OPRT) mRNA level.

Conclusions: Oral anticancer drug, S-1, was no less effective than UFT as an adjuvant therapy for stage III colorectal cancer. Tissue levels of both DPD and OPRT mRNA were important parameters for postoperative prognosis in patients with stage III colorectal cancer who take oral 5-FU derivatives for adjuvant therapy.

No significant financial relationships to disclose.

[Histological complete response in a case of primary squamous cell carcinoma of the stomach treated by chemotherapy with docetaxel and cisplatin plus 5-fluorouracil]

The patient was a 68-year-old man with melena. Endoscopic examination revealed a type 2 advanced tumor in the mid body and an elevated lesion in the upper body of the stomach. Biopsy specimens from both lesions were diagnosed histologically as squamous cell carcinoma. Abdominal CT showed thickening of the midbody in the greater curvature and bulky lymph nodes along the lesser curvature (No. 3), and the greater curvature(No. 4d). We diagnosed Stage IIIB (cP0, cH0, cT4, cN1, cM0) cancer, but we concluded radical resection would be difficult due to lymph node invasion to the diaphragm and mesocolon. DCF combination therapy (docetaxel 75 mg/m2 day 1, CDDP 75 mg/m2 day 1, 5-FU 750 mg/m2 day 1-5) was administered. After 3 courses of chemotherapy, endoscopic examination and abdominal CT findings showed remarkable reduction of the primary tumor and the lymph node metastasis, indicating a partial response (PR) to the chemotherapy. After consultation with the patient, total gastrectomy with lymph node dissection (D2) was performed. The pathological specimens showed no cancer cells in the gastric wall and lymph nodes, so the histological effect was judged as Grade 3. This case suggested that DCF combination chemotherapy may prove useful to treat patients with advanced squamous cell carcinoma of the stomach.

[A successful two-stage treatment with CDDP and CPT-11 for pancreatic neuroendocrine carcinoma with liver metastasis]

A 59-year-old man was diagnosed as having a pancreatic carcinoma with synchronous liver metastasis at initial surgery. After wedge resection of liver tumor for histopathological analysis and gastro-jejunostomy, he was treated with 3 cycles of combined systematic chemotherapy consisting of CDDP and CPT-11, because of histopathological diagnosis confirming a neuroendocrine carcinoma of the pancreas. After chemotherapy, there was no recurrence and the primary tumor was reduced in size. Therefore, pancreatico-duodenectomy was performed as a curative treatment in two stages. During the follow-up, the patient has been alive without any signs of recurrence for 20 months since the diagnosis. Recently, several consecutive chemotherapies have been an effective modality to improve a poor prognosis for unresectable neuroendocrine carcinoma.

The usefulness of endoscopic transpapillary procedure in post-cholecystectomy bile duct stricture and post-cholecystectomy bile leakage

This study was conducted to examine the usefulness of endoscopic transpapillary procedure in post-cholecystectomy bile duct stricture and postcholecystectomy bile leakage. Endoscopic transpapillary procedure was performed in 18 cases of post-cholecystectomy bile duct stricture and 6 cases of post-cholecystectomy bile leakage. In the bile duct stricture cases, the patients were assessed for the stricture by endoscopic retrograde cholangiography (ERC), and then underwent endoscopic sphincterotomy (EST) for tube stent insertion. The stents was replaced every 3 to 6 months, and the treatment was continued until the patients became stent-free. Successful therapy was defined as a stent-free condition without hepatic disorder. In the bile leakage cases, the leakage was located by ERC and EST was performed. Then, endoscopic nasobiliary drainage (ENBD) tube was inserted at the proximal side of the bile leakage, and the therapeutic outcome was defined as successful if disappearance of the leakage was confirmed by cholangiography at a later date. Endoscopic transpapillary procedure was 100% successful in both post-cholecystectomy bile duct stricture cases (18/18) and post-cholecystectomy bile leakage cases (6/6). There was no accident due to the treatment. Restricture occurred in 5.5% (1/18) of the patients, but additional therapy was successful and the stent was removed. Also, there was no accident due to endoscopic transpapillary procedure. Endoscopic transpapillary procedure in postcholecystectomy bile duct stricture and postcholecystectomy bile leakage was demonstrated to be a less invasive, safe, and useful method.

A patient with adenocarcinoma of the jejunum successfully diagnosed by preoperative endoscopy for the small intestine

In this study, the authors report the case of a 35-year-old man diagnosed preoperatively as having adenocarcinoma of the jejunum using a conventional endoscopy, usually used for the examination of the large intestine.

Effect of the herbal medicine Inchin-Ko-To for serum bilirubin in hepatectomized patients

BACKGROUND/AIMS

Persistent hyperbilirubinemia is a symptom of postoperative liver failure after hepatectomy. We examined the effectiveness of a herbal medicine, Inchin-Ko-To (ICKT), on postoperative serum bilirubin levels in patients undergoing liver resection.

METHODOLOGY

Patients were divided into two groups. ICKT group (n=50), 7.5g of ICKT was administered orally from three days before the operation and it continued after the operation. Control group (n=50), ICKT was not administered perioperatively.

RESULTS

There was no significant difference between the two groups in postoperative serum total bilirubin levels, but in indirect bilirubin, the ICKT group showed significant decrease compared with the control group. Decreasing effect of postoperative serum bilirubin levels was much more conspicuous when a large amount of liver parenchyma was resected. In that subgroup of patients, serum all bilirubin subdivisions significantly decreased in the ICKT (n=12) group compared with controls (n=11).

CONCLUSIONS

ICKT may be an effective and fresh agent in postoperative management of liver resection by its potent choleretic effect.

A case of small cell carcinoma of the common bile duct

Small cell carcinoma occasionally occurs in the gastrointestinal tract, but rarely in the biliary tract. We report a case of small cell carcinoma which occurred in the common bile duct. A 66-year-old female complained of epigastralgia and weight loss. Computed tomography and ultrasonography showed a mass near the pancreas head and dilatation of the intrahepatic bile ducts. Endoscopic nasobiliary drainage was undertaken, and it revealed obstruction of the common bile duct. The patient was diagnosed preoperatively as having extrahepatic bile duct cancer. Upon laparotomy, a tumor was found to be located in the middle common bile duct. Pylorus-preserving pancreaticoduodenectomy was performed. The main trunk of the portal vein and the right hepatic artery were resected concomitantly because of tumor involvement. Postoperative pathological examination revealed well-differentiated papillary adenocarcinoma on the surface of the bile duct lumen, but a large part of the extraductal component was small cell carcinoma. Upon immunohistochemical examination, synaptophysin and chromogranin A were found to be focally positive in small cell carcinoma, but negative for L-26 and CEA. The patient then underwent two postoperative courses of systemic chemotherapy. Nevertheless, she died of cancer recurrence eight months after the operation, which showed that the tumor had a highly lethal nature, with rapid and widespread dissemination. Further therapeutic trials are needed to improve survival in such cases.

Effect of the herbal medicine Dai-kenchu-to for serum ammonia in hepatectomized patients

BACKGROUND/AIMS

Prolonged paralytic ileus occurring in hepatectomized patients may induce hyperammonemia or bacterial translocation, which injures the remnant liver function and sometimes causes post-resection liver failure. We examined the effectiveness of the herbal medicine, Dai-kenchu-to (DKT), on postoperative serum ammonia levels in patients with liver resection and compared it with lactulose.

METHODOLOGY

Patients with liver resection were divided into three groups. Lactulose group (n=31), 16g of lactulose was administered orally three times a day from the first postoperative day. DKT group (n=27), 5g of DKT was administered in the same fashion. Control group (n=26), neither lactulose nor DKT was administered. In all three groups, 16g of lactulose was administered three times a day for three days preoperatively.

RESULTS

There was no significant difference among the groups in age, gender and preoperative hepatic functional values, such as ICG-R15 or galactose tolerance test. There was also no difference in parenchymal hepatic resection rate, operative time and amount of intraoperative bleeding volume. Postoperative serum ammonia levels were significantly lower in the DKT group than control and lactulose groups. Instances of delayed flatulence and occurrence of diarrhea were also fewer in the DKT group.

CONCLUSIONS

DKT may become a more effective and safe agent than lactulose in postoperative management of liver resection.

Hepatic resection under in situ hypothermic hepatic perfusion

BACKGROUND/AIMS

Temporary inflow occlusion of the portal triad has been used frequently in hepatectomy to minimize bleeding. On the other hand, Pringle's maneuver produces ischemic-reperfusion injury especially in patients with underlying liver disease.

METHODOLOGY

Thirty-seven cases of hepatic resections were performed with intermittent Pringle's maneuver (IP group; n = 17) and in situ hypothermic perfusion (CP group; n = 20). In the CP group, hepatic inflow was continuously occluded, and 4-degree Centigrade Ringer's lactate was administered by drip during resection. Hepatic outflow occlusion was not performed.

RESULTS

All patients tolerated the procedures well. Cold perfusion technique significantly decreased both the times required and the blood loss in hepatectomy (p < 0.05). Serum hyaluronic acid levels gradually increased after the induction of hepatectomy and peaked 10 minutes after reperfusion in the both groups. Thereafter, it decreased and showed a significantly lower level in the CP group until 60 minutes after reperfusion (p < 0.05). Hepaplastin levels remained significantly higher in the CP group one week after operation (p < 0.05).

CONCLUSIONS

Using the technique of in situ hypothermic perfusion, we can prolong the ischemic time safely with minimal systemic influence even in cases with underlying liver diseases. This may compare favorably with intermittent Pringle's maneuver in terms of reducing hepatic sinusoidal endothelial cell damage during hepatectomy and reperfusion.

Flash-related synchronization and desynchronization revealed by a multiple band frequency analysis

The fast Fourier transform (FFT) is a good method to estimate power spectral density (PSD), but the frequency resolution is limited to the sampling window, and thus the precise characteristics of PSD for short signals are not clear. To relax the limitation, a multiple band-pass filter was introduced to estimate the precise course of PSDs for flash visual evoked potentials (VEPs). Signals were recorded during -200 and 600 ms using balanced noncephalic electrodes, and sampled at 1,000 Hz in 12 bits. With 1 Hz and 10 ms resolutions, PSDs were estimated between 10 and 100 Hz. Background powers at the alpha- and beta-bands were high over the posterior scalp, and powers around 200 ms were evoked at the same bands over the same region, corresponding to P110 and N165 of VEPs. Normalized PSDs showed evoked powers around 200 ms and suppressed powers following the evoked powers over the posterior scalp. The evoked powers above the 20 Hz band were not statistically significant, however, the gamma band was significantly evoked intra-individually; details in the gamma bands were varied among the subjects. Details of PSDs were complicated even for a simple task such as watching flashes; both synchronization and desynchronization occurred with different distributions and different time courses.

[X-ray and endoscopic diagnosis of esophageal achalasia]

We evaluated diagnostic X-ray and endoscopic examination findings in 486 patients with esophageal achalasia. Concerning the association between the duration of disease and the X-ray dilatation type, the duration was 1-4 years in more than 50% of patients with the Sp type, a mean of 8.5 years in those with the F type, and frequently more than 10 years in those with the S type. Endoscopy is generally used to determine the presence or absence of abnormal movement. In achalasia, the endoscope can be inserted into the stomach despite resistance at the stenotic site, and the mucosal surface is normal. Squamous cell carcinoma as a complication was observed in 21 patients (4.3%). The carcinoma complication rate was higher with a longer duration of disease and a longer observation period. The mean total course including the postoperative course was 27 years. Long-term and periodic X-ray and endoscopic observation of the disease course is important, and iodine staining is indispensable for early detection of esophageal cancer.

Gastric and non-gastric signals in electrogastrography

Electrogastrography (EGG) is the cutaneous recording of gastric myoelectrical activity, and the dominant frequency reflects the rhythm of the gastric slow wave. Ambulatory EGG is contaminated with a large amount of motion artifacts, and it is unclear how much of the signals comprising the dominant frequency originates from non-gastric sources. The aim of the present study was to evaluate the pattern of gastric and non-gastric signals in the dominant frequency histogram (DFH) obtained from long-term ambulatory EGG recordings. Ten normal controls and five post-gastrectomy patients participated in the present study. Twenty-four hour ambulatory EGG was recorded under normal daily conditions. The DFH of normal controls showed two distinctive peaks, and that of the post-gastrectomy patients, a single peak. The common peak at approximately 1.5 cpm was seen in both DFHs, and the peak at 3 cpm was seen only in the DFH of normal controls. Thus, the common peak was thought to be a product of non-gastric origin. In conclusion, the dominant frequency consists of gastric and non-gastric components which have a specific distribution pattern in the DFH. These findings quantified the contribution of gastric and non-gastric signals to the dominant frequencies in long-term ambulatory EGG.

Effective hepatic artery chemoembolization for advanced hepatocellular carcinoma with extensive tumour thrombus through the hepatic vein

BACKGROUND AND AIMS

Advanced hepatocellular carcinoma (HCC) with extensive tumour growth through the hepatic vein still has an extremely poor prognosis, even after cancer chemotherapy and/or transarterial embolization. Although aggressive surgical treatments using extracorporeal circulation and liver transplantation have been performed by some authors, the reported results were still unsatisfactory. In this study, we report the favourable result of hepatic artery chemoembolization and subsequent surgical resection in three patients with advanced HCC with extensive tumour thrombus through the hepatic vein.

METHODS AND RESULTS

Three irresectable patients with HCC with extensive tumour thrombus through the hepatic vein underwent hepatic artery chemoembolization with aclarubicin, mitomycin C, lipiodol and/or Gelfoam. After the reduction of tumour extent with hepatic artery chemoembolization, two of the three patients underwent surgical resection. These two patients are still alive at 59 and 21 postoperative months, respectively. In the other case, the extent of the tumour and functional reserve of the liver prevented us from performing surgical resection, but the patient is doing well 62 months after the initial treatment.

CONCLUSIONS

Hepatic artery chemoembolization with aclarubicin, mitomycin C, lipiodol and/or Gelfoam might be an effective treatment for irresectable advanced HCC with extensive tumour thrombus into the inferior vena cava or the right atrium through the hepatic vein. Radical surgical resection might be applicable for selected patients without high surgical risk after reducing tumour extent by hepatic artery chemoembolization.

Treatment of unresectable hepatic hilar malignancies with self-expanding metallic stents

BACKGROUND/AIMS

This study assesses the treatment of biliary obstruction in patients with hilar malignancies by metallic stents.

METHODOLOGY

Twenty-one consecutive patients with unresectable malignant biliary obstruction at the hepatic hilum (Bismuth type II, III and IV) were treated with percutaneous transhepatic placement of self-expandable metallic endoprostheses. The endoprostheses were successfully inserted in all patients. In 12 patients all segments of the liver were drained and in 9 patients partial segments of the liver were drained.

RESULTS

Seventeen patients (81%) showed relief from jaundice and could be freed of external drainage tubes. Ten patients (48%) showed no recurrent symptoms due to stent obstruction until death. Overall survival was 4.86+/-4.15 (mean+/-SD) months, stent patency was 3.76+/-3.64 months and comfort index representing a ratio of well-being was 70.5+/-38.3%. There was no significant difference in survival rate, stent patency or comfort index between the groups with complete and those with partial drainage.

CONCLUSIONS

Even in patients with complicated hepatic hilar biliary occlusions, internal drainage using metallic stents can relieve jaundice and leave patients free of external tubes with a comfortable quality of life.

A case of classical carcinoid tumor of the gallbladder: review of the Japanese published works

A 58 year-old man was admitted to Kimitsu Chuo Hospital complaining of epigastralgia. Abdominal ultrasound and computed tomography revealed a polypoid lesion at the neck of the gallbladder. Given the pre-operative diagnosis of gallbladder carcinoma, we resected the gallbladder along with the extrahepatic bile duct. There was a papillary tumor (25 x 16 mm) at the neck of the gallbladder. Histopathological examinations showed a subserosal nodular proliferation of uniform small tumor cells. Grimelius staining was slightly positive and Fontana-Masson staining was negative. Most of the tumor cells stained positively for chromogranin A and neuron-specific enolase (NSE), and some of the tumor cells were positive for pancreatic polypeptide. The presence of neurosecretory intracytoplasmic granules was proven ultrastructurally. It was diagnosed as a classical carcinoid tumor of the gallbladder. We reviewed the Japanese reported cases and discussed the difference in clinicopathological findings between classical and atypical carcinoid tumors of the gallbladder. Classical carcinoids of the gallbladder have neither a metastatic nor invasive character, and an extremely favorable prognosis compared with atypical carcinoids. The difference in character between classical and atypical carcinoids of the gallbladder is thought to be derived from their histogenetic origin.

Reduced hepatic acute-phase response after simultaneous resection for gastrointestinal cancer with synchronous liver metastases

Serum cytokines and hepatic acute-phase responses were studied in seven patients undergoing simultaneous resection of primary gastrointestinal cancer and synchronous metastatic liver tumours and in 12 undergoing partial hepatectomy alone for metachronous hepatic metastases. The incidence of postoperative infectious complications was significantly higher after simultaneous resection than after partial hepatectomy alone (P < 0.05). Although the peak interleukin 6 level was significantly higher after simultaneous resection (P < 0.05), plasma levels of acute-phase proteins were significantly lower (P < 0.05). The results suggest that simultaneous resections further reduce the hepatic acute-phase response and render patients liable to infection compared with partial hepatectomy alone, and result in a higher incidence of postoperative infective complications.

A successful treatment for hepatocellular carcinoma with atrial tumor thrombus

A 66-year-old man with an advanced hepatocellular carcinoma and tumor thrombus extending into the right atrium was treated by transcatheter arterial infusion of lipiodol and aclarubicin. This brought about a remarkable reduction of the tumor and the disappearance of the right atrial tumor thrombus. The tumor was then radically resected by hepatic posterior segmentectomy with combined resection of the right hepatic vein, where the tumor thrombus remained. He is doing well without any signs of recurrence 22 months after the operation.

Increased serum interleukin-6 level and reduction of hepatic acute-phase response after major hepatectomy

It has been proposed that a major hepatectomy impairs the liver-related host defense mechanism. The changes in the levels of serum inflammatory cytokines and plasma acute-phase proteins synthesized in the liver were measured after partial hepatectomy. Peak levels of serum interleukin-6 were significantly higher after extended lobectomy than after lobectomy or segmentectomy (p < 0.01). Serum interleukin-1 beta and tumor necrosis factor alpha levels showed no significant changes. Plasma levels of acute-phase proteins were significantly lower after lobectomy or extended lobectomy (p < 0.05). A reduced hepatic acute-phase response probably renders patients liable to infection after major hepatectomy.

Reduced hepatic functional reserve in cirrhosis and obstructive jaundice with special reference to histological morphometric analysis and galactose elimination capacity

To evaluate liver dysfunction in patients with obstructive jaundice (OJ), morphological and functional hepatic mass was analyzed in comparison with cirrhosis (LC). Total hepatic parenchymal ratio (THPR) was estimated by morphometric analysis and hepatic functional mass by galactose tolerance test (GaTT) in 30 patients who underwent hepatectomy. The value of GaTT in patients with LC was remarkably depressed compared to those with normal liver function (p < 0.001). It was also depressed in OJ (p < 0.05 vs. normal liver), but less than in LC (p < 0.05). However, THPR decreased only in LC (p < 0.05 vs. either normal liver or OJ). A significant correlation between the value of GaTT and THPR was revealed in patients with LC, but not in OJ. These results suggested that liver dysfunction in OJ was independent of the decreased number of hepatocytes, differing from LC.

Increased levels of human hepatocyte growth factor in serum and peritoneal fluid after partial hepatectomy

OBJECTIVE/METHOD

It has been reported that inflammatory cytokines up-regulate human hepatocyte growth factor synthesis in vitro. To demonstrate the relation of this growth factor to interleukin-6 and tumor necrosis factor alpha, the changes in the levels of these cytokines were measured in serum and peritoneal fluid in 22 patients after partial hepatectomy.

RESULTS

Serum and fluids levels of cytokines showed a maximum within 3 days after surgery. Cytokines concentrations were much higher in fluid than in serum (p < 0.05). The maximum serum levels of human hepatocyte growth factor were significantly correlated with those of interleukin-6, intraoperative blood loss, and operating time (p < 0.05) but not resected liver weights. In fluid level, the growth factor was also correlated with interleukin-6 (p < 0.05) but with tumor necrosis factor alpha.

CONCLUSIONS

These results suggest that human hepatocyte growth factor might be locally produced in the injured tissue associated with interleukin-6 and independently of resected liver weights.