Reappraisal of Total Pancreatectomy in 45 Patients With Pancreatic Ductal Adenocarcinoma in the Modern Era Using Matched-Pairs Analysis: Multicenter Study Group of Pancreatobiliary Surgery in Japan.

OBJECTIVE: The aim of this study was to reappraise the clinical role of total pancreatectomy with curative intent in patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: In 2001 to 2011 database from 7 institutions in Japan, 45 (3.1%) of 1451 patients with PDAC underwent total pancreatectomy (TP group), and 885 patients underwent pancreaticoduodenectomy (PD group). A matched-pairs group consisted of 45 patients matched for age, sex, year, resectability status, and neoadjuvant therapy (matched-PD group). Clinicopathological data, overall survival, and disease-free survival were compared between groups. RESULTS: Clinical features of the TP group revealed higher-stage disease, greater surgical stress, a higher frequency of lymph node metastasis, and a lower adjuvant chemotherapy completion rate compared with the PD group (P < 0.05). Overall survival and disease-free survival in the TP group were significantly worse than those in the PD group (P < 0.05). Multivariate analysis revealed resectability status, neoadjuvant therapy, blood transfusion, lymph node metastasis, and adjuvant therapy to be significant prognostic factors. No differences in mortality and morbidity rates were observed between the 2 groups. A matched-pairs analysis revealed similar surgical outcomes and overall survival. CONCLUSIONS: The surgical outcome of total pancreatectomy for patients with PDAC is acceptable. When margin-negative resection is expected, total pancreatectomy should not be abandoned in the modern era.

Multicenter comparative study of laparoscopic and open distal pancreatectomy using propensity score-matching.

BACKGROUND: Laparoscopic distal pancreatectomy has been shown to be associated with favorable postoperative outcomes using meta-analysis. However, there have been no randomized controlled studies yet. This study aimed to compare laparoscopic and open distal pancreatectomy using propensity score-matching. METHODS: We retrospectively collected perioperative data of 2,266 patients who underwent distal pancreatectomy in 69 institutes from 2006-2013 in Japan. Among them, 2,010 patients were enrolled in this study and divided into two groups, laparoscopic distal pancreatectomy and open distal pancreatectomy. Perioperative outcomes were compared between the groups using unmatched and propensity matched analysis. RESULTS: After propensity score-matching, laparoscopic distal pancreatectomy was associated with favorable perioperative outcomes compared with open distal pancreatectomy, including higher rate of preservation of spleen and splenic vessels (P < 0.001); lower rates of intraoperative transfusion (P = 0.020), clinical grade of pancreatic fistula (International Study Group on Pancreatic Fistula grade B and C; P < 0.001), and morbidity (P < 0.001); and shorter hospital stay (P = 0.001), but a longer operative time (P < 0.001). CONCLUSIONS: Laparoscopic distal pancreatectomy was associated with more favorable perioperative outcomes than open distal pancreatectomy.

Late-onset bile leakage after hepatic resection.

BACKGROUND: Postoperative bile leakage can be a serious complication after hepatic resection. Few studies have analyzed patients according to the time of onset of bile leakage. We analyzed differences between patients with early- and late-onset bile leakage after hepatic resection and assessed clinical characteristics and outcomes in patients with late-onset leakage. METHODS: Between 2008 and 2010, 1,009 patients underwent hepatic resection at 4 participating university hospitals and 2 community hospitals. Fifty-two patients (5.1%) with postoperative bile leakage were divided into an early-onset group (<2 weeks after surgery, n = 34) and a late-onset group (≥2 weeks after surgery, n = 18). Patient characteristics and outcomes were collected prospectively and analyzed retrospectively. RESULTS: The proportion of patients who underwent intra-abdominal placement of a drainage catheter was significantly less in the late-onset group than the early-onset group. All 18 patients in the late-onset group developed intra-abdominal infection, and 2 died of sepsis. The proportion of patients who underwent invasive treatment (abdominal paracentesis, endoscopic biliary drainage, or second hepatic resection) was significantly greater in the late-onset group than in the early-onset group. The time to resolution of bile leakage was significantly greater in the late-onset group than the early-onset group. CONCLUSION: Patients should be monitored carefully for bile leakage for several weeks after hepatic resection, because late-onset bile leakage can cause serious complications. Intra-abdominal infection should also be treated as soon as possible, because it may induce refractory bile leakage with serious complications.

Higher complication rate in hepatocellular carcinoma patients undergoing prophylactic cholecystectomy with curative hepatic resection.

AIMS: We performed a retrospective analysis to evaluate the short and long-term impact of simultaneous prophylactic cholecystectomy with hepatectomy in these patients. METHODS: We identified 642 patients who underwent curative hepatocellular carcinoma resection between 2001 and 2005 at five university hospitals. One hundred and twenty-five hepatocellular carcinoma patients who received left lateral sectionectomy or partial resection in the left lateral and Spiegel lobes were identified and followed. They were divided into two groups, 74 with and 51 without simultaneous cholecystectomy. None of these patients had gallbladder stones or polyps at preoperative diagnosis. RESULTS: Although not statistically significant, the operating time was longer and blood loss was greater in the cholecystectomy group. Patients in the cholecystectomy group had a significantly higher postoperative morbidity rate. Surgical complications according to the Clavien classification differed significantly between the two groups. Variables significantly associated with complications in the univariate and multivariate analyses were simultaneous cholecystectomy and operative blood loss ≥ 1000 ml. CONCLUSION: Simultaneous cholecystectomy of the asymptomatic gallbladder with curative resection of hepatocellular carcinoma in the left lateral section or Spiegel lobe resulted in higher postoperative complications. Consequently, the gallbladder should be preserved except in cases of gallbladder stones or polyps.

[Asymptomatic longterm survival in a patient with sigmoid colon lymph node metastasis with cancerous ascites of unknown origin].

A 63-year-old man bearing a palpable tumor had a lymph node metastasis adjacent to the sigmoid colon that was detected by computed tomography and positron emission tomography. The sigmoid colon and enlarged lymph nodes were surgically resected, and cancerous ascites were present. Pathologically, the tumor in the lymph node was a poorly-differentiated adenocarcinoma that was positive for CA19-9 as well as CK7(-/+), CK20(+/-), VEGF(+), p 53(+)and MIB-1 (>10%). We treated this case as a pancreatic or bile duct carcinoma due to the patient's markedly elevated serum levels of CA19-9 and SPan-1. However, we could not make a conclusive diagnosis. Gemcitabine-based chemotherapy was administered, and the patient had no signs of recurrence for 24 months after the operation. Then, a recurrence was identified by imaging studies, and the chemotherapy was changed to paclitaxel and carboplatin. The patient had stable disease until tumor regrowth was identified 38 months after the operation, chemotherapy was then stopped. However, at 48 months after the operation, the patient remains well and has no symptoms. Our case suggests that surgery and the appropriate choice of anticancer drugs may contribute to the long-term survival of patients with cancer of an unknown primary origin.

Abnormalities in fatty acids in plasma, erythrocytes and adipose tissue in Japanese patients with colorectal cancer.

AIM: In previous animal studies, we confirmed that linoleic acid (LNA) enhanced colon carcinogenesis, whereas eicosapentaenoic acid (EPA) had protective effects in azoxymethane-induced colon tumorigenesis. In regard to the protective effects of marine n-3 polyunsaturated fatty acids (PUFAs) on colorectal cancer however, evidence from epidemiological studies is inconsistent. MATERIALS AND METHODS: In the present study we investigated the fatty acid composition in plasma, red blood cells (RBCs) and adipose tissue from Japanese patients with colorectal cancer, or benign disease. RESULTS: Sixty-one patients with histologically-confirmed colorectal cancer and 42 patients with non-malignant disease were recruited for this study. The fatty acid composition of the total phospholipid (PL) fraction of plasma and washed RBCs was determined by gas chromatography. The fatty acid composition of the triacylglycerol (TAG) fraction of subcutaneous adipose tissue was determined in a similar manner. The EPA proportion in the plasma and RBC PL fractions was significantly lower in patients with cancer than in the controls (p<0.05). Similarly, the LNA proportion in the RBC PL fraction was lower in patients with cancer, but no changes were found in the plasma PL fraction. Arachidonic acid was the only PUFA in the adipose TAG fraction that exhibited significant differences, with higher levels in the patients with cancer than in the controls. CONCLUSION: Our findings suggest that patients with cancer have abnormalities in PUFAs in the plasma PL, erythrocyte PL, and adipose TAG fractions. Further investigation is needed to clarify the differences in the results between the various fractions.

Fatty acid composition of plasma, erythrocytes and adipose: their correlations and effects of age and sex.

The composition of fatty acids in abdominal subcutaneous adipose tissue and the correlation of fatty acid values of plasma and erythrocytes had not been reported in Japan. The aim of the present study was to investigate the fatty acid composition and correlation of plasma and erythrocyte phospholipids (PL) and adipose triacylglycerols (TG) in 75 adult patients admitted for non-malignant diseases. We also examined the relationship of n-3 and n-6 polyunsaturated fatty acid (PUFA) with patients' characteristics. The total n-3 PUFA were 11.2, 11.8 and 1.9%, and the ratios of n-6/n-3 were 2.41, 1.87 and 8.20 in plasma and erythrocyte PL and adipose TG, respectively. There were the highest correlations for total n-3 PUFA and the n-6/n-3 ratio between plasma and erythrocyte PL and adipose TG. There was a positive correlation between n-3 PUFAs and age, but a negative correlation was found between n-6 PUFAs and age. There was no significant difference in the values of PUFAs in plasma and erythrocyte PL and adipose TG between men and women. The patients with cholesterol cholecystolithiasis showed a significantly lower proportion of eicosapentaenoic acid in plasma and erythrocyte PL than those of the other patients. Our findings suggest that PUFA in plasma and erythrocyte PL may be good biomarkers and more acceptable for studying participants than adipose TG.