Histological pancreatic findings correlate with computed tomography attenuation and predict postoperative pancreatic fistula following pancreatoduodenectomy.

BACKGROUND: Although a soft pancreas is a widely-accepted reliable risk factor for postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD), there is no established preoperative evaluation of pancreatic texture. METHODS: Two hundred thirty-seven patients who underwent PD with histological pancreatic assessment were retrospectively enrolled. The degree of fibrosis and fatty infiltration was scored histologically as seven grades and five grades, respectively. Computed tomography (CT) attenuation of the pancreas was measured on preoperative unenhanced CT images. Correlations between the CT attenuation of the pancreas and the histological pancreatic findings, and the development of POPF were analyzed. RESULTS: The fibrosis grade was significantly higher for hard pancreas than for soft pancreas (p < 0.001), whereas the fatty infiltration grade was similar between the two types (p = 0.161). CT attenuation of the pancreas was inversely correlated with both fibrosis grade (Spearman's rank correlation coefficient ([r] = -0.609, p < 0.001) and fatty infiltration grade (r = -0.382, p < 0.001). Multivariate analysis showed that body mass index ≥25 kg/m2 (odds ratio [OR]: 5.64, p < 0.001) and fibrosis grade ≤2 (OR: 18.0, p < 0.001) were independent risk factors for clinically significant POPF. CONCLUSION: Histological pancreatic texture can be evaluated with CT attenuation and might be helpful in preoperatively predicting the development of POPF after PD.

Stent graft migration with massive hemorrhage following pancreaticoduodenectomy: A serious complication of endovascular pseudoaneurysm repair.

Highlight Endovascular pseudoaneurysm repair with a stent graft enables aneurysm treatment and vessel preservation; however, little is known about its complications. Sano and colleagues describe a case of massive intestinal bleeding associated with stent-graft migration. They used a multidisciplinary approach with endoscopic hemostasis and endovascular embolization to overcome this unprecedented difficulty.

Pathological complete response by advanced hepatocellular carcinoma with massive macrovascular invasion to hepatic arterial infusion chemotherapy: a case report.

BACKGROUND: Advanced hepatocellular carcinoma (HCC) with macrovascular invasion has an extremely dismal prognosis. We report a rare case of multiple HCC with tumor thrombosis in the portal vein and inferior vena cava that was initially treated with hepatic arterial infusion chemotherapy (HAIC); later resection revealed pathological complete response. CASE PRESENTATION: A 75-year-old man presented with HCC in his right liver, with tumor thrombosis growing to the right portal vein and the inferior vena cava, and bilateral intrahepatic liver metastases. He underwent HAIC (5-fluorouracil [170 mg/m2] + cisplatin [7 mg/m2]) via an indwelling port. Although the tumor shrank and tumor marker levels decreased rapidly, we abandoned HAIC after one cycle because of cytopenia. We resumed HAIC 18 months later because of tumor progression, using biweekly 5-fluorouracil only [1000 mg] due to renal dysfunction. However, after 54 months, the HAIC indwelling port was occluded. The patient therefore underwent a right hepatectomy to resect the residual lesion. Histopathological findings showed complete necrosis with no viable tumor cells. The patient has been doing well without postoperative adjuvant therapy for more than 10 years after initially introducing HAIC and 6 years after the resection, without evidence of tumor recurrence. CONCLUSIONS: HAIC can be an effective alternative treatment for advanced HCC with macrovascular invasion.

Third-generation cephalosporin for antimicrobial prophylaxis in pancreatoduodenectomy in patients with internal preoperative biliary drainage.

BACKGROUND: The aim of the present study was to investigate whether the incidence of surgical site infection after pancreatoduodenectomy decreased after changing the prophylactic antibiotic to a third-generation cephalosporin in patients with unknown preoperative bile culture results after biliary drainage. METHODS: In a retrospective study of 138 pancreatoduodenectomy patients who underwent endoscopic biliary stenting and for whom recent preoperative bile culture results were unavailable, cefazolin sodium hydrate was administered as perioperative prophylactic antibiotic therapy from 2010 to 2014 (n = 69); whereas ceftriaxone was administered from 2014 to 2017 (n = 69) based on the results of institutional culture surveillance. The incidence of surgical site infection was compared between the two groups and the risk factor of surgical site infection was also evaluated. RESULTS: The incidence of overall surgical site infection in the ceftriaxone group was significantly lower than that in the cefazolin sodium hydrate group for both Clavien-Dindo grade ≥II (28% versus 52%, P = .005) and Clavien-Dindo grade ≥IIIa (20% vs 41%, P = .016). A multivariate analysis revealed that the prophylactic administration of cefazolin sodium hydrate was associated with a higher incidence of overall surgical site infection in both Clavien-Dindo grade ≥II and Clavien-Dindo grade ≥IIIa (odds ratio 2.56, P = .019; odds ratio 3.03, P = .020, respectively). In the cefazolin sodium hydrate group, most of the patients with positive perioperative cultures had Enterobacteriaceae, which were intrinsically resistant to cefazolin sodium hydrate, and most were susceptible to ceftriaxone. CONCLUSION: The prophylactic administration of third-generation cephalosporin reduced the incidence of surgical site infection after pancreatoduodenectomy in patients who underwent preoperative endoscopic biliary stenting.

The Radiological Differentiation of Hypervascular Intrahepatic Cholangiocarcinoma from Hepatocellular Carcinoma with a Focus on the CT Value on Multi-phase Enhanced CT.

BACKGROUND/AIM: This study aimed to investigate whether hypervascular intrahepatic cholangiocarcinoma (HICC) can be differentiated from hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Among 100 patients with intrahepatic cholangiocarcinoma, 22 patients were diagnosed with HICC based on the computed tomography (CT) value in the late arterial phase as follows: the CT value of the tumor ≥ that of the liver parenchyma. The CT values of the HICC were compared to those of HCC cases (n=120). RESULTS: The CT value of HICC was lower in the unenhanced phase (UP) (p=0.016) and higher in the equilibrium phase (EP) (p<0.001) in comparison to HCC. The non-tumorous liver (odds ratio [OR]: 6.35, p=0.002) and an E/U ratio (the mean CT value of the tumor in the EP to that in the UP) of >2.3 (OR=13.1, p<0.001) were independent diagnostic factors for differentiating HICC from HCC. CONCLUSION: E/U ratio is useful for differentiating between HICC and HCC.

Combined resection of the transpancreatic common hepatic artery preserving the gastric arterial arcade without arterial reconstruction in hepatopancreatoduodenectomy: a case report.

BACKGROUND: Surgeons sometimes must plan pancreatoduodenectomy (PD) for patients with a variant common hepatic artery (CHA) branching from the superior mesenteric artery (SMA) penetrating the pancreatic parenchyma, known as a transpancreatic CHA (tp-CHA). CASE PRESENTATION: A 67-year-old man was admitted to our hospital because of liver dysfunction. A duodenal tumor was identified by gastrointestinal endoscopy, and a biopsy revealed a neuroendocrine tumor. Computed tomography showed multiple metastases in the left three sections of the liver. As an anatomical variant, the CHA branched from the SMA and passed through the parenchyma of the pancreatic head, and all hepatic arteries branched from the CHA. Furthermore, the arcade between the left and right gastric artery (RGA) was detected, and the RGA branched from the root of the left hepatic artery. PD and left trisectionectomy of the liver were performed. The tp-CHA was resected with the pancreatic head, and the gastric arterial arcade was preserved to maintain the right posterior hepatic arterial flow. Postoperatively, there were no signs of hepatic ischemia. CONCLUSIONS: When planning PD, including hepatopancreatoduodenectomy, for patients with a tp-CHA, surgeons should simulate various situations for maintaining the hepatic arterial flow. The preservation of the gastric arterial arcade is an option for maintaining the hepatic arterial flow to avoid arterial reconstruction.

The 2012 International Consensus Guidelines of Intraductal Papillary Mucinous Neoplasms of the Pancreas (Fukuoka Criteria) Predict the Malignant Potential, Even in Actual Clinical Situations.

OBJECTIVES: The aim of the present study was to validate the use of the 2012 International Consensus Guidelines for intraductal papillary mucinous neoplasm (IPMN) (Fukuoka criteria) in patients without findings of obstructive jaundice and/or an enhanced solid component. METHODS: This retrospective study included patients who underwent pancreatectomy for IPMN between October 2002 and September 2016. The sensitivity, specificity, and positive and negative predictive values for malignancy were calculated for each feature of high-risk stigmata. RESULTS: Of the 135 patients who underwent surgery for IPMN, 50 (37.0%) had low/intermediate-grade dysplasia, 25 (18.5%) had high-grade dysplasia, and the remaining 60 (44.5%) had invasive carcinoma. A malignant potential was, thus, present in 63% of all resected cases. Considering an actual clinical situation, the predictors for malignant potential were assessed in 62 patients without findings of obstructive jaundice and/or an enhanced solid component. A multivariate analysis revealed that the Fukuoka criteria were the only independent factor for predicting the malignant potential (odds ratio, 5.69; P = 0.036). CONCLUSIONS: The present study suggested that malignant potential can be accurately detected by faithfully keeping to the Fukuoka criteria. Using these criteria enables us to identify patients with malignant potential, even in the actual clinical situations.

Pancreaticoduodenectomy with hepatic arterial revascularization for pancreatic head cancer with stenosis of the celiac axis due to compression by the median arcuate ligament: a case report.

A 71-year-old woman presented to our hospital because pancreatic head cancer was suspected on a medical checkup. Computed tomography showed a 30 mm low-density lesion in the pancreatic head, and the stenosis of the celiac axis (CA) due to the median arcuate ligament (MAL) compression. We made a preoperative diagnosis of pancreatic head cancer and performed laparotomy. Transection of the MAL failed to restore adequate hepatic arterial flow, necessitating arterial revascularization, which was achieved by end-to-end anastomosis between the gastroduodenal artery and the middle colic artery. After reconstruction, Doppler ultrasonography showed improved hepatic arterial signal. The patient was discharged 16 days after surgery with no complications. When planning pancreaticoduodenectomy (PD) for such patients with CA stenosis due to MAL compression, surgeons should simulate a situation of insufficient hepatic arterial flow after division of the MAL, and prepare for reconstruction of the hepatic artery during PD.

Surgical Strategy for T1 Duodenal or Ampullary Carcinoma According to the Depth of Tumor Invasion.

AIM: To investigate the utility of local resection (LR) for T1 duodenal carcinoma and T1 ampullary carcinoma. PATIENTS AND METHODS: Between June 2002 and November 2014, a total of 64 patients with pathological T1 (pT1) ampullary carcinoma (25 patients) and pT1 duodenal carcinoma (39 patients) were treated. Of these, 33 patients underwent local resection (LR group), while the other 31 patients underwent pancreatoduodenectomy (PD group). RESULTS: The LR group had 31 patients with pT1a and 2 patients with pT1b. PD group had 18 patients with pT1a and 13 patients with pT1b. One patient with pT1b duodenal carcinoma (20.0%) and one patient with pT1b ampullary carcinoma (10.0%) developed lymph node metastasis, while none of the patients with pT1a disease developed metastases. CONCLUSION: LR may be considered in the patients preoperatively diagnosed with T1a duodenal carcinoma and T1a ampullary carcinoma.