Primary retroperitoneal mullerian adenocarcinoma.

Mullerian tumors are extremely rare malignancies in the retroperitoneum. We report a case of a 46-year old woman who presented with an eight year history of lower abdominal mass. Ultrasonography (US) and computed tomography (CT) demonstrated a 15×10 cm cystic mass in the left lower retroperitoneum. As serial percutaneous needle aspiration cytology was negative for malignancy, she was observed for seven years. Eleven months ago, the mass was excised. The histopathology was reported as mucinous adenocarcinoma of the retroperitoneum. Six cycles of intraperitoneal (IP) chemotherapy was administered during the last six months after diagnosis of recurrence by aspiration cytology and high serum tumor markers (CEA, CA19-9). A few days ago, positron emission tomographic (PET) scanning showed evidence of local recurrence and single vertebral metastasis, so she was admitted again for systemic chemotherapy. Meticulous revision of additional sections of the tumor revealed papillary, serous, mucinous, and endometrioid subtypes of the mullerian adenocarcinoma. To our knowledge, there has been no similar case described in the literature.

Safety and efficacy of bidirectional chemotherapy for treatment of patients with peritoneal dissemination from gastric cancer: Selection for cytoreductive surgery.

There is no standard treatment for peritoneal carcinomatosis (PC) from gastric cancer. New bidirectional chemotherapy (neoadjuvant intraperitoneal-systemic chemotherapy protocol (NIPS)) was developed. The aim of the present study was to assess the safety and efficacy of NIPS and to show the selection for cytoreductive surgery on PC from gastric cancer. Seventy-nine patients with PC from gastric cancer were treated with NIPS. A peritoneal port system was introduced into the abdominal cavity. The peritoneal wash cytological examination through a port was done before and after NIPS. The patients were treated with oral TS-1 twice a daily for 21 days, followed by a 1-week rest. On day 1, 8, and 15 from the start of oral TS-1 administration, 30 mg/m(2) of Docetaxel and 30 mg/m(2) of cisplatinum with 500 ml of saline were introduced into the peritoneal cavity through the port. A median course of oral TS-1 was 2.1 course and a median time of IP chemoterapy was 5.8. Peritoneal free cancer cells (PFCCs) had been detected in 65 (82.2%) patients before NIPS, and the positive cytology changed to be negative in 41 (63.0%) patients after NIPS. After NIPS, 41 patients underwent laparotomy, and complete cytoreduction was done in 32 (78%) patients. Complete cytoreduction was done in 27 (51.9%) of 52 patients with negative cytology but in only 4 (14.8%) of 27 patients with positive cytology (P < 0.001). Patients with negative cytology after NIPS survived significantly longer than those with positive cytology. The adverse effects after NIPS were mild and there was no treatment-related deaths. The grade 3/4 hematological adverse effects were found in 2 (2.6%) patients. Grade 3 renal toxicity and port site infection was found in three patients, respectively. NIPS using a port system is a safe and effective treatment for PC. Peritoneal wash cytology through a port system is a good indicator to select the patients to perform cytoreductive surgery.

The surgical procedure and clinical results of subtotal stomach preserving pancreaticoduodenectomy (SSPPD) in comparison with pylorus preserving pancreaticoduodenectomy (PPPD).

BACKGROUND: Subtotal stomach preserving pancreaticoduodenectomy (SSPPD) is compared retrospectively with pylorus preserving pancreaticoduodenectomy (PPPD). METHODS: During 2002-2005, 21 patients (13 female, 8 male) underwent SSPPD. The mean age was 64.3 (range 33-80). PPPD was performed for 12 patients after 1999. Days of hospital stay, operation time, operative blood loss, postoperative morbidity and mortality, days of nasogastric intubation, days until liquid diet, delayed gastric emptying, postoperative change of serum Albumin value, were compared between SSPPD and PPPD. Clinical characteristics (age, gender, benign, or malignant condition, presence of preoperative jaundice, preoperative value of serum Albumin) were analyzed in both procedures. RESULTS: In comparison of clinical characteristics, all factors were similar between PPPD and SSPPD. There were also quite similar results in days of hospital stay, operation time, operative blood loss, postoperative morbidity and mortality. Days of nasogastric intubation, days until liquid diet in PPPD were significantly longer than those in SSPPD and the incidence of delayed gastric emptying in PPPD was significantly higher than that in SSPPD. Finally, PPPD and SSPPD postoperative change of serum Albumin value were statistically similar. CONCLUSIONS: We consider SSPPD as one of the most favorable procedures in patients who undergo pancreaticoduodenectomy.

Clinical results on intra-arterial adjuvant chemotherapy for prevention of liver metastasis following curative resection of pancreatic cancer.

BACKGROUND: We report here the clinical results of intra-arterial adjuvant chemotherapy for the prevention of liver metastasis following curative resection of pancreatic carcinoma. METHODS: Twenty-two patients with pancreatic cancer underwent the radical operation between January 1999 and April 2005. Intra-arterial adjuvant chemotherapy with cisplatin (CDDP) and 5-fluorouracil (5FU) was selectively performed on nine patients; the remaining 13 patients did not receive chemotherapy and comprised the control group. RESULTS: Demographics and clinical characteristics were almost identical in the two groups. Liver metastasis occurred in three of nine patients (33%) in the chemotherapy group and in seven of 13 patients (54%) in the control group. The intra-arterial adjuvant chemotherapy had the tendency to suppress the rate of liver metastasis. The median survival period was 15.8 months for the nine patients who underwent the intra-arterial adjuvant chemotherapy following surgery and 13.4 months for the 13 patients of the control group who were curatively resected without the intra-arterial adjuvant chemotherapy. Cumulative survival rate was improved by the intra-arterial adjuvant chemotherapy. CONCLUSIONS: In patients with pancreatic cancer who underwent the curative operation, the intra-arterial adjuvant chemotherapy had the tendency to suppress the rate of liver metastasis and improve cumulative survival.

[Long-term results of peritonectomy on the patients with peritoneal carcinomatosis].

Peritonectomy was done for 125 patients with peritoneal carcinomatosis (PC): 19-pseudomyxomaperitonei (PMP), 15-appendiceal carcinoma (AC), 20-colorectal cancer, 67-gastric cancer, 2-small bowel cancer and 2-peritoneal mesothelioma. Cytoreduction by the standard techniques was done in 130 patients with PC. Complete cytoreduction (CC-0) was achieved in 85 of 125 (68%) patients, who have undergone peritonectomy, but was performed only in 28 of 130 (21%) by the standard surgical techniques. CC-0 could be done to patients with peritoneal cancer indices (PCI) of less than 14. A Cox model showed that significant prognostic factors are CC-0, and the patients were younger than 66 years old. Accordingly, peritonectomy increased the incidence of CC-0, and may have improved the prognosis of patients with PC. Peritonectomy is recommended for patients with PMP, AC and colorectal cancer. In gastric cancer, it is indicated for patients with PCI less than 14.

New method for prevention of bile leakage after hepatic resection.

BACKGROUND: The usefulness of fibrin glue and bioabsorbable polyglicolic acid (PGA) felt to prevent the bile leakage was studied. METHODS: Eighty-eight patients who underwent hepatic resection without biliary reconstruction from 2001 through 2005 were studied. We divided 88 patients into 37 patients of Group A (who underwent hepatic resection between January 2001 and March 2003) and 51 patients of Group B (who underwent hepatic resection between April 2003 and January 2005). The fibrin glue was applied to the excision site of remnant liver in the patients of Group A. On the other hand, the fibrin glue and bioabsorbable PGA sheet were applied in the patients of Group B. RESULTS: In Group A, the post-operative bile leakage occurred in 3 of 37 patients (8.1%). The post-operative bleeding occurred in 1 of 37 patients (2.7%). And the post-operative wound infection occurred in 4 patients (10.8%). In Group B, no post-operative bile leakage and bleeding were observed in 51 patients. And the post-operative wound infection occurred in 3 patients (5.9%). The difference between Groups A and B in the rate of bile leakage was statistically significant. CONCLUSIONS: The combination of fibrin glue and bioabsorbable PGA felt was extremely favorable for prevention of bile leakage after hepatic resection.

A resected case of advanced duodenal carcinoma with occlusion of the celiac artery.

A 75-year-old woman with vomiting, admitted on March 7 2002, was diagnosed with advanced duodenal carcinoma based on ultrasonography (US), computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangio-ancreatography (MRCP), percutaneus transhepatic cholangiography. Angiography showed the celiac artery to be occluded. The common hepatic artery was demonstrated via the gastroduodenal artery (GDA). We conducted a probe laparotomy and resected connective tissue with the celiac ganglion and lymph nodes surrounding the celiac artery. The frozen specimen showed no malignancy. Then the celiac artery was exposed and celiac axis compression syndrome was not seen. A portion of the greater saphenous vein was taken from the patient's right thigh and grafted between the common hepatic artery and the supraceliac portion of the aorta. One end of the saphenous vein was anastomosed to the side of the common hepatic artery. The other end of the saphenous vein was anstomosed to the aorta in an end to side fashion. After the reconstruction of celiac circulation, we performed radical pancreaticoduodenectomy. The postoperative course was not eventful and the patient was discharged from the hospital 5 weeks after surgery.

A resected case of multiple intraductal papillary mucinous tumors of the pancreas with US-guided ductal branch-oriented partial pancreatectomy.

A 69-year-old man with epigastralgia was admitted on August 26, 2002 and diagnosed with multiple intraductal papillary mucinous tumors by various imagings. The cystic tumor of pancreas head had a diameter of 2 cm, and the mural nodule of the cystic tumor measured only 3 mm. In the pancreas body the cystic tumor was measured at 1.5 cm with the mural nodule of the cystic tumor measuring 3 mm. It was believed that the tumors were benign. However, a mural nodule of the cystic lesion was recognized, thus, the possibility of malignancy could not be completely ruled out. The reduction operation for preservation of pancreatic parenchyma should be selected for these circumstances. Ductal branch-oriented partial pancreatectomy was performed on September 6, 2002 with intraoperative ultrasonography and a Cavitron Ultrasonic Aspirator, preserving the main pancreatic duct and normal pancreatic parenchyma. The operation was successful, and the histopathological diagnosis of the tumors was intraductal papillary adenoma of the pancreas.

The surgical procedure and clinical results of the duct to mucosa pancreaticojejunostomies with resection of jejunal serosa.

BACKGROUND: Pancreatic anastomotic leakage often results in severe complications of sepsis, intra-abdominal bleeding, pancreatic fistula, and is a significant cause of morbidity and mortality. An appropriate technique to minimize pancreatic leakage is very important. Recently we have performed duct to mucosa pancreaticojejunostomy with resection of jejunal serosa and obtained positive results. PATIENTS AND METHODS: During 1999-2005, 52 patients (25 females, 27 males) underwent duct to mucosa pancreaticojejunostomy with resection of jejunal serosa after pancreatic head resections for benign (n=6) and malignant disease (n=46). The mean age was 64.0 years (range 33-80). RESULTS: Mean post-operative hospital stay was 32.3 days. Morbidity rate due to early post-operative complication was 7.7% (pulmonary embolism in 1, pneumothorax in 1, wound infection in 2), with no pancreatic leakage. CONCLUSIONS: There were low complication rates and an absence of pancreatic anastomotic leakage was observed in 52 patients. We consider that this pancreatic anastomotic technique is extremely favorable for pancreaticojejunostomy.