RESUMEN
AIM: To validate the utility of hepatic resection combined with complementary radiofrequency ablation (RFA) compared with resection alone for patients with multiple hepatocellular carcinoma (HCC), and to compare these results with those of a previous report. MATERIALS AND METHODS: A total of 78 HCC patients with multiple (≤5) tumours who were initially treated with hepatic resection only (Resection group) or with combined hepatic resection and RFA (Combination group) were included. Overall and disease-free survival were analysed. RESULTS: There were 21 women and 57 men with a median age of 72.5 (64.3-76.8) years. Fifty-three patients were treated with resection alone and 25 received combination therapy. The 3-, 5-, and 7-year cumulative overall survival rates were 81.2%, 68.2%, and 57.1%, respectively, in the Resection group, and 81.3%, 59.6%, and 42.4%%, respectively, in the Combination group (hazard ratio [HR], 1.462; 95% confidence interval [CI], 0.682-3.136; p=0.329). The 1-, 3-, and 5-year cumulative disease-free survival rates were 61.4%, 45.7%, and 39.8%, respectively, in the Resection group, and 53.1%, 18.6%, and 0%, respectively, in the Combination group (HR, 2.080; 95% CI, 1.157-3.737; p=0.014). The overall survival rate was not significantly different between the Resection and Combination groups in patients within the up-to-seven HCC criteria (n=56; HR, 2.101; 95% CI, 0.805-5.486; p=0.130) or those beyond these criteria (n=22; HR, 0.804; 95% CI, 0.197-3.286; p=0.761). CONCLUSIONS: The combination of hepatic resection and RFA therapy may be an effective strategy for HCC patients with multiple tumours.
Asunto(s)
Carcinoma Hepatocelular/cirugía , Ablación por Catéter/métodos , Neoplasias Hepáticas/cirugía , Anciano , Terapia Combinada , Femenino , Humanos , Hígado/cirugía , Masculino , Persona de Mediana Edad , Reproducibilidad de los Resultados , Resultado del TratamientoRESUMEN
BACKGROUND: Although some retrospective studies have suggested the value of adjuvant therapy, no recommended standard exists in bile duct cancer. The aim of this study was to test the hypothesis that adjuvant gemcitabine chemotherapy would improve survival probability in resected bile duct cancer. METHODS: This was a randomized phase III trial. Patients with resected bile duct cancer were assigned randomly to gemcitabine and observation groups, which were balanced with respect to lymph node status, residual tumour status and tumour location. Gemcitabine was given intravenously at a dose of 1000 mg/m2 , administered on days 1, 8 and 15 every 4 weeks for six cycles. The primary endpoint was overall survival, and secondary endpoints were relapse-free survival, subgroup analysis and toxicity. RESULTS: Some 225 patients were included (117 gemcitabine, 108 observation). Baseline characteristics were well balanced between the gemcitabine and observation groups. There were no significant differences in overall survival (median 62·3 versus 63·8 months respectively; hazard ratio 1·01, 95 per cent c.i. 0·70 to 1·45; P = 0·964) and relapse-free survival (median 36·0 versus 39·9 months; hazard ratio 0·93, 0·66 to 1·32; P = 0·693). There were no survival differences between the two groups in subsets stratified by lymph node status and margin status. Although haematological toxicity occurred frequently in the gemcitabine group, most toxicities were transient, and grade 3/4 non-haematological toxicity was rare. CONCLUSION: The survival probability in patients with resected bile duct cancer was not significantly different between the gemcitabine adjuvant chemotherapy group and the observation group. Registration number: UMIN 000000820 (http://www.umin.ac.jp/).
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Adenocarcinoma/tratamiento farmacológico , Antimetabolitos Antineoplásicos/uso terapéutico , Neoplasias de los Conductos Biliares/tratamiento farmacológico , Procedimientos Quirúrgicos del Sistema Biliar , Carcinoma Adenoescamoso/tratamiento farmacológico , Desoxicitidina/análogos & derivados , Adenocarcinoma/mortalidad , Adenocarcinoma/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de los Conductos Biliares/mortalidad , Neoplasias de los Conductos Biliares/cirugía , Carcinoma Adenoescamoso/mortalidad , Carcinoma Adenoescamoso/cirugía , Quimioterapia Adyuvante , Desoxicitidina/uso terapéutico , Esquema de Medicación , Femenino , Estudios de Seguimiento , Humanos , Inyecciones Intravenosas , Masculino , Persona de Mediana Edad , Análisis de Supervivencia , Resultado del Tratamiento , GemcitabinaRESUMEN
BACKGROUND: The aim of the study was to investigate the prognostic impact of lymph node metastasis in cholangiocarcinoma using three different classifications. METHODS: Patients who underwent pancreaticoduodenectomy for distal cholangiocarcinoma in 24 hospitals in Japan between 2001 and 2010 were included. Survival was calculated by means of the Kaplan-Meier method and differences between subgroups were assessed with the log rank test. The Cox proportional hazards model was used to identify independent predictors of survival. χ(2) scores were calculated to determine the cut-off value of the number of involved nodes, lymph node ratio (LNR) and total lymph node count (TLNC) for discriminating survival. RESULTS: Some 370 patients were included. The median (range) TLNC was 19 (3-59). Nodal metastasis occurred in 157 patients (42·4 per cent); the median (range) number of involved nodes and LNR were 2 (1-19) and 0·11 (0·02-0·80) respectively. Four or more involved nodes was associated with a significantly shorter median survival (1·3 versus 2·2 years; P = 0·001), as was a LNR of at least 0·17 (1·4 versus 2·3 years; P = 0·002). Involvement of nodes along the common hepatic artery, present in 21 patients (13·4 per cent), was also associated with a shorter survival (median 1·3 versus 2·1 years; P = 0·046). Multivariable analysis among 157 node-positive patients identified the number of involved nodes as an independent prognostic factor (risk ratio 1·87; P = 0·002). CONCLUSION: The number of involved nodes was a strong predictor of survival in patients with distal cholangiocarcinoma.
Asunto(s)
Neoplasias de los Conductos Biliares/mortalidad , Neoplasias de los Conductos Biliares/patología , Conductos Biliares Intrahepáticos , Colangiocarcinoma/mortalidad , Colangiocarcinoma/secundario , Ganglios Linfáticos/patología , Pancreaticoduodenectomía/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares Intrahepáticos/cirugía , Colangiocarcinoma/patología , Colangiocarcinoma/cirugía , Femenino , Humanos , Japón , Estimación de Kaplan-Meier , Escisión del Ganglio Linfático/mortalidad , Metástasis Linfática , Masculino , Persona de Mediana Edad , Tratamientos Conservadores del Órgano/métodos , Tratamientos Conservadores del Órgano/mortalidad , Pancreaticoduodenectomía/métodos , Pronóstico , Estudios ProspectivosRESUMEN
We report two cases of surgically proven supravesical hernia, one an internal supravesical hernia and the other an external supravesical hernia. Abdominal computed tomography showed the relation of the incarcerated intestine anterior to and compressing the urinary bladder. Although neither case was diagnosable preoperatively, we believe that the preoperative diagnosis of supravesical hernia by abdominal computed tomography is possible.
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Hernia Inguinal/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Anciano , Hernia Inguinal/cirugía , Humanos , Masculino , Persona de Mediana EdadRESUMEN
The right umbilical portion (right-sided round ligament) has been discussed as an intrahepatic portal venous anomaly associated with "left-sided gallbladder" in several reports. We treated two patients with right umbilical portion (RUP) associated with cholangiocarcinoma. Left hepatectomies were performed, preserving the residual hepatic blood flow and biliary continuity. From our experience in these patients we propose the presence of anomalous configuration of the intrahepatic biliary tree in RUP, because both patients showed medial segmental bile ducts ramified from the right and left hepatic ducts. In general, although the medial segmental bile duct ramified from the left, we surmised that this abnormal bilateral drainage pattern may not be a rare phenomenon in RUP. Special attention may be required to focus on the anatomy of the portal tributaries and biliary ramifications in RUP.
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Neoplasias de los Conductos Biliares/diagnóstico por imagen , Neoplasias de los Conductos Biliares/cirugía , Conductos Biliares Intrahepáticos/anomalías , Colangiocarcinoma/diagnóstico por imagen , Colangiocarcinoma/cirugía , Hepatectomía/métodos , Neoplasias de los Conductos Biliares/patología , Conductos Biliares Intrahepáticos/diagnóstico por imagen , Colangiocarcinoma/patología , Colangiografía , Resultado Fatal , Estudios de Seguimiento , Humanos , Pruebas de Función Hepática , Masculino , Persona de Mediana Edad , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
The utility of hepatic vein reconstruction following resection of segments VII and VIII plus the right hepatic vein (RHV) is still controversial. The purpose of this study was to investigate the surgical benefits of hepatic vein reconstruction using stapled vascular clips and the draining area of hepatic vein using angiographic computed tomography (CT) to determine strict indications for hepatic vein reconstruction. Five patients underwent RHV reconstruction by external iliac vein graft using stapled vascular clips (VCS clips) following resection of segments VII and VIII, regardless of whether an inferior right hepatic vein (IRHV) was present. In eight other patients CT during arterial portography (CTAP) under temporary RHV occlusion using a balloon catheter was performed to determine the drainage area of the RHV. Operating times were 240 to 400 minutes (mean 336 +/- 59 minutes), and the mean hepatic vein reconstruction time was 26 +/- 5 minutes. There were no complications related to the surgery. Follow-up examinations showed patency of the graft in all cases; three patients are still alive with long-term graft patency of 10 to 24 months. CTAP under RHV occlusion demonstrated that segment VI and part of segment V were almost hypoattenuated in cases of absent or small IRHV, although those segments were hyperattenuated in thick IRHV and RHV-IRHV communicating patients. In conclusion, this anastomotic technique using vascular clips resulted in sound patency of the graft, which was accomplished by a simple technique. Preoperative CT AP with the RHV occlusion method can be useful for determining whether hepatic vein reconstruction is necessary.
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Venas Hepáticas/cirugía , Vena Ilíaca/trasplante , Engrapadoras Quirúrgicas , Anciano , Carcinoma Hepatocelular/cirugía , Cateterismo , Femenino , Hepatectomía/métodos , Humanos , Cirrosis Hepática/complicaciones , Pruebas de Función Hepática , Neoplasias Hepáticas/secundario , Neoplasias Hepáticas/cirugía , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
We report a case of a pancreaticoduodenal artery (PDA) aneurysm in association with celiac axis occlusion. A 54 year-old female complaining of abrupt onset of abdominal pain was admitted to our hospital. On admission, abdominal CT examination revealed a hematoma in the retroperitoneal space. Selective superior mesenteric artery (SMA) angiography disclosed an aneurysm in the anterior inferior pancreaticoduodenal artery (AIPDA). The celiac axis was occluded and blood was flowing to the liver and spleen via the enlarged pancreaticoduodenal arcade from the SMA. Transcatheter embolization of the aneurysm was performed successfully. Up to 1996, there have been 37 reported cases of PDA aneurysm in association with celiac axis stenosis or occlusion, including this one. Transcatheter embolization was performed successfully in only 5 of these cases. The formation of this type of PDA aneurysm is thought to be a result of the increased blood flow in the pancreaticoduodenal arcade due to celiac axis stenosis or occlusion. The transcatheter embolization performed in our report produced a far greater blood flow, which may lead to further aneurysmal formation. Careful follow-up is therefore necessary.
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Aneurisma/terapia , Arteriopatías Oclusivas/terapia , Arteria Celíaca , Duodeno/irrigación sanguínea , Embolización Terapéutica , Páncreas/irrigación sanguínea , Aneurisma/diagnóstico por imagen , Angiografía , Arteriopatías Oclusivas/complicaciones , Arteriopatías Oclusivas/diagnóstico por imagen , Arteria Celíaca/diagnóstico por imagen , Femenino , Humanos , Procesamiento de Imagen Asistido por Computador , Persona de Mediana Edad , Tomografía Computarizada por Rayos XRESUMEN
Obturator hernia is relatively rare and occurs mostly in elderly, thin, multiparous women. Recent reports have highlighted the importance of pelvic computed tomography (CT) for the preoperative diagnosis. Thirty-six patients with an obturator hernia operated in our hospital were divided retrospectively into two groups (group A: 18 operations from 1973 to 1986, before we used CT; group B: 18 CT cases from 1987 to 1995). Preoperative diagnoses, operative procedures, and postoperative course were reviewed. No statistically significant differences were found between groups A and B in terms of patient characteristics. Rates of accurate preoperative diagnoses were significantly higher in group B: 39% (7/18) in group A and 78% (14/18) in group B (p = 0.018). The intraoperative findings, occurrence of postoperative complications, and overall mortality rates were similar between the two groups. There were four postoperative deaths (mortality rate 11%). Three of four patients who died had panperitonitis because of small bowel perforation. The correct preoperative diagnosis of obturator hernia was facilitated by CT of the pelvis, but it has no impact on patient outcome. Early diagnosis and surgical intervention are essential for this rare entity.
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Hernia Obturadora/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Anciano , Anciano de 80 o más Años , Causas de Muerte , Femenino , Hernia Obturadora/cirugía , Humanos , Perforación Intestinal/complicaciones , Intestino Delgado/patología , Intestino Delgado/cirugía , Cuidados Intraoperatorios , Laparotomía , Tiempo de Internación , Masculino , Peritonitis/etiología , Complicaciones Posoperatorias , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
A case of obstructive colitis caused by possible stricture of colostomy is herein reported. A 58 year old female with an obstructive sigmoid colon cancer underwent an emergency descending decompression colostomy. At laparotomy, the colon proximal to the carcinoma was markedly distended and the bowel wall was thin, but the serosa appeared normal. Postoperatively, however, abdominal pain and distension persisted and low grade fever developed. Diarrhea through the colostomy continued. Nine days after the initial surgery, she underwent a left hemicolectomy. An abnormally thickened segment was identified in the resected specimen; normal mucosa was lost and several pseudopolyps were scattered. Histopathological findings of the abnormal segment were consistent with obstructive colitis. A preserved segment of normal mucosa intervened between the site of colostomy and the abnormal segment of obstructive colitis. A possible stenosis of the colostomy was considered to have caused colostomy dysfunction and subsequent obstructive colitis. She was complicated with anastomotic leakage due to the diseased colon being used for anastomosis. Obstructive colitis should be kept in mind in patients with obstructive colonic carcinomas who complain of persistent abdominal pain, distension and diarrhea in the early postoperative period after colostomy.
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Colitis/etiología , Colostomía/efectos adversos , Obstrucción Intestinal/etiología , Colitis/patología , Colitis/cirugía , Colon/patología , Colon/cirugía , Femenino , Humanos , Obstrucción Intestinal/patología , Obstrucción Intestinal/cirugía , Persona de Mediana Edad , Neoplasias del Colon Sigmoide/cirugíaRESUMEN
We describe herein the first successful implementation of intraportal stent placement combined with right portal vein embolization as preoperative management against far advanced gallbladder carcinoma. The patient was a 66-year-old woman with obstructive jaundice, in whom computed tomography confirmed that gallbladder carcinoma had invaded the liver and that massive lymph node metastases involved the hepatoduodenal ligament. Portography also revealed severe stenosis of the main portal trunk to less than 2 mm in diameter. To prevent the contribution of intraportal thrombosis and ensure postoperative liver functional reserve, an intraportal metallic stent implantation was conducted simultaneously with right portal vein embolization via a single route using the percutaneous transhepatic approach. There were no complications following this technique, and the patient subsequently underwent hepato-ligament-pancreatoduodenectomy. The resected specimen disclosed a well-expanded stent containing no thrombus. This method could therefore be an amenable strategy for the preoperative treatment of far advanced biliary malignancies in selected patients.
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Embolización Terapéutica , Neoplasias de la Vesícula Biliar/terapia , Vena Porta , Stents , Trombosis/prevención & control , Anciano , Femenino , Neoplasias de la Vesícula Biliar/cirugía , Humanos , Pancreaticoduodenectomía/métodos , Cuidados PreoperatoriosRESUMEN
OBJECTIVE: Lactate dehydrogenase (LDH) has been reported to be a sensitive indicator of pancreatic necrosis (PN). In patients with biliary pancreatitis (BP), however, liver enzymes are generally elevated early in the course of the disease because of acute inflammatory liver cell injury caused by ampullary stones impacted during their transpapillary passage. Accordingly, the identification of PN using the initial high LDH activity as an indicator of PN in BP may not be accurate. In patients with ongoing PN, LDH would be expected to increase thereafter. We hypothesized that an elevation of the ratio of LDH to aspartate aminotransferase (AST) (LDH/AST) would better reflect PN in BP. METHODS: The plasma concentrations of the LDH/AST ratio over a 3-wk postadmission period were evaluated and compared with serial computed tomograpy (CT) scans of the abdomen in two groups of patients with BP, consisting of 5 PN patients and 17 non-PN patients. A group of 50 healthy adults served as controls for the LDH/AST ratio measurement. RESULTS: On postadmission days 1 and 2, the LDH/AST ratios in both groups of patients were low, with no significant difference. In the PN patients, the LDH/AST ratio increased thereafter, reached peak values, and decreased. In the non-PN patients, the LDH/AST ratio increased gradually, but remained within the control range. In the PN patients, the LDH/AST ratios on postadmission days 3, 5, and 7 were significantly higher than those of the non-PN patients. The CT scans of the abdomen of the PN patients showed an initial edematous pancreas with the development of late PN. The peak values of the LDH/AST ratio correlated well with the extent of PN. CONCLUSION: An elevated LDH/AST ratio identifies patients who develop PN. The LDH/AST ratio could be used as an indicator of PN in BP patients.