Distal pancreatectomy with duct-to-mucosa pancreaticogastrostomy: a novel technique for preventing postoperative pancreatic fistula.

BACKGROUND: Management of the pancreatic remnant after distal pancreatectomy remains a clinically relevant problem and a significant clinical challenge. We evaluated the safety and efficacy of duct-to-mucosa pancreaticogastrostomy for preventing pancreatic fistula development after distal pancreatectomy. METHODS: Twenty-one patients underwent distal pancreatectomy using the duct-to-mucosa pancreaticogastrostomy and the clinical data were collected prospectively. Pancreatic fistula was defined and classified according to the international study group definition. RESULTS: The median surgical time was 236 minutes, with a median intraoperative blood loss of 250 mL. Morbidity was 5% and mortality was nil. The postoperative pancreatic fistula rate of clinically relevant grade B or C fistulae was 0%, although the biochemical grade A fistula rate was 29%. Delayed gastric emptying developed in only 1 patient (5%). CONCLUSIONS: Duct-to-mucosa pancreaticogastrostomy may be a safe and effective technique for preventing pancreatic fistula development after distal pancreatectomy when performed by experienced surgeons who are skilled in this technique.

Reduced pancreatic parenchymal thickness indicates exocrine pancreatic insufficiency after pancreatoduodenectomy.

BACKGROUND: The aim of this study was to investigate whether perioperative morphologic characteristics are predictive of exocrine pancreatic function after pylorus-preserving pancreatoduodenectomy (PPPD) with pancreaticogastrostomy. MATERIALS AND METHODS: A 13C-labeled mixed triglyceride breath test was performed in 52 patients after PPPD to assess postoperative exocrine pancreatic function. A value of percent 13CO2 cumulative dose at 7 h (%CD-7 h) of less than 5% was considered diagnostic of exocrine pancreatic insufficiency. Pre- and postoperative pancreatic parenchymal thicknesses were calculated using computed tomography (CT) scans, and compared by means of receiver operating characteristic (ROC) analysis. RESULTS: Thirty-four (65.4%) of 52 patients were found to have exocrine pancreatic insufficiency based on the breath test. With ROC analysis for identification of exocrine pancreatic insufficiency, the areas under the ROC curve for the postoperative pancreatic parenchymal thickness were higher than those for the preoperative pancreatic parenchymal thickness (0.904 and 0.702, respectively, P=0.009). When the cut-off value of the postoperative pancreatic parenchymal thickness was set at 13.0 mm, the sensitivity and specificity for identifying exocrine pancreatic insufficiency were 88.2% and 88.9%, respectively. CONCLUSION: Reduced postoperative pancreatic parenchymal thickness is a reliable indicator of exocrine pancreatic insufficiency after PPPD.

Number of metastatic lymph nodes, but not lymph node ratio, is an independent prognostic factor after resection of pancreatic carcinoma.

BACKGROUND: This study evaluated the prognostic significance of the number of metastatic lymph nodes and the ratio of metastatic nodes to total number of examined lymph nodes (lymph node ratio, LNR) after resection of pancreatic carcinoma. STUDY DESIGN: Records of 119 consecutive patients with pancreatic ductal carcinoma, who underwent R0 or R1 pancreatectomy with regional node dissection, were reviewed retrospectively. Clinical factors, pathologic factors including number of metastatic nodes and LNR, and survival were analyzed by univariate and multivariate analyses. RESULTS: Overall survival rates were 78%, 28%, and 20% at 1, 3, and 5 years, respectively. The median numbers of evaluated lymph nodes and involved nodes were 28 and 3, respectively. Univariate analysis revealed that tumor location, postoperative adjuvant chemotherapy, tumor differentiation, choledochal invasion, portal or splenic vein invasion, extrapancreatic nerve plexus invasion, resection margin status, node status, number of involved nodes, LNR, International Union against Cancer (UICC) pT factor, and UICC stage correlated significantly (p < 0.05) with increased survival. By multivariate analysis, negative node metastasis (p = 0.008) and 0 or 1 involved node (p = 0.004), but not LNR, correlated independently with longer survival. The 1-, 3-, and 5-year survival rates of patients with 0 or 1 metastatic node and patients with 2 or more metastatic nodes were 91%, 48%, and 40% and 66%, 10%, and 0%, respectively. CONCLUSIONS: The number of metastatic nodes, but not LNR, is one of the most powerful prognostic factors after resection of pancreatic carcinoma.

Hepatic angiomyolipoma: a case report.

We experienced a rare case of hepatic angiomyolipoma (AML). A 66-year old Japanese female presented inhomogeneous echogenic lesion in the lateral segment of the liver on ultrasonography. Contrast computed tomography (CT) revealed early arterial enhancement within the lesion that stayed hyperdense in the equilibrium phase. Magnetic resonance imaging (MRI) demonstrated a non-homogeneous and partially high intensity mass on both T1- and T2-weighted images. Selective hepatic digital subtraction angiography (DSA) showed the lesion to be inhomogeneously hypervascular, supplied via branches of the left hepatic artery. The patient underwent elective left hemihepatectomy. Microscopic findings demonstrated that the tumor was composed of fat cells, blood vessels, and smooth muscle cells. Most of the spindle cells were immunoreactive to homatropine methylbromide 45 (HMB-45), alpha-smooth muscle actin and Melan-A/MART-1. Morphological pattern and immunophenotype were consistent with hepatic angiomyolipoma.

Prognostic impact of perioperative serum CA 19-9 levels in patients with resectable pancreatic cancer.

BACKGROUND: Pancreatic cancer is one of the most deadly cancers, and serum carbohydrate antigen 19-9 (CA19-9) level has been reported to be a useful prognostic marker in pancreatic cancer. The purpose of this study was to determine which prognostic factor (preoperative or postoperative serum CA19-9 level) is more useful. METHODS: Pre- and postoperative serum CA19-9 levels were measured in 109 patients who underwent surgical resection for pancreatic cancer between 1998 and 2009, and their relationships to clinicopathological factors and overall survival were analyzed with univariate and multivariate methods. RESULTS: In univariate analysis, tumor location (P = 0.019), postoperative adjuvant chemotherapy (P < 0.001), residual tumor factor status (P < 0.001), UICC pT stage (P = 0.004), lymph node metastasis (P = 0.015), and UICC final stage (P = 0.015) were significantly associated with overall survival. Differences in overall survival were significant between groups divided on the basis of four postoperative CA19-9 cutoff values (37, 100, 200, and 500 U/ml) but not significant between groups divided on the basis of the same four preoperative CA19-9 cutoff values. Pre- to postoperative increase in CA19-9 level also was significantly associated with poor prognosis. In multivariate analysis, postoperative adjuvant chemotherapy (hazard ratio, 1.59; P = 0.004) and postoperative CA19-9 cutoff value of 37 U/ml (HR, 1.64; P = 0.004) remained independent predictors of prognosis. CONCLUSIONS: Postoperative CA19-9 level is a better prognostic factor than preoperative CA19-9 level, and curative surgery for resectable pancreatic cancer should be tried regardless of the preoperative CA19-9 level.

Middle pancreatectomy with pancreaticogastrostomy: a technique, operative outcomes, and long-term pancreatic function.

BACKGROUND AND OBJECTIVES: Middle pancreatectomy is infrequently performed in selected patients. The rationale is to preserve pancreatic function. This study evaluates a technique, operative outcomes, and long-term exocrine and endocrine pancreatic function of the middle pancreatectomy procedure. METHODS: Nineteen patients who underwent middle pancreatectomy between 1996 and 2008 were reviewed. Indications included eight intraductal papillary-mucinous neoplasms, five endocrine tumors, one serous and two mucinous cystadenomas, and three other benign lesions. Reconstruction of the distal pancreatic remnant was performed with pancreaticogastrostomy using the duct-to-mucosa method in 16 patients and with Roux-en-Y end-to-end pancreaticojejunostomy in 3 patients. RESULTS: Median operative time was 215 min. Perioperative mortality was nil. Morbidity was 53%, including 9 (47%) pancreatic fistulas. One patient with hemorrhage, complicated by a pancreatic fistula was successfully treated by endovascular embolization. No patients required postsurgical reoperation. Only one patient had clinical exocrine insufficiency requiring pancreatic enzyme supplementation. None developed postresection new-onset insulin-dependent diabetes. CONCLUSIONS: Middle pancreatectomy with pancreaticogastrostomy is feasible and reasonable technique. Although the incidence of pancreatic fistula formation may still be higher compared to conventional resection, long-term exocrine, and endocrine pancreatic function may be preserved. Thus, careful patient selection and experienced pancreatic surgeons in high-volume centers are of great importance.

Combination of polyglicolic acid felt and fibrin glue for prevention of pancreatic fistula following pancreaticoduodenectomy.

The most frequent cause of morbidity following pancreaticoduodenectomy is pancreatic fistula. An appropriate technique to minimize pancreatic fistula is very important. Polyglicolic acid felt combined with fibrin glue has been applied in other organ surgery with excellent results and without any notable adverse reactions. We herein describe a new technique for prevention of pancreatic fistula using the combination of polyglicolic acid felt and fibrin glue as an adjunct of pancreaticoenterostomy following pancreaticoduodenectomy. Polyglicolic acid felt combined with fibrin glue as an adjunct of pancreaticoenterostomy was applied prospectively to 25 consecutive patients undergoing pancreaticoduodenectomy. Drain amylase was measured daily after the surgery and the incidences of complications were recorded. Median drain amylase on day 1 after surgery was 745 IU/L, on day 2 it was 427 IU/L, on day 3 it was 97 IU/L, and on day 5 it was 38 IU/L. Three patients (12%) developed grade A pancreatic fistula. No grade B or C pancreatic fistula was observed. No re-do operations, no postoperative percutaneous drainage, and no surgical mortality occurred. The combination of polyglicolic acid felt and fibrin glue was extremely favorable for prevention of pancreatic fistula following pancreaticoduodenectomy.

Adjuvant gemcitabine plus S-1 chemotherapy improves survival after aggressive surgical resection for advanced biliary carcinoma.

OBJECTIVE: The aim of this study was to evaluate the efficacy of adjuvant gemcitabine plus S-1 chemotherapy after aggressive surgical resection for advanced biliary carcinoma. SUMMARY BACKGROUND DATA: No effective adjuvant therapy for advanced biliary carcinoma has been reported although its prognosis is extremely poor. METHODS: Medical records were reviewed for 103 patients with International Union Against Cancer (UICC) stage II biliary carcinoma who underwent aggressive surgical resection. About 50 patients received 10 cycles of adjuvant gemcitabine plus S-1 chemotherapy and 53 patients did not. Clinicopathological factors and patient survival were compared between the 2 groups using univariate and multivariate analysis. A cycle of chemotherapy consisted of intravenous gemcitabine 700 mg/m(2) on day 1 and oral S-1 50 mg/m(2) for 7 consecutive days, followed by a 1-week break from chemotherapy. RESULTS: Patient demographics, tumor characteristics, and surgical procedures did not differ between the 2 groups. Aggressive surgical procedures including major hepatectomy or pancreatoduodenectomy were performed for 94 of 103 patients. In the chemotherapy group, 37 patients (74%) were given the full number of 10 cycles. The use of postoperative adjuvant chemotherapy (P < 0.001) and surgical margin status (P = 0.003) were independently associated with long-term survival by multivariate analysis. Five-year survival rates of patients who did or did not receive postoperative adjuvant chemotherapy were 57% and 24%, respectively (P < 0.001). Toxicity during chemotherapy was mild. CONCLUSIONS: Adjuvant gemcitabine plus S-1 chemotherapy may be one of several factors contributing to improved outcomes after aggressive surgical resection of advanced biliary carcinoma in recent years.

Analysis of fat digestive and absorptive function after subtotal gastrectomy by a 13C-labeled mixed triglyceride breath test.

BACKGROUND/AIM: In the choice of reconstructions, digestive and absorptive disturbances, resulting in weight loss after subtotal gastrectomy, remain a problem. The aim of this study was to compare fat absorptive function after Billroth I (B-I) and Roux-en-Y (RY) reconstructions after subtotal gastrectomy for gastric cancer. METHODS: A (13)C-labeled mixed triglyceride breath test was performed in 31 patients after subtotal gastrectomy and in 15 healthy volunteers to assess fat digestive and absorptive function. Seventeen B-I reconstructions and 14 RY reconstructions were performed after subtotal gastrectomy. Fat digestive and absorptive function was determined by percent (13)CO(2) cumulative dose at 7 h. Relationship between fat absorptive function and perioperative factors were analyzed. RESULTS: Gender distribution, mean age, pathological staging, level of lymph node dissection, preservative procedure of the vagus nerve and mean follow-up period in the two surgical groups did not differ significantly. Only the type of reconstruction (p = 0.024) was associated with differences in fat digestive and absorptive function by univariate analysis: B-I reconstruction was superior to RY reconstruction. CONCLUSIONS: Fat digestive and absorptive function after B-I reconstruction was superior to that after RY reconstruction, probably because the B-I reconstruction was the procedure that permitted food passage through the duodenum.

Gemcitabine-based adjuvant chemotherapy improves survival after aggressive surgery for hilar cholangiocarcinoma.

BACKGROUND: The prognosis of hilar cholangiocarcinoma is dismal although aggressive surgery including major hepatectomy has been performed. The aim of this study was to clarify useful prognostic factors and the usefulness of gemcitabine-based adjuvant chemotherapy for patients with hilar cholangiocarcinoma who had undergone aggressive surgical resection. METHODS: Medical records of 42 patients with hilar cholangiocarcinoma who underwent surgical resection were reviewed retrospectively. Univariate and multivariate models were used to analyze the effect of various clinicopathological factors on long-term survival. RESULTS: Overall 1-, 3-, and 5-year survival rates of the 42 patients with hilar cholangiocarcinoma were 81%, 42%, and 30%, respectively (median survival time, 21.5 months). Univariate analysis revealed that adjuvant gemcitabine-based chemotherapy, tumor differentiation, lymph node metastasis, and surgical margin status were associated significantly with long-term survival (P < 0.05). Furthermore, use of a Cox proportional hazards regression model indicated that only adjuvant gemcitabine-based chemotherapy was a significant independent predictor of a favorable prognosis (P = 0.035). The toxicity of adjuvant gemcitabine-based chemotherapy was mild. Five-year actuarial survival rates of patients who did or did not receive adjuvant gemcitabine-based chemotherapy were 57% and 23%, respectively (P = 0.026). CONCLUSIONS: Postoperative adjuvant gemcitabine-based chemotherapy may be a promising strategy to improve survival after surgical resection for hilar cholangiocarcinoma. A prospective randomized study should be done to confirm the results of this study.

Predictive factors for exocrine pancreatic insufficiency after pancreatoduodenectomy with pancreaticogastrostomy.

INTRODUCTION: The aim of this study was to determine risk factors for exocrine pancreatic insufficiency after pancreatoduodenectomy (PD) with pancreaticogastrostomy (PG). MATERIAL AND METHODS: A (13)C-labeled mixed triglyceride breath test was performed in 61 patients after PD to assess exocrine pancreatic function. Percent (13)CO(2) cumulative dose at 7 h <5% was considered diagnostic of exocrine pancreatic insufficiency. Abdominal computed tomography scans were utilized to assess the dilatation of the main pancreatic duct (MPD dilatation) in the remnant. RESULTS: Thirty-eight of 61 patients (62.3%) were diagnosed with exocrine pancreatic insufficiency. Univariate analysis identified significant associations between two preoperative factors (preoperative impaired endocrine function and a hard pancreatic texture induced by preexisting obstructive pancreatitis), plus one postoperative factor (MPD dilatation caused by PG stricture) and exocrine pancreatic insufficiency (P < 0.05). Multivariate analysis determined that all three of these factors were independent factors (P < 0.05). CONCLUSIONS: Although exocrine pancreatic insufficiency after PD may be partly explainable by preexisting obstructive pancreatitis prior to surgery, surgeons desiring to obtain better postoperative exocrine pancreatic function after PD would be well-advised to devote considerable attention to preventing PG stricture.

Usefulness of human telomerase reverse transcriptase in pancreatic juice as a biomarker of pancreatic malignancy.

OBJECTIVES: Human telomerase reverse transcriptase (hTERT), one of the subunits of telomerase, is a promising diagnostic marker for pancreatic cancer. In the present study, we did a large-scale analysis of 115 preoperative pancreatic juice specimens to evaluate the feasibility of detection of hTERT expression by immunohistochemistry for preoperative diagnosis of pancreatic malignancy. METHODS: The expression of hTERT was examined by immunohistochemistry in preoperative pancreatic juice samples. RESULTS: In pancreatic juice samples, hTERT expression was detectable in 84% of pancreatic ductal adenocarcinomas (PDACs), whereas 62% of PDACs were positive by cytology. In intraductal papillary mucinous neoplasms (IPMNs), hTERT expression was detectable in 88% of malignant IPMNs, whereas only 22% were positive by cytology. The sensitivity, specificity, and overall accuracy of hTERT expression for differentiation between carcinoma and other benign diseases were 85.1%, 82.1%, and 84.3%, respectively, whereas the same values for cytologic accuracy were 47.1%, 89.3%, and 57.4%, respectively. When the results of cytology and hTERT expression were combined, the sensitivity and overall accuracy increased to 92.0% and 87.8%, respectively. CONCLUSIONS: Our results suggested that the assessment of hTERT expression in preoperative pancreatic juice increased the sensitivity and accuracy of diagnosis of PDACs and malignant IPMNs without using special techniques.

Invasive intraductal papillary-mucinous neoplasm of the pancreas: comparison with pancreatic ductal adenocarcinoma.

BACKGROUND AND OBJECTIVES: The aim of this study was to clarify the clinicopathological differences between patients with invasive intraductal papillary-mucinous neoplasm (IPMN) of the pancreas and pancreatic ductal adenocarcinoma. METHODS: The medical records of 16 patients with invasive IPMN and 106 patients with pancreatic ductal adenocarcinoma, who underwent surgical resection, were retrospectively reviewed, and the clinicopathological factors and survival were compared between the two groups. RESULTS: The presence of retroperitoneal tissue invasion, portal or splenic vein invasion, nodal involvement, and positive surgical margins were significantly lower in patients with invasive IPMN than in those with ductal adenocarcinoma (P < 0.05). The actuarial 5-year overall survival rates in patients with invasive IPMN and ductal carcinoma were 40% and 18%, respectively (P = 0.008). However, the actuarial 5-year survival rate of patients with invasive IPMN was only 27% for UICC stage II disease, although this was significantly higher than that of patients with UICC stage II ductal adenocarcinoma (P = 0.049). CONCLUSIONS: Invasive IPMN has a favorable prognosis compared with pancreatic ductal adenocarcinoma that is likely due to the less aggressive nature of the disease. However, the prognosis for cases of advanced invasive IPMN is not always favorable despite complete tumor resection.

Main pancreatic duct obstruction due to a small nonfunctioning endocrine tumor of the pancreas.

A 65-year-old Japanese male was referred to our hospital for evaluation of a main pancreatic duct obstruction. Two months previously, he had suffered an attack of acute pancreatitis that was resolved with conservative treatment. Dynamic contrast-enhanced study by multidetector row computed tomography revealed a well-enhanced 5 x 5 mm mass in the head of the pancreas with dilatation of the main pancreatic duct in the body and tail. On endoscopic retrograde pancreatography, obstruction of the main pancreatic duct in the head of the pancreas was noted. Pancreatic juice cytology was nondiagnostic. Endoscopic ultrasonography demonstrated a well-defined hypoechoic mass, about 5 mm in size, with distal main pancreatic duct dilatation. The patient underwent elective pylorus-preserving pancreaticoduodenectomy. Pathological examination revealed a well-differentiated endocrine tumor of the pancreas of uncertain behavior, 5 mm in size. Immunohistochemically, the tumor was diffusely positive for chromogranin A and synaptophysin, and focally it was positive for insulin, glucagon, and CA19-9; it was negative for gastrin. The final diagnosis was main pancreatic duct obstruction secondary to a nonfunctioning endocrine tumor of the pancreas of uncertain behavior. Of note, a small nonfunctioning endocrine tumor of the pancreas is important in the differential diagnosis of main pancreatic duct obstruction demonstrated by radiographic examinations.

Usefulness of a 13C-labeled mixed triglyceride breath test for assessing pancreatic exocrine function after pancreatic surgery.

BACKGROUND: Although the fecal elastase-1 test is a satisfactory pancreatic exocrine function test, breath tests that use stable isotopes have been developed recently as alternatives. We evaluated the usefulness of a (13)C-labeled mixed triglyceride breath test for assessing pancreatic exocrine function after pancreatic surgery. METHODS: The breath test and the fecal elastase-1 test were performed on 7 healthy volunteers, 10 patients with chronic pancreatitis, and 95 patients after pancreatic surgery. The breath test was analyzed with isotope ratio mass spectrometry and the cumulative recovery of (13)CO(2) at 7 hours (% dose (13)C cum 7h) was calculated. The fecal elastase-1 concentration was determined immunoenzymatically. RESULTS: Both the fecal elastase-1 concentration and the % dose (13)C cum 7h of chronic pancreatitis patients and pancreatic resection patients were less than those of healthy volunteers. In all subjects, % dose (13)C cum 7h correlated with the fecal elastase-1 concentration (n = 112, R(2) = 0.14, P < .01). Accuracy rates for clinical symptoms, including clinical steatorrhea, for the fecal test and the breath test were 62 and 88%, respectively. CONCLUSION: The (13)C-labeled mixed triglyceride breath test might be more useful than the fecal elastase-1 test for evaluating pancreatic exocrine function after pancreatic resection.

Impact of adjuvant gemcitabine plus S-1 chemotherapy after surgical resection for adenocarcinoma of the body or tail of the pancreas.

BACKGROUND: Few patients with pancreatic body or tail carcinoma are candidates for surgical resection, and the efficacy of postoperative adjuvant chemotherapy for patients with pancreatic body or tail carcinoma has not been elucidated. The aim of this study was to determine the effect of adjuvant gemcitabine and S-1 therapy for patients with adenocarcinoma of the body or tail of the pancreas who had undergone surgical resection by distal pancreatectomy. MATERIALS AND METHODS: Medical records of 34 patients with pancreatic body or tail carcinoma who underwent surgical resection were reviewed retrospectively. Eighteen patients received postoperative adjuvant gemcitabine and S-1 chemotherapy. Univariate and multivariate models were used to analyze the effect of various clinicopathological factors on long-term survival. RESULTS: There were no deaths due to surgery. Overall, 1-, 2-, and 5-year survival rates were 69%, 40%, and 25%, respectively (median survival time, 14.4 months). Univariate analysis revealed that adjuvant gemcitabine plus S-1 chemotherapy, blood transfusion, splenic artery invasion, lymph node metastasis, surgical margin status, and International Union Against Cancer stage were associated significantly with long-term survival (P < 0.05). Furthermore, use of a Cox proportional hazards regression model indicated that adjuvant gemcitabine plus S-1 chemotherapy and absence of lymph node metastasis were significant independent predictors of a favorable prognosis (P < 0.05). CONCLUSION: Postoperative adjuvant gemcitabine plus S-1 chemotherapy may improve survival after surgical resection for pancreatic body or tail carcinoma.

Randomized clinical trial to assess the efficacy of ulinastatin for postoperative pancreatitis following pancreaticoduodenectomy.

BACKGROUND AND OBJECTIVES: Ulinastatin, an intrinsic trypsin inhibitor, has proved to be effective for the prevention of acute pancreatitis after endoscopic retrograde cholangiopancreatography. The aim of this study was to assess the efficacy of ulinastatin for postoperative pancreatitis following pancreaticoduodenectomy in a randomized clinical trial. METHODS: Patients undergoing pancreaticoduodenectomy were randomized to receive perioperative ulinastatin or placebo. Levels of serum amylase, drain amylase, and urine trypsinogen-2 were measured. RESULTS: A total of 42 patients were enrolled (20 in the ulinastatin group, 20 in the placebo group, 2 excluded). Two patients in the ulinastatin group and nine patients in the placebo group developed hyperamylasemia (P = 0.013) No patient in the ulinastatin group and five patients in the placebo group developed pancreatitis (P = 0.016). One patient in the ulinastatin group and two patients in the placebo group developed grade A pancreatic fistula (P = 0.548). Serum amylase levels at 4 hr and postoperative days 1, 2, and 3, and drain amylase levels on days 2 and 3 were significantly lower in the ulinastatin group than in the placebo group. CONCLUSIONS: Prophylactic administration of ulinastatin reduced the levels of serum and drain amylase and the incidence of postoperative pancreatitis following pancreaticoduodenectomy.

Long-term pancreatic endocrine function following pancreatoduodenectomy with pancreaticogastrostomy.

BACKGROUND AND OBJECTIVES: The aim of this study was to evaluate long-term pancreatic endocrine function following pancreatoduodenectomy with pancreaticogastrostomy. METHODS: Records of 52 patients who had survived for three or more years following pancreatoduodenectomy with pancreaticogastrostomy were studied retrospectively. Serum HbA(1c) levels had been measured prior to and at 3- to 6-month intervals after surgery. RESULTS: Three of 42 patients with normal preoperative serum HbA(1c) levels (5.8%) showed deterioration of glucose tolerance. Five of these eight patients developed a pancreatic fistula postoperatively. However, the average serum HbA(1c) levels of patients with normal preoperative serum HbA(1c) levels have remained within the normal range for 3-10 years after surgery. CONCLUSIONS: Pancreatic endocrine function was maintained for a long-term period after pancreatoduodenectomy with pancreaticogastrostomy. Impaired glucose tolerance appeared to be associated with postoperative pancreatic fistula formation.

Adjuvant gemcitabine plus S-1 chemotherapy after surgical resection for pancreatic adenocarcinoma.

BACKGROUND: The aim of this study was to determine the effectiveness of adjuvant gemcitabine plus S-1 chemotherapy for patients with pancreatic carcinoma. METHODS: Patients admitted for curative surgery for pancreatic adenocarcinoma received adjuvant chemotherapy with 10 cycles of gemcitabine plus S-1 every 2 weeks. Each chemotherapy cycle consisted of intravenous gemcitabine, 700 mg/m(2), on day 1 and orally administered S-1, 50 mg/m(2), for 7 consecutive days, after which there was a 1-week pause of chemotherapy. RESULTS: Twenty-seven patients were entered into this study. According to the TNM system, 4 (15%), 2 (7%), 6 (22%), and 15 (56%) patients were diagnosed with stage IA, IB, IIA, and IIB disease, respectively. Overall and disease-free survival rates were 86% and 60% at 1 year, 66% and 45% at 2 years, and 33% and 45% at 3 years, respectively. Toxicity during chemotherapy was mild. CONCLUSIONS: Adjuvant gemcitabine plus S-1 chemotherapy appears to be a promising treatment for patients after surgical resection of pancreatic adenocarcinoma.

An antecolic Roux-en Y type reconstruction decreased delayed gastric emptying after pylorus-preserving pancreatoduodenectomy.

The aim of this study was to identify a preferable procedure reducing the incidence of delayed gastric emptying (DGE) after pylorus-preserving pancreatoduodenectomy (PPPD). Data on 132 consecutive patients with pancreatobiliary disease, who underwent PPPD, were collected retrospectively. A retrocolic Billroth I type reconstruction (B-I group) and an antecolic Roux-en Y type reconstruction (R-Y group) were performed for 54 and 78 patients after PPPD, respectively. Clinical measures of DGE were compared between the two groups. The incidence of DGE was 81% in B-I group and 10% in R-Y group (P < 0.001). The type of reconstruction (P < 0.001), operative time (P = 0.016), and postoperative complications (P = 0.001) were significantly associated with DGE by univariate analysis. Only the type of reconstruction (P < 0.001) was identified as an independent factor, which was associated with DGE by multivariate analysis. An antecolic Roux-en Y type duodenojejunostomy could be a useful reconstruction method after PPPD to prevent the occurrence of DGE.