Efficacy of laparoscopic resection in elderly patients with colorectal cancer.

PURPOSE: The perioperative outcomes of laparoscopic colorectal surgery in elderly patients were compared with those of open surgery in elderly patients and those of laparoscopic surgery in nonelderly patients to evaluate the feasibility and efficacy of laparoscopic surgery in elderly patients with colorectal cancer. METHODS: The data of the patients who underwent surgical resection for colorectal cancer between January 2007 and September 2012 were retrospectively collected. The clinical backgrounds and outcomes of elderly patients (≥ 70 years of age) who underwent laparoscopic surgery (EL group) were compared with those of elderly patients who underwent open surgery (EO group) and those of nonelderly patients (< 70 years of age) who underwent laparoscopic surgery (NL group). RESULTS: Compared with the EO group, the EL group showed significantly less blood loss (15 versus 100 ml), fewer postoperative complications (10.7 versus 36.7 %), earlier resumption of an oral diet (4 versus 5 days) and shorter postoperative hospital stays (16 versus 28 days). A case-matched analysis showed similar results. All perioperative outcomes were equivalent between the EL and NL groups. CONCLUSIONS: Laparoscopic colorectal surgery in elderly patients with cancer was not only superior to open surgery in elderly patients, but also equivalent to laparoscopic surgery in nonelderly patients in terms of the postoperative outcomes.

A complete response in small cell carcinoma of the esophagus treated by s-1/cisplatin combined chemotherapy and radiotherapy.

Small cell carcinoma of the esophagus (SmCCE) is a rare disease which is considered to be more malignant than the most common types of esophageal cancer. The optimal treatment strategy for this disease still remains controversial. A 69-year-old male was diagnosed to have SmCCE (stage IIIA, T3N1M0). Due to the patient's poor general condition, chemo-radiotherapy consisting of S-1/cisplatin therapy and a total of 60 Gy of radiotherapy was performed. After the treatment, the main lesion completely disappeared while some ulceration remained. A histological examination revealed no viable cancer cells in biopsy specimens obtained by endoscopy. Computed tomographic examinations showed a decreased wall thickness of the esophagus and an improvement in the swelling of the lymph nodes. S-1 monotherapy was administered following the main chemoradiation therapy, and it was performed for a total of 20 courses. The patient has been doing well without recurrence for over 3 years. We judged the effect to be a complete response. This combination chemo-radiotherapy with S-1 and cisplatin may therefore be one of the effective treatments against SmCCE.

Cyst size indicates malignant transformation in branch duct intraductal papillary mucinous neoplasm of the pancreas without mural nodules.

OBJECTIVES: In branch duct intraductal papillary mucinous neoplasm (IPMN) of the pancreas, the importance of the cyst size to predict malignancy is still controversial. Our aim was to elucidate the malignant potential of branch duct IPMN without mural nodules (flat branch duct IPMN). METHODS: Seventy-three patients with flat branch duct IPMNs were studied in our institution. RESULTS: There were 6 malignant IPMNs in this series, all of which were 30 mm or more in size, whereas there was no malignancy in IPMNs of less than 30 mm. Statistically significant predictors of malignancy were atypical cytological condition and main pancreatic duct (MPD) diameter of 5 mm or more. The cyst size of 30 mm or more tended to be associated with malignancy. The frequency of malignancy in flat branch duct IPMNs with the size of 30 mm or more and MPD diameter of less than 5 mm was 3.6%, whereas there were 5 malignant cases (26.3%) in flat branch duct IPMNs with the size of 30 mm or more and MPD diameter of 5 mm or more. CONCLUSIONS: We conclude that the size criteria (> or =30 mm) to predict malignancy proposed in the international consensus guidelines is appropriate and resection or meticulous follow-up using cytological examination and MPD dilatation is needed in patients with flat branch duct IPMNs.

Factors in intraductal papillary mucinous neoplasms of the pancreas predictive of lymph node metastasis.

BACKGROUND: Little is known about the frequency of lymph node metastasis (LNM) in intraductal papillary mucinous neoplasms (IPMNs), and we have not been able to determine how much lymph node dissection is necessary in individual cases. The aim of this study was to investigate the predictive factors for the LNM in IPMNs. METHODS: Medical records of 120 patients pathologically diagnosed as having IPMN were reviewed, and 16 possible predictive factors regarding the LNM were analyzed. RESULTS: LNM was observed in 7 patients (6%), all of whom were diagnosed as having mural nodules preoperatively. Sensitivity, specificity, and accuracy of preoperative imaging for detecting mural nodules of IPMNs in this study were 84, 97, and 90%, respectively. Univariate analysis using 61 patients having mural nodules preoperatively revealed that the size of mural nodules ≥10 mm and positive imaging findings for invasive tumor and possible LNM were significant predictive factors for the LNM. Multivariate analysis demonstrated that only an imaging finding for invasive tumor was an independent significant predictive factor. Positive and negative predictive values of the imaging finding of invasive IPMNs for LNM were 50 and 98%, respectively. CONCLUSIONS: Standard lymph node dissection would be recommended in patients with IPMNs with mural nodules demonstrating preoperative imaging findings for invasive carcinomas. and IAP.

Autoimmune pancreatitis diagnosed after pancreatoduodenectomy and successfully treated with low-dose steroid.

A 69-year-old woman presented with obstructive jaundice and a 30-mm hypoechoic mass in the pancreatic head on ultrasonography. Magnetic resonance imaging (MRI) revealed enlargement of the pancreatic head with dilatation of the upstream main pancreatic duct and no dilatation of the proximal biliary tree. Endoscopic retrograde pancreatography showed a localized irregular narrowing of the main pancreatic duct in the head of the pancreas. Pylorus-preserving pancreatoduodenectomy (PPPD) was performed under the diagnosis of pancreatic head cancer. Histopathological examination showed fibrosis with lymphoplasmacytic infiltration, suggesting the diagnosis of autoimmune pancreatitis (AIP). Serum IgG concentration was within normal limits immediately after the operation but was elevated 4 months later, when MRI showed enlargement of the remnant pancreas, with a peripheral rim of low intensity. Oral administration of prednisolone was initiated, at a dose of 5 mg/day. The serum IgG concentration declined and MRI showed improvement of the pancreatic enlargement and the disappearance of the peripheral rim. AIP has not relapsed for 1 year so far, with the patient being kept on 5 mg/day prednisolone. This communication reports a patient with AIP showing an interesting clinical course.

Construct validity for eye-hand coordination skill on a virtual reality laparoscopic surgical simulator.

BACKGROUND: This study was carried out to investigate whether eye-hand coordination skill on a virtual reality laparoscopic surgical simulator (the LAP Mentor) was able to differentiate among subjects with different laparoscopic experience and thus confirm its construct validity. METHODS: A total of 31 surgeons, who were all right-handed, were divided into the following two groups according to their experience as an operator in laparoscopic surgery: experienced surgeons (more than 50 laparoscopic procedures) and novice surgeons (fewer than 10 laparoscopic procedures). The subjects were tested using the eye-hand coordination task of the LAP Mentor, and performance was compared between the two groups. Assessment of the laparoscopic skills was based on parameters measured by the simulator. RESULTS: The experienced surgeons completed the task significantly faster than the novice surgeons. The experienced surgeons also achieved a lower number of movements (NOM), better economy of movement (EOM) and faster average speed of the left instrument than the novice surgeons, whereas there were no significant differences between the two groups for the NOM, EOM and average speed of the right instrument. CONCLUSIONS: Eye-hand coordination skill of the nondominant hand, but not the dominant hand, measured using the LAP Mentor was able to differentiate between subjects with different laparoscopic experience. This study also provides evidence of construct validity for eye-hand coordination skill on the LAP Mentor.

Long-term results of treatment for pancreaticobiliary maljunction without bile duct dilatation.

HYPOTHESIS: Resection of the gallbladder together with the dilated bile duct is the preferred treatment for pancreaticobiliary maljunction (PBM) with bile duct dilatation, whereas this treatment for PBM without bile duct dilatation is still controversial. DESIGN: Retrospective study of 196 patients from January 1979 to November 2004. SETTING: Two university hospitals. PATIENTS: One hundred ninety-six patients with PBM, 152 (78%) with and 44 (22%) without bile duct dilatation, formed the basis of this study. MAIN OUTCOME MEASURES: The effects of cholecystectomy on long-term results in the patients without bile duct dilatation. RESULTS: Significant differences were observed in patients without bile duct dilatation: patients were older, carcinoma of the gallbladder was more prevalent (19 patients [43.2%] without dilatation vs 9 patients [5.9%] with dilatation), and pancreatic cancer and pancreatitis were also more frequent. Most of their gallbladder carcinomas were found at stage IV (63%). The outcome was very poor in stage IV, whereas 5 patients in stage I and II lived for more than 5 years after surgery. Of the 44 patients without bile duct dilatation, 23 with carcinoma of the gallbladder or pancreas died and the other 2 were lost to follow-up. The remaining 19 patients were alive at the study's conclusion after cholecystectomy without bile duct resection. None of them had bile duct carcinoma at the time of surgery or during the mean follow-up period of 9 years after surgery. CONCLUSIONS: Prophylactic cholecystectomy without bile duct resection is the best treatment option for patients with PBM without bile duct dilatation. Possible association of gallbladder carcinoma should be kept in mind at the time of treatment of patients with PBM when the bile duct is not dilated.

Type of gastrointestinal reconstruction affects postoperative recovery after pancreatic head resection.

BACKGROUND/PURPOSE: The postoperative recovery of gastric motility with various reconstructions after pancreatic head resection has been reported. However, little is known about this recovery after pancreatic head resection with segmental duodenectomy (PHRSD). Some have attributed gastric stasis after pylorus-preserving pancreatoduodenectomy (PPPD) to tube gastrostomy, but its effect on gastric motility has not been investigated. In this study, the postoperative recovery after PHRSD and PPPD, and gastric motility with and without gastrostomy after PPPD were investigated. METHODS: We analyzed the first appearance of gastric phase III motility, postoperative systemic status, and body weight (BW; n = 32). The Imanaga PPPD and PHRSD were compared because the procedures differ only in the length of the remaining duodenum. Traverso and Roux-en-Y PPPDs were compared because the two procedures are similar except for the creation of gastrostomy. RESULTS: (1) Times to first appearance of gastric phase III motility and BW recovery were significantly better after PHRSD than after the Imanaga PPPD (P < 0.05). (2) Times to first gastric phase III motility and resumption of a regular diet as well as periods of gastric sump tube use and postoperative hospital stay were significantly shorter after the Roux-en-Y than after the Traverso PPPD (P < 0.05). CONCLUSIONS: Preservation of as long a portion of the duodenum as possible, the choice of a Roux-en-Y duodenojejunostomy, and the avoidance of peritoneal fixation of the gastric wall may be factors that improve the recovery of gastric motility and BW after pancreatic head resection.

Total pancreatectomy for intraductal papillary-mucinous tumor of the pancreas: reappraisal of total pancreatectomy.

BACKGROUND/AIMS: Total pancreatectomy is rarely performed as the treatment of pancreatic carcinoma because of markedly impaired quality of life and poor prognosis. Intraductal papillary-mucinous tumor (IPMT) of the pancreas is characterized by extensive intraductal spread and favorable outcome even in its invasive stage. The role of total pancreatectomy was reappraised in the treatment of IPMT. METHODOLOGY: A total of five Japanese patients with IPMT underwent total pancreatectomy and their clinical follow-up data were reviewed. RESULTS: Total pancreatectomy was performed due to massive involvement of the entire pancreas in two patients, positive surgical margins on frozen section in one, benign IPMT with concomitant pancreatic cancers in one and recurrent IPMT in the remnant pancreas after distal pancreatectomy for IPMT in the other. Three of them underwent total pancreatectomy of the Whipple type, another underwent total gastrectomy and the other underwent the pylorus-preserving method. Surgical margins were negative by histology and no lymph node metastases were evident. Two patients had severe infection including liver abscess in one and pneumonia in the other. The former died on postoperative day 82 and the latter was controlled by medical treatment and discharged on postoperative day 73. The other three patients had an uneventful postoperative course and were discharged from 29 to 62 days after the operation. Long-term follow-up of the four patients revealed that three patients had hypoglycemic attacks, two diabetic retinopathy and two fatty liver. The four patients were doing well from 683 to 4,140 days after the operation without signs of recurrence. CONCLUSIONS: Total pancreatectomy would be indicated as a treatment of benign or malignant IPMT with extensive involvement when patients' condition permits and gives a chance of cure, although careful long-term medical care and follow-up are essential.

Radiation therapy, bypass operation and celiac plexus block in patients with unresectable locally advanced pancreatic cancer.

BACKGROUND/AIMS: The great majority of pancreatic cancers are unresectable due to local invasion and/or distant metastasis. The treatment options for such patients include bypass operation, celiac plexus block, radiation therapy (RT), chemotherapy and immunotherapy. RT is divided into intraoperative radiation therapy (IORT) and external radiation therapy (ERT). Appropriate palliative treatment remains controversial. METHODOLOGY: Our experience with palliative treatments including bypass operation, celiac plexus block and RT (IORT and ERT) was retrospectively reviewed in 31 Japanese patients with unresectable locally advanced pancreatic cancer. The 31 patients consisted of seven with no RT, six with ERT alone, seven with IORT alone and 11 with both IORT and ERT. Gastrojejunostomy was performed in 25 patients and biliary bypass was done in 29 patients for the therapeutic or prophylactic purpose. RESULTS: No patients developed gastroduodenal obstruction or jaundice until death. Imaging findings after the treatment showed a decrease in tumor size in 11 of the 18 patients examined, an increase in four and no change in the other three. Of 19 patients complaining of back pain before the operation, the pain had disappeared in 12 but persisted in the other seven after the operation. No patients developed back pain after the treatment. Of the 12 patients with pain relief, nine had both RT and celiac plexus block, two RT alone and the other neither RT nor celiac block. Cumulative 0.5-year and 1.0-year survival rates in the group with RT(-), ERT alone, IORT alone IORT and ERT and IORT were 42.9%, 100%, 100%, 100% and 0%, 33.3%, 57.1% and 45.5%, respectively. The survival curve of the RT(-) group was significantly worse than that of the ERT alone group (P = 0.0029), IORT alone group (P = 0.0101) and IORT and ERT group (P = 0.0109). The survival curves of the three RT groups were similar. CONCLUSIONS: RT significantly prolonged survival of patients with unresectable locally advanced pancreatic cancer and combined palliative treatments including bypass operation, celiac plexus block and RT (ERT or IORT) are recommended for such patients.

Clinical aspects of intraductal papillary mucinous neoplasm of the pancreas.

Intraductal papillary mucinous neoplasm (IPMN) is a spectrum of neoplasia in the pancreatic duct epithelium characterized by cystic dilation of the main and/or branch pancreatic duct. According to the site of involvement IPMNs are classified into three categories, i.e., main duct type, branch duct type, and combined type. Most branch duct IPMNs are benign, whereas the other two types are often malignant. A large size of branch duct IPMN and marked dilation of the main pancreatic duct indicate the presence of adenoma at least. The additional existence of large mural nodules increases the possibility of malignancy in all types. Of recent interest is the relatively high prevalence of synchronous and/or metachronous malignancy in various organs, including the pancreas. The prognosis is favorable after complete resection of benign and noninvasive malignant IPMNs. Malignant IPMNs acquiring aggressiveness after parenchymal invasion necessitate adequate lymph node dissection. On the other hand, asymptomatic branch duct IPMNs without mural nodules can be observed without resection for a considerably long time. This review addresses available data, current understanding, controversy, and future directions.

ERT following IORT improves survival of patients with resectable pancreatic cancer.

BACKGROUND/AIMS: The clinical course of patients with pancreatic carcinoma remains dismal despite the recent advances of diagnostic and therapeutic procedures. One of the main causes is residual carcinoma cells, especially at the retroperitoneal aspect after pancreatectomy. Radiation therapy (RT) [intraoperative radiation therapy (IORT) and external radiation therapy (ERT)] is a therapeutic strategy to conquer the remaining cancer cells. METHODOLOGY: Effects of RT were retrospectively examined in 81 patients with pancreatectomy for pancreatic cancer together with early and late complications. RESULTS: Preoperative clinical data were not different between the RT(+) and RT(-) groups excluding peripheral lymphocyte counts. Postoperative early complications equally occurred including pancreatic fistula. Regarding late complications (>2 months after operation), stomal ulcer, vertebral fracture, pseudoaneurysm, intraabdominal hemorrhage, and liver abscess were present only in patients with RT. Glucose intolerance tended to be more frequent in the RT (+) group, i.e. 12 (63%) of the 19 with RT examined and 14 (42%) of the 33 without RT examined. Follow-up imaging showed recurrence in 27 (71%) of the 38 patients without RT and 13 (52%) of the 25 patients with RT. The sites of the recurrence were not different by the presence or absence of RT. One-year, 3-year and 5-year cumulative survival rates were similar between the RT (-) group (100%, 39%, 21%, respectively) and IORT (+) alone group (100%, 29% and 17%, respectively). The rates in the IORT (+) and ERT (+) group were 100%, 54% and 28%, respectively, which tended to be better than those in the other two groups, but the differences were not statistically significant. CONCLUSIONS: These findings suggest that only the combination of IORT and ERT somewhat improves the short-term clinical course of patients with resectable pancreatic cancer, although there are some RT-related late complications. It is recommended that ERT be added to IORT after pancreatectomy for pancreatic cancer to improve the clinical course, once IORT has been performed.

Duodenum is important for the sphincter of Oddi motor response to cholecystokinin octapeptide in conscious dogs.

BACKGROUND: We investigated the role of the duodenum in the sphincter of Oddi response to cholecystokinin-octapeptide (CCK-OP), using conscious dogs. METHODS: In controls, a cannula was inserted into the duodenum opposite the papilla for retrograde manometry. In the duodenectomy group, the entire duodenum was resected, while preserving the papilla, which was implanted into the jejunum, and the cannula was placed. Sphincter motility was recorded after bolus injections of 20 and 100 ng/kg of CCK-OP. RESULTS: CCK-OP at 20 ng/kg produced sphincter relaxation followed by contraction in the controls, but produced no changes after duodenectomy. CCK-OP at 100 ng/kg caused strong contractions followed by relaxation in the controls, but caused only contractions after duodenectomy. CONCLUSIONS: (1) Relaxation and delayed contraction of the sphincter induced by 20 ng/kg of CCK-OP require the presence of the duodenum; (2) early contractions of the sphincter induced by 100 ng/kg of CCK-OP do not require the duodenum; (3) the duodenum plays an important role in the actions of CCK-OP on sphincter motility.

Appleby operation for pancreatic body-tail carcinoma: report of three cases.

The clinical course of patients with carcinoma of the pancreas, especially of the body-tail, remains dismal despite recent advances in diagnostic and therapeutic procedures. We present three case reports to evaluate the role of the Appleby operation in the treatment of pancreatic body-tail cancer. Care 1 was a 55-year-old Japanese woman who underwent the Appleby operation for mucinous cystadenocarcinoma of the body and tail of the pancreas invading the stomach, celiac axis, superior mesenteric and splenic arteries, and the splenic, superior mesenteric, and portal veins. Local recurrence and peritoneal dissemination with malignant ascites were found 7 months later and she died 10 months after the operation. Case 2 was a 61-year-old Japanese man who underwent the Appleby operation with 20 Gy radiation therapy for invasive ductal carcinoma of the body of the pancreas involving the celiac axis, common hepatic, splenic, and left gastric arteries, and the splenic vein. Peritoneal dissemination with malignant ascites was evident 5 months later and he died 14 months after the operation. Case 3 was a 50-year-old Japanese man who underwent the Appleby operation with 20 Gy radiation therapy for invasive ductal carcinoma of the body of the pancreas invading the stomach, splenic artery, celiac axis, and splenic vein. Multiple hepatic metastases were found 2 months later and the patient died 8 months after the operation. Based on our experience of these three cases, we conclude that the indications for the Appleby operation to treat locally advanced pancreatic body carcinoma are still limited because it does not improve quality of life or clinical outcome.

Role of duodenum on sphincter of Oddi motility in conscious dogs.

Our aim was to determine the role of the duodenum in controlling sphincter of Oddi motility using conscious dogs after total duodenectomy. In a control group (N = 6), a cannula was implanted into the duodenum opposite to the papilla to allow retrograde sphincter manometry. In a duodenectomy group (N = 6), the papillae were preserved at total duodenectomy and sutured to thejejunum anastomosed to the stomach (neoduodenum). The cannula was implanted opposite to the implanted papillae. Interdigestive and postprandial sphincter and duodental or neoduodenal motility were recorded by manometric and myoelectric methods. Duodenectomy disrupted sphincter cyclic motility associated with the intestinal migrating motor complex and increased sphincter activity throughout the cycle. Sphincter activity increased immediately after feeding and did not differ between the two groups. In conclusion, during the interdigestive period, the duodenum has a distinct role in regulating sphincter cyclic motility. The initiation of the fed pattern of sphincter motility does not need the duodenum.