Number of Examined Lymph Nodes as a Risk Factor for Recurrence in pT1N+ or pT2-3N0 Gastric Cancer.

BACKGROUND/AIM: Japanese Gastric Cancer Treatment Guidelines do not recommend adjuvant chemotherapy after radical gastrectomy for pathological stage (p) T1N+ or pT2~3N0 gastric cancer. However, some patients experience disease recurrence. This study aimed to identify the risk factors for recurrence in pT1N+ or pT2-3N0 gastric cancer. PATIENTS AND METHODS: The study included 157 patients with diagnosed pT1N+ or pT2-3N0 gastric cancer who underwent radical gastrectomy at our institution between January 2001 and December 2020. Clinicopathological data and surgical data were obtained. Independent prognostic factors were analyzed using a Cox proportional hazards regression model. RESULTS: Thirteen patients (8.3%) experienced disease recurrence. Multivariate analysis revealed that the number of examined lymph nodes was an independent prognostic factor for recurrence-free survival (hazard ratio=10.90; 95% confidence interval=1.39-85.86; p=0.023). The group with ≤35 examined lymph nodes had significantly worse recurrence-free survival compared with the group with ≥36 examined lymph nodes (80.7% versus 98.7%; p=0.0005). CONCLUSION: The number of examined lymph nodes (≤35) was an independent risk factor for recurrence after radical gastrectomy with pT1N+ or pT2-3N0 gastric cancer.

The linkage between medical student readiness for interprofessional learning and interest in community medicine.

OBJECTIVES: The purpose of this study is to investigate the relationship between medical student readiness for interprofessional learning and interest in community medicine prior to incorporating community-oriented interprofessional education into the curriculum. METHODS: A questionnaire was administered to students at Nagasaki University School of Medicine in Japan during each of three consecutive years (N=2244). The Readiness for Interprofessional Learning Scale (RIPLS) was administered in addition to a questionnaire to evaluate interest in community medicine. The Kruskal-Wallis and Steel-Dwass tests were used to determine differences between school years. Correlation between the RIPLS score and interest in community medicine was evaluated with Spearman's rank correlation coefficient. Relationships between RIPLS score and demographic parameters, and interest in community medicine were evaluated with multiple linear regression analysis. RESULTS: Eighty-four percent (1891/2244) of students responded. The RIPLS score was highest in school year 1, followed by year 6, year 5, year 3, and years 4 and 2. Interest in community medicine correlated with the RIPLS score (rs = 0.332, p < 0.001), but less in year 1 (rs = 0.125, p = 0.002) than in other years. RIPLS score was significantly associated with gender, age, school year, interest in community medicine, but not the year that the survey was conducted. CONCLUSIONS: Community-oriented interprofessional education has the potential to improve attitudes towards interprofessional learning. When introducing this promising education into the curriculum from year 1, attracting students' interest in community medicine should be considered.

Clinical Value of Serum p53 Antibody in the Diagnosis and Prognosis of Esophageal Squamous Cell Carcinoma.

BACKGROUND/AIM: Identifying useful biomarkers is central to selecting optimal therapeutic strategies for esophageal squamous cell carcinoma (ESCC). Serum p53 antibody (S-p53Ab), squamous cell carcinoma antigen (SCC-Ag), and carcinoembryonic antigen (CEA) were investigated to evaluate the significance of single and combined tumor markers in determining the diagnosis and prognosis of ESCC. MATERIALS AND METHODS: Serum samples were obtained preoperatively from 133 patients with histologically-confirmed ESCC, including 32 patients with stage I (24.1%). Levels of S-p53Ab were assessed by enzyme-linked immunosorbent assay, using a new version of a highly specific, quantitative kit. The cut-off value for S-p53Ab was 1.3 U/ml. RESULTS: S-p53Ab was detected in 39.1% (52 out of 133) of patients with ESCC, including 40.0% (20 out of 50) of patients with early-stage ESCC. Positive rates for S-p53Ab, CEA, and SCC-Ag among patients with stage I ESCC (n=32) were 40.6%, 12.5%, and 31.3%, respectively. Positivity for S-p53Ab was not associated with positivity for CEA or SCC-Ag (p=0.249 and 0.747, respectively). The positive rate for diagnosis of ESCC increased from 39.1% to 65.4% when S-p53Ab was combined with SCC-Ag in this study. We found no significant correlation between the presence of S-p53Ab in ESCC and overall survival. Conversely, Cox regression analysis revealed that the International Union Against Cancer/TNM classification and systemic inflammation score were independent prognostic factors for ESCC in this series (hazard ratio(HR)=3.811, 95% confidence interval(CI)=1.548-9.378, p=0.004; and HR=2.218; 95% CI=1.087-4.523, p=0.029, respectively). Kaplan-Meier analysis revealed significant differences between patients with elevated S-p53Ab and SCC-Ag and patients with elevated levels of only one or neither of these factors (p=0.009). CONCLUSION: The diagnostic rate with S-p53Ab was better than that with SCC-Ag and CEA in patients with early-stage ESCC. Combined detection of S-p53Ab and SCC-Ag can markedly improve diagnostic sensitivity and may permit more accurate stratification of patients with ESCC.

Clinical significance of the C-reactive protein-to-albumin ratio for the prognosis of patients with esophageal squamous cell carcinoma.

The aim of the present study was to investigate the prognostic value of the C-reactive protein-to-albumin ratio (CAR) and compare it with other inflammation-based prognostic scores (Glasgow prognostic score, modified Glasgow prognostic score, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, prognostic nutritional index and prognostic index) in patients with esophageal squamous cell cancer (ESCC). A database of 116 patients with primary ESCC who underwent treatment at the Division of Surgical Oncology at Nagasaki University Hospital between January 2007 and August 2014 was retrospectively reviewed and the correlations between CAR and overall survival (OS) were investigated. Kaplan-Meier and Cox regression analyses were used to assess independent prognostic factors. The area under the curve (AUC) was used to compare the prognostic value of different scores. According to the receiver operator characteristics analysis, the recommended cut-off value for CAR was 0.042, with an AUC of 0.678 (sensitivity 31.1%, specificity 66.7%). Thus, patients were dichotomized into low (<0.042) and high (≥0.042) CAR groups. On multivariate analysis, CAR was found to be significantly associated with OS in patients with ESCC [hazard ratio (HR)=2.350; 95% confidence interval (CI): 1.189-4.650; P=0.014], as was tumor-node-metastasis stage (HR=3.059; 95% CI: 1.422-6.582; P=0.004). In addition, CAR had a higher AUC value (0.678) compared with several other systemic inflammation-based prognostic scores (P<0.001). This study suggested that CAR is a novel and promising inflammation-based prognostic score in patients with ESCC. Due to its simplicity, affordability and availability, CAR may be important for improving clinical decision-making and may contribute to more rational study design and analyses.

Clinical Significance of Serum p53 Antibody in the Early Detection and Poor Prognosis of Gastric Cancer.

BACKGROUND: The aim of this retrospective study was to evaluate the clinical relevance of serum p53 antibody (S-p53Ab) as a biomarker and to investigate whether its diagnostic value could be improved when combined with other biomarkers of gastric cancer (GC). PATIENTS AND METHODS: Serum samples were obtained preoperatively from 208 patients with histologically-confirmed GC, including 126 stage I patients (60.6%). Levels of S-p53Ab were assessed by a commercial laboratory using an anti-p53 detection kit. The cut-off value for S-p53Ab was 1.3 U/ml. RESULTS: S-p53Ab was detected in 16.3% (34 of 208) of patients with GC, including 13.6% (22 of 162) of patients with early-stage GC. The positive rates for S-p53Ab, carbohydrate antigen 19-9 (CA19-9), and carcinoembryonic antigen (CEA) of patients with stage I GC were 10.3% (13/126), 2.4% (3/126), and 8.7% (11/126), respectively. Positivity for S-p53Ab was not associated with CA19-9 or CEA positivity (p=0.098 and 0.053, respectively). The positive rate for a diagnosis of GC increased from 16.3% to 29.3% when S-p53-Ab was combined with CEA in this study. We found no significant correlation between the presence of S-p53Ab in GC and overall survival. Conversely, Cox regression analysis revealed that a high level of CA19-9 was an independent prognostic factor for GC in this series (hazard ratio(HR)=3.864; 95% confidence interval(CI)= 1.248-11.959; p=0.019). Kaplan-Meier analyses demonstrated significant differences in survival between patients with elevated levels of both S-p53Ab and CEA and those with elevated levels of only one or neither. CONCLUSION: The diagnostic rate of S-p53Ab was better than that of CA19-9 and CEA in patients with stage I GC. Combined detection of S-p53Ab and CEA may improve the diagnostic sensitivity and may permit more accurate stratification of GC patients.

Recruitment of Young Medical Apprentices (RYOMA) project: a comprehensive surgical education program at a local academic institute in Japan.

OBJECTIVES: The number of young surgeons in Japan has significantly decreased in recent years, which may lead to future problems in the medical field. Therefore, comprehensive training programs for young surgeons are needed. DESIGN: Retrospective study SETTING: We developed a specific education program called the "Recruitment of Young Medical Apprentices" (RYOMA) project. PARTICIPANTS: We performed this project between January 2008 and August 2013 on fourth- to sixth-year medical students and internship doctors. The RYOMA project included step-by-step surgical education programs on open and scopic procedures as dry, wet, and animal laboratory training. Our goal was to increase the number of young and specialist surgeons. RESULTS: Based on an interview questionnaire answered by 90 medical students, most young students were interested in surgical training and several chose to become surgeons in the future. The most positive opinions regarding the field of surgery were the impressive results achieved with surgery, whereas negative opinions included the difficulty of the surgical skill, physical concerns related to difficult work environments, and the severity of surgical procedures. The present program has begun to resolve negative opinions through adequate training or simulations. Of the 19 medical students and internship doctors who attended the RYOMA project in 2008, 17 trainees (90%) were satisfied with this special surgical program and 16 (88%) showed interest in becoming surgeons. The number of participants considering the field of surgery increased between 2008 and 2013. Of 23 participants, 19 (83%) had a positive opinion of the program after the training. CONCLUSIONS: Gaining experience in surgical training from an early stage in medical school and step-by-step authorized education by teaching staff are important for recruiting students and increasing the number of young surgeons.

Comparison of results between pylorus-preserving pancreaticoduodenectomy and subtotal stomach-preserving pancreaticoduodenectomy: report at a single cancer institute.

BACKGROUND/AIMS: Pylorus-preserving pancreaticoduodenectomy (PPPD) has the advantage of achieving good nutritional status postoperatively, but delayed gastric empty (DGE) is a frequent complication leading to a longer fasting period. Subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) is an alternative option to preserve nutritional status and shorten the fasting period. We retrospectively compared clinical results between PPPD and SSPPD. METHODOLOGY: PPPD was performed in 28 patients and SSPPD in 27, between 2000 and 2009. RESULTS: Pancreatic carcinoma was more frequent in the SSPPD group (p = 0.041). Operating time was longer in the SSPPD group (610 min) than in the PPPD group (540 min; p = 0.031). Blood loss was greater in the SSPPD group (1810 mL) than in the PPPD group (1306 mL; p = 0.048). Period of NG intubation and fasting period were shorter in the SSPPD group (6 days and 9 days, respectively) compared to the PPPD group (15 days and 19 days, respectively; p <0.01 each). Severe DGE was 7% in the SSPPD group and 46% in the PPPD group (p <0.01). Postoperative complications and nutritional status in the early period did not differ between groups, although incidence of fatty liver was higher in the SSPPD group (78%) than in the PPPD group (25%; p <0.01). CONCLUSIONS: SSPPD is a useful alternative for pancreaticoduodenectomy. Further prospective studies with longer follow-up are warranted to clarify the superiority and problems associated with this procedure.

Single-incision laparoscopy-assisted subtotal gastrectomy for intractable gastric ulcer: a case report.

PURPOSE: Single-incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain and accelerated recovery. Although there have been reports of cholecystectomy and appendectomy using SILS, there have been few reports of gastric resection with intracorporeal reconstruction of the digestive tract using SILS. The first single-incision laparoscopic gastrectomy with intracorporeal reconstruction is reported. METHODS: Preliminary experience with single-incision laparoscopic gastrectomy with intracorporeal reconstruction for a patient with an intractable gastric ulcer is reported. RESULTS: Single-incision laparoscopy-assisted subtotal gastrectomy and Roux-en-Y reconstruction were performed. Operative time for gastrectomy and paraduodenal hernioplasty was 412 minutes, and blood loss was 90 g. No intraoperative or postoperative complications developed. CONCLUSIONS: Single-incision laparoscopy-assisted gastrectomy for intractable gastric ulcer is technically feasible. Intracorporeal reconstruction of the digestive tract was performed safely using a linear endoscopic stapler. This surgical approach is a further advance toward scarless surgery of the stomach.

Relationship between microvessel count and clinicopathological characteristics and postoperative survival in patients with pancreatic carcinoma.

BACKGROUND/AIMS: The present study aimed to elucidate the relationship between microvessel count (MVC) according to CD34 expression and clinicopathological characteristics or prognosis in pancreatic carcinoma (PC) patients who underwent hepatectomy. METHODOLOGY: CD34 expression was analyzed using immunohistochemical methods. Mean MVC in 5 areas per specimen and clinicopathological factors were consecutively examined in 42 PC patients. RESULTS: Median MVC for PC patients was 123/mm2, which was applied as a cut-off value. Higher MVC was significantly associated with the advanced Japanese tumor-node-metastasis stage IVa and IVb (p=0.034). Univariate survival analysis identified higher carcinoembryonic antigen (CEA) and CA19-9 level, infiltrative type on macroscopic examination, invasive ductal carcinoma, node metastasis and higher tumor-node-metastasis classification were significantly associated with poor survival. The 5-year overall survival rate in the higher MVC group tended to be lower than that in the higher MVC group (37 vs. 55%), but not statistically significant (p=0.15). CONCLUSIONS: Tumor MVC might be a candidate prognostic marker of PC patient survival after pancreatectomy and further investigation in a larger series is warranted to clarify the significance of this marker.

Usefulness of omental wrapping to prevent biliary leakage and delayed gastric emptying in left hepatectomy.

BACKGROUND/AIMS: To identify the clinical significance of the omental wrapping (OW) technique after left hepatectomy to reduce bile leakage and delayed gastric emptying. We examined clinical and surgical parameters after left hepatectomy with or without biliary reconstruction in 79 patients. METHODOLOGY: This was a retrospective study of data from 14 patients undergoing OW compared to 65 patients in the control group. RESULTS: Bile leakage and delayed emptying after hepatectomy were observed in 15 and 11 patients, respectively. Gender, background liver function, liver diseases and preoperative liver function tests were not significantly different between both groups. Prevalence of extent of hepatectomy, existence of segment 1 resection, biliary-enteric anastomosis, operating time and blood loss were also not significantly different between groups. Prevalence of bile leakage was similar between the OW and the control group (14 vs. 20%) (p=0.91). Prevalence of delayed gastric emptying was not significantly different between groups, but this complication was not observed in the OW group in comparison with the control group (0% vs. 20%) (p=0.31). Prevalence of other complications and hospital stay after hepatectomy were similar between groups. CONCLUSIONS: Significant differences for preventing left hepatectomy related complications were not found; however, it is possible that OW could reduce delayed gastric emptying.

Evaluation of surgical resection for pancreatic carcinoma at a Japanese single cancer institute.

BACKGROUND/AIMS: Surgical resection is a radical treatment option for pancreatic carcinoma (PC); however, it is still difficult to cure and patient prognosis is poor at this stage. METHODOLOGY: We examined the demographics, surgical records and outcome in 64 patients with hilar PC undergoing surgical resection. RESULTS: Pancreatoduodenectomy (PD) was carried out in 48 patients, distal pancreatectomy (DP) in 14 and total pancreatectomy in two. Postoperative complications were observed in 18 patients (28%) but no hospital deaths. All stage I patients showed carcinoma in situ of intraductal papillary mucinous carcinoma (IPMC). Postoperative adjuvant chemotherapy was performed in 15 patients (23%) using gemcitabine or S-1. Cancer recurrence was observed in 36 patients (56%) and 31 died of carcinoma. The 5-year cancer-free and overall survival rate was 12% and 14%, respectively. CA19-9 level, morphological type, T category, lymph node metastasis, extrapancreatic nerve plexus invasion, retropancreatic tissue invasion, distal bile duct invasion, duodenal invasion and arterial system invasion were significant poor prognostic factors; however, portal vein system invasion was not significantly associated with prognosis. Cancer infiltration at bile duct cut-end and dissected peripancreatic tissue margin and presence of residual tumor showed a poor prognosis. Surgical prognosis in only non-invasive IPMC was satisfactory. CONCLUSIONS: Radically extended surgical resection is necessary and newly effective adjuvant chemotherapy is a promising modality to improve patient survival in PC patients.

Diagnosis of small-bowel metastasis of hepatocellular carcinoma by double-balloon enteroscopy.

INTRODUCTION: Hepatocellular carcinoma (HCC) is a major cause of cancer-related deaths around the world. Nearly half of patients with HCC display metastatic disease at the time of initial diagnosis, frequently involving the liver, bone, brain, lungs, and adrenal glands, but gastrointestinal involvement is rare. Melena occurring secondary to a metastatic tumor from HCC is particularly rare. Herein, we present a case of melena secondary to metastatic HCC after chemoradiation to lung and brain metastases from HCC, diagnosed preoperatively by double-balloon enteroscopy. To the best of our knowledge, this represents the first such case to be reported. PRESENTATION OF CASE: 60-Year-old man had been diagnosed with hepatitis B virus-associated hepatocellular carcinoma (HCC). He was readmitted for investigation of general fatigue and iron-deficiency anemia. Esophagogastroduodenoscopy, total colonoscopy, and CT failed to identify any cause for gastrointestinal bleeding. Double-balloon enteroscopy, however, revealed small bowel metastasis from HCC preoperatively. After 5 days of conservative management, segmental small bowel resection and end-to-end anastomosis were performed. The histological appearances were considered typical for moderately differentiated HCC. DISSCUSSION: Endoscopic findings of gastrointestinal metastasis from HCC vary, such as raised and centrally ulcerated lesions, polypoid tumors, or submucosal tumors. Immunohistochemical findings are thus key to differentiating HCC from adenocarcinoma in the diagnosis of GIT metastasis. Some patients with gastrointestinal bleeding remain undiagnosed even after upper endoscopy and total colonoscopy, and most such patients will display bleeding sites in the small bowel. Video capsule endoscopy and DBE have been introduced recently for the evaluation of the small bowel. DBE, which was developed by Yamamoto et al.,(5) allowed us to obtain biopsy specimens, circumventing one limitation of capsule endoscopy. In this case, DBE contributed significantly to diagnosis and treatment. CONCLUSION: DBE thus seems to represent a valuable method, particularly in the preoperative setting, due to the possibility of precisely identifying the tumor site and achieving preoperative diagnosis.

Experience of surgical resection for hilar cholangiocarcinomas at a Japanese single cancer institute.

BACKGROUND/AIMS: Surgical resection is a radical treatment option for hilar bile duct carcinoma (HBDC); however, it is still difficult to cure and postoperative morbidity is high at this stage. METHODOLOGY: We examined the demographics, surgical records and outcome in 38 patients with hilar cholangiocarcinoma undergoing operation. RESULTS: Five patients (13%) underwent probe laparotomy because of peritoneal dissemination or liver metastasis. Of 33 patients, extended hemi-hepatectomy was performed in 32 patients. Postoperative complications were observed in 46% including hepatic failure in 3 and hospital death was observed in 4 patients. Advanced tumor stage more than stage III was observed in 23 patients. Curability of operation was A in 5 patients, B in 17 and C in 11 and postoperative adjuvant chemotherapy was administered in 24% including photodynamic therapy in 3. Tumor recurrence was observed in 41% of HBDC patients. The 3- and 5-year tumor-free survival was 38% and 10%, respectively and 3- and 5-year overall survival was 48% and 32%, respectively. By comparison with tumor stage or final curability, survival rates were not significantly different between groups. CONCLUSIONS: Surgical resection is still the only curative treatment option to improve patient survival even in advanced stage HBDC.

Prediction of indocyanine green retention rate at 15 minutes by correlated liver function parameters before hepatectomy.

BACKGROUND: Indocyanine green retention rate at 15 min (ICGR15) is a useful marker of liver function in deciding on the extent of hepatectomy. To determine ICGR15 regardless of liver condition, we sought to establish a formula for converted ICGR15 based on conventional blood tests and technetium-99 m galactosyl human serum albumin ((99m)Tc-GSA) scintigraphy. MATERIALS AND METHODS: We measured liver function parameters, including ICGR15, in 307 patients, including 265 liver cancer patients without biliary obstruction (no obstruction group) and 42 with biliary obstruction (obstruction group). RESULTS: In the no obstruction group, multiple regression analysis identified blood pool clearance ratio (HH15), liver uptake ratio (LHL15) calculated by heart and liver activity between 3 and 15 min after injection of (99m)Tc-GSA, and serum hyaluronic acid as significant correlates (P < 0.05). The calculated converted ICGR15 was then equal to 0.02∗HA + 0.276∗(HH15∗100)-0.501∗(LHL15∗100) + 41.41. The mean difference between actual and converted ICGR15 was significantly lower in the obstruction than in the no obstruction group (P = 0.031). A significantly larger proportion of patients of the obstruction group had lower converted ICGR15 than those of the no obstruction group (P = 0.045). CONCLUSION: The converted ICGR15 is useful for evaluating hepatic function in patients with biliary obstruction who plan to undergo major hepatectomy.

Distal gastrectomy for advanced gastric cancer with vascular anomaly after coronary bypass grafting using the right gastroepiploic artery.

A 77-year-old woman with a history of coronary artery bypass grafting 5 years earlier presented with anemia and was diagnosed with advanced gastric cancer involving the pylorus. Preoperative angiography revealed that the right gastroepiploic artery (RGEA) graft was patent. Multidetector-row computed tomography showed the running pattern of the RGEA graft and also revealed a vascular anomaly belonging to type V of Adachi's classification. Adachi's type V is a rare vascular anomaly in which the common hepatic artery originates from the superior mesenteric artery. The patient was treated successfully with a distal gastrectomy and removal of the D2 lymph node with preservation of the RGEA graft. Because of the difficulty in confirming the running pattern of the artery during the surgery, it is important to define the arterial running pattern preoperatively by using multidetector-row computed tomography, including 3-dimensional angiographic imaging.

Prognosis of patients with hepatocellular carcinoma after hepatic resection: are elderly patients suitable for surgery?

AIM: The indication for hepatectomy is still controversial in elderly patients with hepatocellular carcinoma (HCC). We examined the clinicopathological features and survival of 188 HCC patients who underwent hepatectomy. PATIENTS/METHODS: Patients were divided into four age groups: Age(<50) group (young patients <50 years of age, n = 9), Age(50-69) group (between 50-69 years, n = 110), Age(70-79) group (70-79 years, n = 57), and Age(≥80) group (≥80 years, n = 12). Physiologic ability and surgical stress (E-PASS) score, including preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were assessed. RESULTS: Proportion of patients of Age(70-79) and Age(≥80) groups increased significantly in the last 5 years (P < 0.01). Co-morbidity, performance status, and American Society of Anesthesiologists score significantly increased with age (P < 0.05). Proportions of patients with irregular findings and necro-inflammatory activity were significantly lower in Age(70-79) and Age(≥80) groups than in other groups (P < 0.05). Systemic postoperative complications were high in Age(70-79) and Age(≥80) groups. PRS increased significantly with age (P < 0.05). Multivariate analysis identified PRS ≥0.32 and age ≥70 years as significant determinants of systemic complications (P < 0.05). There were no significant differences in postoperative survivals among the groups. CONCLUSIONS: Careful follow-up and proper decision on hepatectomy upon assessment of PRS are important in elderly HCC patients.

Measurement of serum marker for bone metastasis (1-CTP) in hepatobiliary and pancreas malignancies.

BACKGROUND/AIMS: Pyridinoline cross-linked carboxyterminal telopeptide of type I collagen (1CTP) is a sensitive serum marker for metastatic bone carcinomas and may also be associated with invasiveness of various carcinomas. To clarify the significance of 1CTP in hepato-biliary pancreas malignancies, we examined the relationship between clinicopathological features and serum level of 1CTP. METHODOLOGY: The subjects were 75 patients who underwent surgical resections including 27 patients with liver carcinomas, 15 with extra-hepatic biliary carcinomas, 14 pancreatic carcinomas and 19 benign diseases. RESULTS: 1CTP level tended to be higher in the malignant diseases than in benign diseases but this difference was not significant (p = 0.065). Compared to benign adenoma, 1CTP level in the malignant diseases was significantly higher (p = 0.049). 1CTP level tended to be higher in patients with cholangitis compared to those with no inflammation or benign tumors (p = 0.065). 1CTP was not correlated with any tumor markers. 1CTP was not associated with node status and vascular infiltrations. 1CTP level tended to be lower in patients with poor differentiation. CONCLUSIONS: Serum level of 1CTP might be a predictive marker for hepatobiliary pancreas malignancies but also reflects the degree of co-existing cholangitis.

Preoperative diagnosis of lymph node metastasis in biliary and pancreatic carcinomas: evaluation of the combination of multi-detector CT and serum CA19-9 level.

BACKGROUND: It is difficult to diagnose lymph node metastasis in biliary and pancreas carcinomas before surgery. AIM: The aim of this study was to assess the utility of the combination of multi-detector computed tomographic (MDCT) findings and serum carbohydrate antigen (CA)19-9 level in the diagnosis of lymph node metastasis in biliary and pancreas carcinomas. METHODS: The subjects were 139 patients with biliary and pancreas carcinomas who underwent surgical resection. We calculated the positive predictive values (PPV), sensitivities, specificities, positive likelihood ratios (PLR) and accuracies of diagnosis by MDCT alone, serum CA19-9 level alone, and their combination. RESULTS: The PPV and sensitivity were higher for node metastasis in hepatoduodenal ligament than in common hepatic artery (CHA) or para-aortic region (PAR). Specificity, accuracy and PLR were highest for CHA in biliary carcinoma. With pancreatic carcinoma, PLR was slightly higher in PAR compared to other regions. The sensitivity of CA19-9 for node metastasis was higher than that of MDCT, while the PPV, specificity, accuracy and PLR were low for both biliary and pancreas carcinoma. The combination of positive CT findings and high CA19-9 level had the highest positive rate for node metastasis for both types of carcinomas. Nodes around the supra-mesenteric vein could not be fully observed on CT. CONCLUSION: The combination of high-resolution MDCT and CA19-9 is useful for the diagnosis of lymph node metastasis in biliary and pancreas carcinomas.

Stepwise education for pancreaticoduodenectomy for young surgeons at a single Japanese institute.

BACKGROUND/AIMS: Expert technique and special anatomical or physiological knowledge are needed in the field of pancreatic surgery. The establishment of basic policies and operative techniques for pancreaticoduodenectomy (PD) and stepwise training for young pancreatic surgeons are necessary. METHODS: We scheduled PD for ampullar, biliary and pancreas carcinoma, and evaluated types of pancreatic anastomosis or results by each operator such as a chief, fellowship and resident doctors (> 5 years after graduation). RESULTS: Based on a questionnaire distributed to young residents (n = 30), only half of them have experienced PD or PPPD, which was related to operating volume at the hospital. Post-operative complications at the teaching hospital were observed in 50 of 88 patients (56%). Post-operative complications were not significantly correlated with the type of anastomosis; however, duct-to-mucosa anastomosis of the pancreas might decrease pancreatic fistula (0% vs. 26% in pancreaticogastrostomy and 13% in pancreaticojejunostomy without duct-to-mucosa anastomosis). Based on the stepwise education protocol of technique, patient demographics, the surgical records and the post-operative complications were not significantly different between experienced teaching surgeons, fellowship surgeons and senior residents, although the time of operation and anastomosis tended to be longer in resident surgeons (p = 0.22). CONCLUSION: Competent operative techniques for inexperienced surgeons and the achievement of safe resection at each stage are our educational goals for PD.

[Evaluation of local coagulation therapy with hepatectomy for liver metastases].

Hepatectomy is accepted as the standard therapy in patients with resectable liver metastases. In recent years, the techniques such as microwave coagulation therapy (MCT) and radiofrequency ablation therapy (RFA) have been developed, so we have many options to treat. We evaluated nineteen subjects with cases of liver metastases who underwent thermoablative procedures with or without hepatectomy. RFA and MCT were used in 6 cases and 2 cases, respectively. In other 11 cases, they received a combined therapy: RFA+hepatectomy in 5 cases, and MCT+hepatectomy in 6 cases. Thermoablative therapy was used for 39 metastatic tumors. The mean tumor size was 13.7 mm, and a local recurrence was observed in 8 nodules (21%). No significant differences were observed in DFS and OS between thermoablative therapy and hepatectomy. Many patients with liver metastases received a repeated treatment, so we have to care about the remnant liver function. We conclude that thermoablative therapy with hepatectomy seems to be a less invasive procedure and effective therapy.