Radiologic and intraoperative detection of need for mesenteric vein resection in patients with adenocarcinoma of the head of the pancreas

ObjectiveThe need for mesenteric venous resection (MVR) is determined by a combination of preoperative radiologic and intraoperative surgical assessments. A single-centre review was performed to determine how efficient these processes are in evaluating the need for MVR.MethodsA retrospective study was performed of 343 patients who received resection for adenocarcinoma of the head of the pancreas, 100 of whom underwent MVR. Three radiologic signs (abutment, fat plane obliteration, focal narrowing) were evaluated for their ability to predict the need for MVR. Pathologic assessment was performed to determine if MVR had been necessary to achieve negative-margin (R0) resection. Microscopic tumour in the vein wall, or within 1 mm of the vein wall, was considered to indicate that MVR had been necessary to achieve an R0 resection.ResultsRadiologic evaluation (showing any of the three signs) had sensitivity of only 60%. Overall, 40% of the patients who required MVR showed none of the signs. Specificity was 77%. A total of 80% of patients who underwent MVR had either microscopic invasion or abutment. R0 resection at the vein margin was achieved in 98% of patients in both the MVR and non-MVR groups.ConclusionsPreoperative radiologic evaluation is not highly reliable in predicting the need for MVR. Therefore, surgical teams performing resections of cancers of the head of the pancreas must be skilled in MVR as the need for this procedure may arise unexpectedly. Surgical assessment of the need for MVR has an accuracy of about 80% and is nearly 100% accurate in determining when MVR is not required.     

Pylorus-preserving pancreaticoduodenectomy with combined resection of the portal vein and gastrointestinal reconstruction by imanaga procedure for ductal cancer of the head of the pancreas

Twenty-six patients who underwent pyloruspreserving pancreaticoduodenectomy (PPPD) for ductal cancer of the head of the pancreas between 1983 and 1993 were reviewed. Gastrointestinal continuity was restored by the methods of Imanaga (n=21) and Traverso (n=5). Combined resection of the portal vein and/or superior mesenteric vein was performed in 13 patients. Surgical complications occurred in 5 patients, but there were no postoperative deaths. Delayed gastric emptying was observed in 42% of patients. The median survival time for all 26 patients was 13 months. Three patients survived for more than 3 years, and one of them is currently alive without recurrence at 10 years. Differences in survival rates were not apparent between patients who underwent PPPD with and without portal vein resection. Survival rate after PPPD was compared with that after pancreaticoduodenectomy (PD) performed between 1974 and 1992; the difference was not significant. Patients who underwent noncurative PPPD had a significantly better survival rate than those who underwent noncurative PD (P<0.05). PPPD has improved the quality of life of the resected patients, without reducing survival rate. At present, PPPD by the Imanaga procedure could be the best choice for management of cancer of the pancreatic head.     

Laparoscopic distal pancreatectomy for adenocarcinoma of the pancreas

Since the first report on laparoscopic distal pancreatec tomy(LDP) appeared in the 1990 s, the procedure ha been performed increasingly frequently to treat both benign and malignant lesions of the pancreas. Man earlier publications have shown LDP to be a good alter native to open distal pancreatectomy for benign lesions although this has never been studied in a prospective randomized manner. The evidence for the use of LDP to treat adenocarcinoma of the pancreas is not as we established. The purpose of this review is to evaluat the current evidence for LDP in cases of pancreati adenocarcinoma. We conducted a review of English language publications reporting LDP results between1990 and 2013. All studies reporting results in patient with histologically proven pancreatic adenocarcinom were included. Thirty-nine publications were found and included in the results for a total of 309 cases of pan creatic adenocarcinoma(potential double publication were not eliminated). Most LDP procedures are per formed in selected cases and generally involve smalle tumors than open distal pancreatectomy(ODP) proce dures. Some of the papers report unselected cases andinclude procedures on larger tumors. The number of lymph nodes harvested using LDP is comparable to the number obtained with ODP, as is the frequency of R0 resections. Current data suggest that similar short term oncological results can be obtained using LDP as those obtained using ODP.     

Tips and tricks of surgical technique for pancreatic cancer: portal vein resection and reconstruction (with videos)

Surgical resection is the only hope for cure in patients with pancreatic cancer. To improve the resectability and achieve better prognosis of this lethal disease, extended resection for pancreatic cancer has been applied. We have performed portal vein resection aggressively for pancreatic cancer with portal vein invasion. We also established a method of portal vein reconstruction using the left renal vein graft for tumors widely extended to the portal vein. Our data show similar survival between patients with portal vein obstruction and those without invasion. We also show that portal vein reconstruction using the left renal vein graft can be performed safely without severe liver damage. With video, we introduce our surgical technique for portal vein resection and reconstruction, especially focusing on the usage of the left renal vein graft, providing several tips for a safe and successful procedure.     

Surgical outcome of adenosquamous carcinoma of the pancreas

Adenosquamous carcinoma is rare, accounting for 3%-4% of all pancreatic carcinoma cases. These tumors are characterized by the presence of variable proportions of mucin-producing glandular elements and squamous components, the latter of which should account for at least 30% of the tumor tissue. Recently, several reports have described cases of adenosquamous carcinoma of the pancreas. However, as the number of patients who undergo resection at a single institute is limited, large studies describing the clinicopathological features, therapeutic management, and surgical outcome for adenosquamous carcinoma of the pancreas are lacking. We performed a literature review of English articles retrieved from Medline using the keywords ＇pancreas＇ and ＇adenosquamous carcinoma＇. Additional articles were obtained from references within the papers identified by the Medline search. Our subsequent review of the literature revealed that optimal adjuvant chemotherapy and/or radiotherapy regimens for adenosquamous carcinoma of the pancreas have not been established, and that curative surgical resection offers the only chance for long-term survival. Unfortunately, the prognosis of the 39 patients who underwent pancreatic resection for adenosquamous carcinoma was very poor, with a 3-year overall survival rate of 14.0% and a median survival time of 6.8 mo. Since the postoperative prognosis of adenosquamous carcinoma of the pancreas is currently worse than that of pancreatic adenocarcinoma, new adjuvant chemotherapies and/or radiation techniques should be investigated as they may prove indispensible to the improvement of surgical outcomes.     

Impact of adjuvant therapy in patients with invasive intraductal papillary mucinous neoplasms of the pancreas

BackgroundThere is limited data on the efficacy of adjuvant therapy (AT) in patients with invasive intraductal papillary mucinous neoplasms of the pancreas (IPMN). This single center retrospective cohort study aims to assess the impact of AT on survival in these patients.MethodsPatients undergoing surgery for invasive IPMN between 1993 and 2018 were included in the study. We compared the clinicopathologic features and evaluated overall survival (OS) using multivariate Cox regression adjusting for adjuvant therapy, age, T and N stage, perineural and lymphovascular invasion. We also assessed survival differences between surgery alone and AT in node negative (N0) and node positive (N+) subgroups.Results103 patients were included in the study; 69 underwent surgery alone while 34 also received AT. Patients in the AT group were significantly younger, presented at higher T and N stages and had more perineural and lymphovascular invasion. Median OS in the surgery alone group was 134 months and 65 months in the AT group, p = 0.052. On multivariate analysis, AT was not associated with improved OS; hazard ratio (HR) = 1.03 (0.52–2.05). In N0 patients, compared to surgery alone, AT was associated with a worse median OS (65 vs 167 months, p = 0.03), whereas in N+ patients there was a non-significant improvement (50.5 vs 20.4 months, p = 0.315).ConclusionAT did not improve survival in the overall cohort even after multivariate analysis. N0 patients have excellent survival, and AT should probably be avoided in them, whereas it may be considered in patients with N+ disease.     

Accuracy of the BAR score in the prediction of survival after liver transplantation

Introduction and aimThe Balance of Risk (BAR) Score, a simple scoring system that combines six independent donor and recipient variables to predict outcome after liver transplantation (LT), was validated in a large U.S./European cohort of patients. This study aims to assess the performance of the BAR score to predict survival after liver transplantation and determine the factors associated with short and long-term survival in Latin-American patients.Material and methodsA retrospective cohort study was performed in 194 patients [112 (55.4%) males; mean age 52 ± 14 years] who underwent 202 LT during the period 2003–2015. Demographic, clinical, pathological and surgical variables, as well as mortality and survival rates, were analyzed. The BAR score was investigated through a receiver operating characteristics (ROC) curve with the calculation of the area under the curve (AUC) to evaluate the predictive score power for 3-month, 1 and 5-year mortality in a matched donor–recipient cohort. Youden index was calculated to identify optimal cutoff points.ResultsThe AUC of BAR score in predicting 3-month, 1-year and 5-year mortality were 0.755 (CI95% 0.689–0.812), 0.702 (CI95% 0.634–0.764) and 0.610 (CI95% 0.539–0.678) respectively. The best cut-off point was a BAR score ≥15 points. In the multivariate analysis BAR score <15 was associated with higher survival rates at 3 months and 1 and 5-years.ConclusionsBAR score <15 points is an independent predictor of better short and long-term survival in Latin-American patients undergoing LT. The BAR scoring system has an adequate diagnostic capacity allowing to predict 3 and 12-month mortality.     

Clinical experience with duodenum-preserving total resection of the head of the pancreas with pancreaticocholedochoduodenostomy

The results of duodenum-preserving total resection of the head of the pancreas (DpTRHP) in 20 patients were compared with the results of pylorus-preserving pancreatico-duodenostomy (PpPD), a procedure in conventional use for the treatment of benign diseases, in 19 patients. The mean operative time for DpTRHP was 4.5±0.9 h, this being not significantly different from that for PpPD, whereas the mean intraoperative blood loss with DpTRHP (825±508ml) was significantly less than that with PpPD (1382±798 ml) (P<0.05). The morbidity and mortality rates of patients treated with DpTRHP were 25% and 0%, respectively, and there were no significant differences between the two surgical treatment groups for these values. The outcome of treatment with DpTRHP was excellent, as was that of PpPD, in terms of the frequency of early gastric stasis, the duration of hospital stay, the patient's capacity for taking food, gaining weight, and working, and the performance status 6 months postoperatively. Thus, DpTRHP, which entails the least extent of resection of the head of the pancreas compared to other currently employed procedures and enables the operator to accomplish reconstruction of the pancreatic and biliary systems without resecting or interrupting the continuity of the digestive tract, was not attended by any serious complications, while, digestive tract function was well preserved, and satisfactory results were produced.     

Duodenum-Preserving resection of the head of the pancreas with denervation of the body and tail of the pancreas in patients with severe chronic pancreatitis

Duodenum-preserving resection of the head of the pancreas with denervation of the body and tail of the pancreas was performed in 41 patients with severe chronic pancreatitis. The major advantage of this procedure is that only the small head of the pancreas is resected, leaving the endocrine and exocrine systems functioning normally, along with the pancreas, duodenum, and bile duct. This procedure provides complete pain relief. Ninety-two percent of the patients experienced complete alleviation of pain and no recurrent pain due to postoperative pancreatitis; 76% of the patients were able to work well postoperatively, and 87% maintained their preoperative body weight. Postoperative glucose tolerance with a normal or glucose tolerance impairment pattern remained unchanged in 67% of the patients, with deterioration occurring in 33% of the patients between 3 months and 3 years postoperatively. However, 21% of the patients with a diabetic pattern preoperatively changed to a glucose tolerance impairment pattern between 3 months and 3 years postoperatively. Our procedure, which includes the dissection of the nerve plexus on the remnant pancreas and a near total resection of the head of the pancreas, allows the patient to maintain a good nutritional state as well as allowing for good endocrine function of the pancreas.     

Regional pancreatectomy and transverse colectomy with mesenteric vascular reconstruction for inflammatory pseudotumour of the head of pancreas and mesenteric root

BackgroundInflammatory myofibroblastic pseudotumour is a rare pancreatic lesion.Case OutlineA 32-year-old woman with such a tumour was treated by a radical operation comprising proximal pancreatic-duodenectomy (Whipple Procedure) and transverse colectomy with resection and reconstruction of the superior mesenteric artery and vein. She remains well 6 years later.DiscussionThe importance of aggressive surgical clearance rather than chemotherapy is highlighted in the management of patients with these unusual tumours.     

Inferior head resection of the pancreas for intraductal papillary mucinous neoplasms

Background

Previous reports have suggested that patients with intraductal papillary mucinous neoplasm (IPMN) have a favorable prognosis after surgical resection. Thus, a variety of types of partial pancreatic resections have been advocated for treating these low-grade malignant tumors. However, the surgical outcome of IPMN after such limited pancreatectomy has not been fully clarified.

Methods

We performed a retrospective review of the clinicopathologic features and surgical outcome in 15 patients who underwent inferior head resection for IPMN at the Chiba University Hospital and National Cancer Center Hospital East between July 1994 and January 2007.

Results

There were 13 patients with noninvasive IPMNs (10 adenomas and 3 noninvasive carcinomas) and 2 patients with minimally invasive intraductal papillary mucinous carcinoma (minimally invasive IPMN). Complete tumor removal (R0 resection) was performed in four patients (80%) with intraductal papillary mucinous carcinoma. Subsequent pancreatoduodenectomy was performed in one patient because of noninvasive carcinoma with multiple mucous lakes in the pancreatic parenchyma. Values for N-benzoyl-l-tyrosyl-p-aminobenzoic acid excretion test results before (n?=?13) and after (n?=?13) the operation were 70.7 and 66.1, showing no significant difference. The 2-h glucose levels in the 75?g oral glucose tolerance test before (n?=?13) and after (n?=?13) the operation were 133 and 146?mg/dl, respectively, showing no significant difference. Pancreatic fistula occurred in 7 (47%) patients. Overall morbidity and mortality rates were 67 and 0%, respectively. The overall 1-, 3-, 5-, and 10-year survival rates for the 15 patients were 100, 79, 79, and 71%, respectively. The 1-, 3-, 5-, and 10-year survival rates for patients with noninvasive IPMN (n?=?13) and those with minimally invasive IPMN (n?=?2) were 100, 92, 92, and 83%; and 100, 0, 0, and 0%, respectively. There was a significant difference in survival between patients with noninvasive IPMN and those with minimally invasive IPMN (p?=?0.0005). No patient with noninvasive IPMN developed recurrent disease. One patient with minimally invasive IPMN died of recurrent peritoneal dissemination 18?months after margin-positive R1 resection. Two patients died of pancreatic ductal adenocarcinoma, 30 and 78?months after inferior head resection.

Conclusions

Pancreatic endocrine and exocrine function was well preserved after inferior head resection. Pancreatic fistula occurred more frequently after inferior head resection than with conventional pancreatoduodenectomy. Patients with noninvasive IPMN had favorable survivals after this procedure. However, one patient with minimally invasive IPMN with margin-positive R1 resection died of recurrent disease. Thus, margin-negative R0 resection should be performed for IPMN.     

Resection of the head of the pancreas in three patients with anomalous arrangement or occlusive diseases of the major abdominal visceral arteries

We resected the head of the pancreas in three patients with occlusive diseases or anomalous arrangement of the abdominal visceral arteries. The first patient who was diagnosed with cancer of the head of the pancreas; pancreatoduodenectomy (PD) was performed. Preoperative celiac angiography showed no significant occlusion of the celiac axis, while superior mesenteric arteriography visualized the common hepatic artery, with delayed retrograde filling. At the completion of the PD, an unsuspected atherosclerotic celiac occlusion was identified. Celiac reconstruction was performed. The second patient was diagnosed with cystadenoma of the head of the pancreas and had congenital ostial occlusion of the superior mesenteric artery (SMA), with dilated pancreaticoduodenal (PD) arcades as a celiacomesenteric collateral pathway. Duodenum-preserving resection of the head of the pancreas was performed, with preservation of the PD arcades. The third patient was diagnosed with cancer of the common bile duct, and exhibited a replaced common hepatic artery that arose from the SMA and formed PD arcades. PD was performed, with revascularization of the common hepatic artery. Following surgery, the three patients have done well for 18, 27, and 9 months, respectively. Careful preoperative investigation to identify abnormalities of the visceral arteries is necessary before resection of the head of the pancreas is performed.     

介入治疗原发性肝细胞癌合并门静脉癌栓66例的临床分析

目的探讨介入治疗原发性肝癌(hepatic cell carcinoma,HCC)合并门静脉癌栓(portal vein tumor thrombus,PVTT)的临床疗效与安全性。方法收集第三军医大学大坪医院收治的66例HCC患者,按照随机数字表法分为联合治疗组和经导管动脉化疗检塞术(TACE)治疗组。联合治疗组采用TACE联合门静脉化疗(PVC)治疗,TACE治疗组采用单独TACE治疗,比较两组患者的临床疗效。结果治疗半年后联合治疗组治疗的有效率和PVTT缩小率分别为72.73%和78.79%,显著高于TACE治疗组的63.64%和51.52%(P0.05)。联合治疗组患者的中位生存时间及半年、1年、2年生存率均较TACE治疗组高(P0.05)。1个月后联合治疗组的毒副反应发生率为36.36%,显著低于TACE治疗组的81.82%(P0.05)。治疗半年后联合治疗组和TACE治疗组的AFP分别为(425.36±113.32)IU/ml和(725.32±113.32)IU/ml(P0.05)。结论 TACE联合PVC治疗HCC合并PVTT可提高中、晚期HCC患者治疗的有效率,改善患者的生存质量,还可降低抗癌药所产生的毒副反应和AFP水平。     

Intraductal papillary mucinous neoplasm of the pancreas with a bifid pancreatic duct

A bifid pancreatic duct presenting a major bifurcation in the main pancreatic duct is one of the anatomical variations of the pancreatic ducts. We encountered a 71-year-old female with a 5-cm-diameter branch duct intraductal papillary mucinous neoplasm of the pancreas in whom preoperative endoscopic retrograde pancreatography demonstrated an anomalous bifurcation of the main pancreatic duct at the body of the pancreas. We performed a distal pancreatectomy, instead of a middle pancreatectomy, with a cutting line at the downstream pancreas to the duct bifurcation point. Intraoperative ultrasonography was useful to confirm the exact location of the pancreatic duct bifurcation as well as the tumor extension. The procedure resulted in a favorable outcome without any postoperative complications. Although a bifid pancreatic duct is an unusual anomalous condition, this case should alert surgeons to be aware of such anatomical variants when performing pancreatic resection, otherwise, incurable pancreatic complications may occur postoperatively.     

Bilateral anatomic resection of the ventral parts of the paramedian sectors of the liver with total caudate lobectomy for deeply/centrally located liver tumors: a new technique maximizing both oncological and surgical safety

Systematic resection of the tumor‐bearing portal territory is reportedly correlated with an improved survival of patients with liver tumors, especially in hepatocellular carcinoma. Despite advances in surgical management, however, anatomic resection of deeply/centrally located tumors remains a challenging procedure not only with technical difficulty but also because of decreased hepatic functional reserve frequently observed due to underlying liver disease. In this report, we have reported a novel technique that allows a promising approach for deeply/centrally located tumors with maximizing both the surgical and oncological safety. Bilateral anatomic resection of the ventral parts of the paramedian sectors (BVPM) offers a sufficient surgical window for safe access to the perihilar region. This technique is based on Hjortsjo's theory for liver anatomy and enables systematic removal of the 3rd‐order portal territories. In addition, the current technique is advantageous in minimizing the loss of the normal liver parenchyma without leaving ischemia or congestion in the future liver remnant. Of the seven consecutive patients who were treated with this procedure, all the patients achieved R0 resection with acceptable rate of major morbidity (1/7, 14%). The BVPM may offer a safe and maximized chance of curative resection for deeply/centrally located liver tumors.     

Distal pancreatectomy with resection of the celiac axis and reconstruction of the hepatic artery for carcinoma of the body and tail of the pancreas

Distal pancreatectomy with resection of the celiac axis can increase resectability of carcinoma of the body and tail of the pancreas. We performed reconstruction of the hepatic artery to avoid complications caused by a decrease in hepatic arterial flow. We carried out distal pancreatectomy with resection of the celiac axis for carcinoma of the body and tail of the pancreas in four patients. When pulsation in the proper hepatic artery was weak after occlusion of the celiac axis, we performed reconstruction of the hepatic artery, using the splenic artery, which had been taken beforehand from the resected specimen. In two patients, we performed reconstruction of the hepatic artery. These two patients underwent reconstruction of the portal vein combined with prolonged clamping of the portal vein. Levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were elevated just after the operation, but recovered to normal levels within 10 days. No complications related to hepatic ischemia were observed. These results suggested that reconstruction of the hepatic artery allowed us to safely perform distal pancreatectomy with resection of the celiac axis for carcinoma of the body and tail of the pancreas.     

Comparison scoring model of severe viral hepatitis and model of end stage liver disease for the prognosis of patients with liver failure in China

AIM:To estimate the prognosis of patients with liver failure using a scoring model of severe viral hepatitis (SMSVH) and a model of end stage liver disease (MELD) to provide a scientific basis for clinical decision of treatment. METHODS:One hundred and twenty patients with liver failure due to severe viral hepatitis were investigated with SMSVH established. Patients with acute,subacute,and chronic liver failure were 40,46 and 34,respectively. The follow-up time was 6 mo. The survival rates of patients with liver failure in 2 wk,4 wk,3 mo and 6 mo were estimated with Kaplan-Meier method. Comparison between SMSVH and MELD was made using ROC statistic analysis. RESULTS:The survival curves of group A (at low risk,SMSVH score ≤ 4) and group B (at high risk,SMSVH score ≥ 5) were significantly different (The 4-wk,3-mo,6-mo survival rates were 94.59%,54.05%,43.24% in group A,and 51.81%,20.48%,12.05% in group B,respectively,P < 0.001). The survival curves of group C (SMSVH scores unchanged or increased),group D (SMSVH scores decreased by 1) and group E (SMSVH scores decreased by 2 or more) were significantly different .The survival rates of groups C,D and E were 66.15%,100%,100% in 2-wk; 40.0%,91.18%,100% in 4-wk; 0%,58.82%,80.95% in 3-mo and 0%,38.24%,61.90% in 6-mo,respectively,P < 0.001). The area under the ROC curve (AUC) of SMSVH scores at baseline and after 2 wk of therapy was significantly higher than that under the ROC curve of MELD scores (0.804 and 0.934 vs 0.689,P < 0.001). CONCLUSION:SMSVH is superior to MELD in theestimation of the prognosis of patients with severe viral hepatitis within 6 mo. SMSVH may be regarded as a criterion for estimation of the efficacy of medical treatment and the decision of clinical treatment.     

Recent advances in multidisciplinary therapy for adenocarcinoma of the esophagus and esophagogastric junction

Esophageal adenocarcinoma (EAC) and adenocarcinoma of the esophagogastric junction (EGJA) have long been associated with poor prognosis. With changes in the spectrum of the disease caused by economic development and demographic changes, the incidence of EAC and EGJA continues to increase, making them worthy of more attention from clinicians. For a long time, surgery has been the mainstay treatment for EAC and EGJA. With advanced techniques, endoscopic therapy, radiotherapy, chemotherapy, and other treatment methods have been developed, providing additional treatment options for patients with EAC and EGJA. In recent decades, the emergence of multidisciplinary therapy (MDT) has enabled the comprehensive treatment of tumors and made the treatment more flexible and diversified, which is conducive to achieving standardized and individualized treatment of EAC and EGJA to obtain a better prognosis. This review discusses recent advances in EAC and EGJA treatment in the surgical-centered MDT mode in recent years.