Preoperative serum carcinoembryonic antigen and carbohydrate antigen 19-9 levels for the evaluation of curability and resectability in patients with pancreatic adenocarcinoma

Background Purpose

Although carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) are the most studied serum tumor markers that have been evaluated for diagnosis and prognosis in patients with pancreatic cancer, little is known of the value of these markers for the prediction of curability and resectability.

Methods

We retrospectively reviewed preoperative serum levels of CEA and CA 19-9 in 244 consecutive patients with pancreatic operations.

Results

Although 159 pancreatic operations seemed “resectable”, 93 of them were judged curative (R0) and the other 66 turned out to be noncurative (R1/2). The remaining 85 failed resection because of unexpected metastasis or locally advanced disease (LD), which was unresectable compared with levels in those patients without liver metastasis or LD. CEA levels were significantly higher in patients with liver metastasis and LD, while CA 19-9 levels were correlated with liver and peritoneal metastases. When both markers were negative, curative (R0) and respectable (R0 + R1/2) operation were performed in 70% and 85% of patients, respectively. Logistic regression analysis indicated that under conditions where both CEA and CA 19-9 were negative, the odds ratios for curative and respectable operations were 4.43 and 3.58, respectively.

Conclusions

Our data suggest that combined preoperative CEA and CA 19-9 levels are suitable for assessing expected curability and resectability in patients with pancreatic cancer.

     

Is major hepatectomy with pancreatoduodenectomy justified for advanced biliary malignancy?

Background/Purpose

Major hepatectomy with concomitant pancreatoduodenectomy (M-HPD) is usually indicated for the resection of diffuse bile duct cancer or advanced gallbladder cancer. This is the only procedure that can potentially cure such advanced cancers, so both a low mortality rate and long-term survival could potentially justify performing this procedure.

Methods

Between 1990 and 2005, the morbidity, mortality, and long-term survival of 26 patients with advanced biliary tract carcinoma 14 with diffuse bile duct cancer, 9 with advanced gallbladder cancer, and 3 with hilar bile duct cancer, who underwent hepatopancreatoduodectomy (HPD) were reviewed and analyzed.

Results

The overall morbidity and mortality rates were 30.8% and 0%, respectively. Postoperative infectious complications occurred in 6 patients (23.0%). The 5-year survival rate of the 14 patients with diffuse bile duct cancer who underwent HPD was 51.9%, while the 5-year survival rate in the 12 of these patients who underwent M-HPD was 61.4%. Patients with diffuse bile duct cancer without residual tumor and those without lymph node metastasis had 5-year survival rates of 68.6% and 80%, respectively. Thirty-three percent (2 of 6) of the patients who underwent M-HPD for advanced gallbladder cancer survived for more than 5 years.

Conclusions

Preoperative biliary drainage, portal embolization, complete external drainage of pancreatic juice, reduction of intraoperative bleeding, and prevention of bacterial colonization of bile may enable the incidence of mortality and hepatic failure to approach zero in patients who undergo HPD. Surgeons should strive for complete clearance of the tumor with a negative surgical margin to achieve long-term survival when performing M-HPD.

     

Prognostic factors for long-term survival in patients with locally invasive pancreatic cancer

Background/Purpose

We aimed to investigate predictors of survival in patients with resectable locally invasive pancreatic cancer.

Methods

The patient cohort consisted of 55 patients with locally invasive pancreatic cancer (International Union Against Cancer [UICC] stage III in 36 patients and stage IV in 19) who had undergone resection. The patients were informed about the advantages and the adverse effects of postoperative chemotherapy, and prospectively selected either observation alone or postoperative chemotherapy. The postoperative chemotherapy regimen options were: (1) intraarterial chemotherapy alone, (2) systemic chemotherapy alone, or (3) intraarterial chemotherapy combined with systemic chemotherapy.

Results

Overall 1-year and 2-year survival rates after resection were 40.5% and 13.5%, respectively. Median survival time was 10.9 months. Twenty-nine patients (52.7%) received postoperative chemotherapy. On univariate analysis, only postoperative chemotherapy was associated with long-term survival (P < 0.01). In the patients with postoperative chemotherapy, the 1-year survival rate and MST were 61.7% and 16.3 months, compared with 20.1% and 7.9 months in the patients without postoperative chemotherapy. Multivariate analysis also showed that only postoperative chemotherapy was identified as an independent survival factor.

Conclusions

It was suggested that postoperative chemotherapy was essential for the improvement of survival in patients with locally invasive pancreatic cancer.

     

Long-term survivors after resection of carcinoma of the head of the pancreas: significance of histologically curative resection

Background/Purpose

The prognosis of patients with pancreatic cancer is said to have not been improved markedly by any procedures in the past 20 years. Since 1973, we have gradually extended the area of dissection when performing curative resection for pancreatic cancer to improve the resection rate and prognosis. Nineteen patients have survived for 3 years or more, and the 5-year survival rates of patients with cancer of the head of the pancreas were 23.9% for macroscopically curative resection and 34.3% for histologically curative resection.

Methods

We histologically observed surgical specimens, cut into 3- to 5-mm sections and compared the histologic characteristics of the 19 patients who survived for 3 years or more with those of 41 patients who died of cancer within 3 years (excluding 6 operative and hospital deaths), in order to find the conditions required for long-term survival.

Results

The following conditions were associated with long-term survival: (1) tumor diameter 3?cm or less; (2) either absence of lymph node metastasis or metastasis limited to the n₁ group; (3) degree of invasion of the anterior pancreatic capsule of zero (s0); and (4) either no retropancreatic invasion (rp0) or exposed retropancreatic invasion (rpe) with no cancer invasion of dissected peripancreatic tissue ew(?).

Conclusions

At present, because the rpe rate is more than 70%, resection of the pancreas, including the superior mesenteric vein and the retropancreatic fusion fascia, is essential for a curative resection, because the retropancreatic tissue between the back of the pancreas and this fascia is anatomically considered to be in the position of the subserosal tissue in the gallbladder or stomach. Combined resection of the superior mesenteric artery may further improve the results of resection for pancreatic cancer, from the anatomical viewpoint.

     

Hepatopancreatoduodenectomy: its suitability for bile duct cancer versus gallbladder cancer

Background/Purpose

We aimed to determine whether bile duct cancer (BDC) or gallbladder cancer (GBC) was a better candidate for hepatopancreatoduodenectomy (HPD).

Methods

Ten patients with BDC and ten with GBC were treated by HPD with major hepatectomy between 1994 and 2004 and compared, in terms of surgical outcome and survival.

Results

In the BDC patients, the International Union Against Cancer (UICC) stage was I in three patients; II in four; III in one; and IV in two; of the GBC patients, one was stage II; four were stage III; and five were stage IV. The reasons for choosing HPD for BDC were: superficial spreading, in three patients; intramural wide invasion, in five; and hepatoduodenal ligament (HDL) invasion, in two; and for GBC, extrahepatic bile duct invasion, in seven; and HDL invasion, in three. The morbidity and mortality rates for BDC and GBC were 40% and 60%, and 0% and 30%, respectively. All three of the GBC patients who died in hospital had undergone a right trisectionectomy with caudate lobectomy. The cumulative 5-year survival rate of the BDC patients was 64%; the 1-year survival rate for the GBC patients was only 20%, and none survived for over 2 years (P < 0.001). Of the patterns of BDC cancer invasion, the superficial-spreading type appeared to have a better prognosis than the others, but the difference was not statistically significant.

Conclusions

HPD is indicated for any type of BDC, but HPD did not show any survival benefits in treating patients with GBC with obstructive jaundice.

     

Long-term outcomes after resection of para-aortic lymph node metastasis from left-sided colon and rectal cancer

Purpose

Para-aortic lymph node (PALN) metastasis from colorectal cancer is rare and often not suitable for surgery. However, in selected patients, radical resection may bring about longer survival. The aim of this study was to evaluate long-term outcomes of resection of left-sided colon or rectal cancer with simultaneous PALN metastasis.

Methods

The study included 2122 patients with left-sided colon or rectal cancer (30 patients with and 2092 patients without PALN metastasis) who underwent resection with curative intent between 2002 and 2013. Clinicopathological characteristics, long-term outcomes of resection, and factors related to poor postoperative survival in patients with PALN metastasis were investigated.

Results

Of a total of 2122 total patients, 16 of 50 patients (32.0%) with lymph node metastasis at the root of the inferior mesenteric artery had PALN metastasis. The 5-year overall survival rates for 18 patients who underwent R0 resection and 12 patients who did not were 29.1 and 10.4%, respectively (p = 0.017). Factors associated with poor postoperative survival among patients who underwent R0 resection were presence of conversion therapy, lack of adjuvant chemotherapy, carcinoembryonic antigen >20 ng/mL, and lateral lymph node metastasis in rectal cancer patients. The 5-year recurrence-free survival rate was 14.8%.

Conclusions

Although recurrence was frequent, R0 resection for left-sided colon or rectal cancer with PALN metastasis was associated with longer survival than R1/R2 resection. Furthermore, the 5-year overall survival rate in the R0 group was relatively favorable for stage IV. Therefore, R0 resection may prolong survival compared with chemotherapy alone in selected patients.

     

Unexpected gallbladder cancer during laparoscopic cholecystectomy

Background/Purpose

In the present study, we investigated the effectiveness of surgeons in determining incidental gallbladder pathologies at laparoscopic cholecystectomy (LC).

Methods

This study included 548 patients with gallstones who underwent LC between May 1, 2001 and October 15, 2003. The surgeon made an incision on the gallbladder wall for inspection, and palpated the mucosa after removing the gallbladder from the abdominal cavity to look for unsuspected pathologies. If an abnormal mucosa was observed or palpated, it was marked with a silk suture and then histopathologic examination was performed.

Results

Fifty of 548 LC specimens were found to be suspi-cious by the surgeon. Histopathological examination of frozen sections revealed incidental pathologies in 15 of these specimens. Strikingly, 5 of these specimens were considered to have gallbladder cancer (GBC). The other incidental pathologies were consistent with adenomyomatosis, xanthogranulomatous cholecystitis, and fibroepithelial and hyperplastic polyps. Four of the other 498 specimens revealed incidental pathologies at definitive histopathological examination, and all of them were consistent with gastric metaplasia. The sensitivity and specificity of the procedure was 78.9% and 93%, respectively.

Conclusions

A simple prosedure; that is, incision and inspection, and palpation of the gallbladder, seems to be useful for the diagnosis of incidental gallbladder pathologies.

     

Hilar cholangiocarcinoma: resectability and radicality after routine diagnostic imaging

Background/Purpose

En-bloc resection has contributed to the improvement of long-term survival in patients with hilar cholangiocarcinoma. In addition, attenuation of intraoperative traumatization of the tumor may decrease tumor spread. The objective of this study was to assess the importance of a routine diagnostic workup for the surgical strategy, radicality, and results in patients with hilar cholangiocarcinoma.

Methods

Between September 1997 and December 2002, 82 patients with hilar cholangiocarcinoma were treated at our department. Preoperative diagnostic workup included endoscopic retrograde cholangiography (ERC), percutaneous transhepatic cholangiography (PTC), computed tomography (CT), and magnetic resonance imaging (MRI). The results of preoperative and retrospective (blinded) assessment of diagnostic data concerning the tumor growth along the bile ducts were compared with the results of surgery.

Results

The resection rate was 75%, and the hospital mortality, 7%. The prospective assessment of the resection to be performed was correct in 81% of cases. In ERC, magnetic resonance cholangiography (MRC), and PTC, tumor assessment was precise in 29%, 36%, and 53%, of cases, respectively. Overestimation occurred more frequently than underestimation. The 3-year survival of patients with formally curative or palliative en-bloc resection was 61% and 15%, respectively. For the 9 patients with hilar resection, the 3-year survival was 25%. Survival of patients was comparable, regardless of whether their tumor had been correctly assessed or over- or underestimated. In the multivariate analysis, R0 resection was the only significant prognostic factor (P = 0.011).

Conclusions

Our routine diagnostic approach led to high resection and survival rates. Obviously a sophisticated diagnostic workup is not an absolute prerequisite for adequate surgery.

     

Do we need histology for a normal-looking gallbladder?

Background/Purpose

Gallbladder cancer (GBC) is a rare malignancy with poor overall prognosis. Simple cholecystectomy is curative if the cancer is limited to mucosa. We aimed here to investigate the need for routine histological examination of gallbladder.

Methods

We carried out a retrospective review of 2890 final pathology reports of processed gallbladder specimens following cholecystectomy due to gallstones disease. The review covered the 10-year period from 1994 to 2004. The notes of all cases of gallbladder cancer were scrutinized, with particular emphasis on presentation, preoperative diagnostic tools using abdominal ultrasound and computed tomography scan, operative findings, and the histology results.

Results

Gallbladder cancer (GBC) was detected in five specimens (0.17%), dysplasia in six (0.2%), and secondaries to gallbladder in three (0.1%). Histological findings confirmed gallstone disease in 97% and rare benign pathology in 3%. The median age of patients with GBC was 61 years (range, 59–84 years). In all five patients, cancer was isolated from thickened fibrotic wall on macroscopic appearance and spread through all layers of the gallbladder wall. The percentage of thickened-wall gallbladder in this study was 38.02% and the cancer incidence in the thickened wall was 0.45%.

Conclusions

A selective policy rather than routine histological examination of nonfibrotic or thickened-wall gallbladder has to be considered. This will reduce the burden on pathology departments, with significant cost savings.

     

Establishment of a Gallbladder Cancer-Specific Survival Model to Predict Prognosis in Non-metastatic Gallbladder Cancer Patients After Surgical Resection

Background

Gallbladder cancer is an invasive cancer with a discouraging prognosis, and early detection and active intervention are of great value.

Aims

To establish a more accurate and effective survival model to predict the prognosis of patients with non-metastatic gallbladder after surgical resection.

Methods

A retrospective analysis was conducted in non-metastatic gallbladder cancer patients who were registered in the surveillance, epidemiology and end results database from 2010 to 2014. Univariate analysis and multivariate analysis were performed for the related factors that might affect the gallbladder cancer-specific survival. A prognostic gallbladder cancer-specific survival model was established using the nomogram tool. The discrimination test was measured by the c-index, and the conformance test was performed by a calibration curve.

Results

In all, 1422 patients with non-metastatic gallbladder cancer were identified. The prognostic factors include age, gender, lymph node dissection, postoperative chemotherapy, tumor size, histological grading, pT stage and pN stage. The gallbladder cancer-specific survival model was established based on the prognostic factors. The model’s c-index was 0.775, and the 7th AJCC staging c-index was 0.649. The calibration curves showed a good correlation between prediction and actual survival.

Conclusions

This study established the gallbladder cancer-specific survival model successfully. Compared with the 7th AJCC stage, this model refined the contribution of the pT stage, pN stage and other related factors and was demonstrated to be more accurate and reliable. More importantly, this model may allow clinicians to screen patients with a poor prognosis for closer follow-up or adjuvant treatment.

     

Segmental adenomyomatosis of the gallbladder predisposes to cholecystolithiasis

Background/Purpose

The aim of the present study was to clarify the association between adenomyomatosis of the gallbladder and cholecystolithiasis.

Methods

A cholecystectomy was performed for cholelithiasis or various other conditions in 1099 patients, of whom 608 had cholecystolithiasis. Adenomyomatosis of the gallbladder was classified as one of three variants: segmental, fundal, and diffuse. Segmental adenomyomatosis has an annular stricture dividing the gallbladder lumen into the “neck compartment” and the “fundal compartment”. Bile lipid analysis was performed in 8 patients with segmental adenomyomatosis.

Results

Adenomyomatosis of the gallbladder was observed in 156 patients (14.2%), of whom 99 had segmental adenomyomatosis, 54 had fundal adenomyomatosis, and 3 had diffuse adenomyomatosis. The prevalence of cholecystolithiasis was higher in patients with segmental adenomyomatosis (88.9%) than in those without adenomyomatosis (52.3%; P < 0.001). Gallstones were detected earlier in patients with segmental adenomyomatosis than in those without (P < 0.001) and were located predominantly in the fundal compartment. Bile in the fundal compartment had lower concentrations of total bile acids (P = 0.012), with an increased cholesterol saturation index (P = 0.012), compared to bile in the neck compartment.

Conclusions

Segmental adenomyomatosis is a condition predisposing to cholecystolithiasis, probably due to the lithogenic environment in the fundal compartment. Fundal or diffuse adenomyomatosis appears to be unrelated to cholecystolithiasis.

     

Transdiaphragmatic approach facilitates resection of large (&gt;12 cm) liver tumors

Background/Purpose

Various (mostly transthoracic) techniques have been proposed to facilitate access to large tumors located in the upper part of the liver, close to the confluence of the major hepatic veins. The purpose of this study was to investigate the safety and efficacy of a transdiaphragmatic mobilization technique for resection of such tumors.

Methods

Twenty-one patients, with tumors ranging from 12 to 22?cm in diameter, underwent liver resections using our technique of diaphragmatic splitting, with the intention of achieving adequate exposure of the inferior vena cava and the hepatocaval junction.

Results

The technique described provided, in all patients, an effective method to achieve the vascular control required for a safe liver resection. Median weight of the excised tumors was 1100?g (range, 817–2860?g).

Conclusions

Large liver tumors (>12?cm) in the upper part of the liver may be approached through a standard bilateral subcostal incision, combined with splitting of the hemidiaphragm, without the need for any kind of thoracic incision.

     

Predictors of hepatic venous trunk invasion and prognostic factors in patients with hepatocellular carcinomas that had come into contact with the trunk of major hepatic veins

Purpose

In this study, we tried to identify the preoperative predictors of hepatic venous trunk invasion and the prognostic factors in patients with hepatocellular carcinoma (HCC) that had come into contact with the trunk of a major hepatic vein over a distance of 1.0?cm or more.

Methods

Forty patients who had such HCCs resected were entered into this study and predictors of hepatic venous trunk invasion and prognostic factors were evaluated by univariate and multivariate analyses.

Results and Conclusions

A combined resection of the HCC and the venous trunk was performed in 29 patients. Hepatic venous trunk invasion was observed in 12 patients, including 2 with inferior vena cava tumor thrombus. A stepwise logistic regression analysis indicated that tumors larger than or equal to 7?cm in diameter and tumors showing a poorly differentiated histological grade were independent predictors of hepatic venous trunk invasion. The survival of patients without venous trunk invasion was significantly better than that for patients with venous trunk invasion (P = 0.048). A univariate analysis revealed that Child–Pugh classification B (P = 0.002), a high des-γ-carboxy prothrombin concentration (≧400?mAU/ml, P = 0.023), a large HCC (≧5.0?cm in diameter, P = 0.002), the presence of portal vein invasion (P < 0.001), the presence of venous trunk invasion (P = 0.048), the presence of intrahepatic metastasis (P < 0.001), and poorly differentiated HCC (P = 0.006) correlated with a worse overall survival after hepatic resection. In a multivariate analysis, however, only the presence of intrahepatic metastasis (P = 0.037, relative risk 8.25) was an independent predictor of poor overall survival.

Conclusions

Large tumors (≥7?cm in diameter) and poorly differentiated HCCs were more likely to be associated with hepatic venous trunk invasion and intrahepatic metastasis was an independent prognostic factor in patients with HCC that had come into contact with the trunk of a major hepatic vein.

     

Pancreas-sparing tumor enucleation for pancreatic mucinous cystic neoplasms: experience with two patients

Background

Because mucinous cystic neoplasms (MCNs) occur in the body and tail of the pancreas, distal pancreatectomy has been conventionally performed. However, enucleation can be adopted in selected patients, preserving the pancreatic parenchyma.

Methods

We experienced two patients with MCN who underwent pancreatic tumor enucleation. Case 1 involved a very large MCN, 23?cm across. Connective tissues between the tumor and the pancreatic parenchyma were not dense, so it was relatively easy to perform pancreatic cyst resection. Case 2 involved a MCN, 5?cm across, located next to the body of the pancreas. Fibrotic changes were so dense that it was difficult to separate the tumor from the pancreatic parenchyma. Careful and gentle dissection enabled pancreas-sparing enucleation without injury to the cyst wall.

Results

Enucleation of MCNs were performed successfully, preserving the pancreatic parenchyma. No complications were observed in either case.

Conclusions

It is important to adopt the appropriate surgical procedure for MCN, considering the balance between radical resection and preservation of pancreatic function. Although careful attention should be paid to the assessment of malignant potential in each case of MCN, pancreas-sparing tumor enucleation can be considered as one of the treatment options in selected patients.

     

A scoring model for predicting survival following primary tumour resection in stage IV colorectal cancer patients with unresectable metastasis

Background

Stage IV colorectal cancer patients with unresectable metastasis who undergo elective primary tumour resection experience heterogeneous post-operative survival. We aimed to develop a scoring model for predicting post-operative survival using pre-operative variables to identify patients who are least likely to experience extended survival following the procedure.

Methods

Survival data were collected from stage IV colorectal cancer patients who had undergone elective primary tumour resection between January 1999 and December 2007. Coefficients of significant covariates from the multivariate Cox regression model were used to compute individual survival scores to classify patients into three prognostic groups. A survival function was derived for each group via Kaplan-Meier estimation. Internal validation was performed.

Results

Advanced age (hazard ratio, HR 1.43 (1.16–1.78)); poorly differentiated tumour (HR 2.72 (1.49–5.04)); metastasis to liver (HR 1.76 (1.33–2.33)), lung (HR 1.37 (1.10–1.71)) and bone (HR 2.08 ((1.16–3.71)); carcinomatosis (HR 1.68 (1.30–2.16)); hypoalbuminaemia (HR 1.30 (1.04–1.61) and elevated carcinoembryonic antigen levels (HR 1.89 (1.49–2.39)) significantly shorten post-operative survival. The scoring model separated patients into three prognostic groups with distinct median survival lengths of 4.8, 12.4 and 18.6 months (p?<?0.0001). Internal validation revealed a concordance probability estimate of 0.65 and a time-dependent area under receiver operating curve of 0.75 at 6 months. Temporal split-sample validation implied good local generalizability to future patient populations (p?<?0.0001).

Conclusion

Predicting survival following elective primary tumour resection using pre-operative variables has been demonstrated with the scoring model developed. Model-based survival prognostication can support clinical decisions on elective primary tumour resection eligibility.

     

Choledocho-choledochostomy: the natural history of healing in pigs

Background/Purpose

Aiming to investigate the natural history of the healing of choledocho-choledochostomies.

Methods

Fifty-five female pigs of 57?kg median weight were used for the experiments. The gallbladder was removed and the common bile duct transected. Continuity was re-established by standardized single-line, interrupted, and inverted sutures. The pigs had a planned postoperative survival of up to 14 days with a subsequent laparotomy for evaluation. Blood samples were drawn prior to the first and the final operations. During laparotomy the animals were investigated for signs of cholascos, and an intraoperative cholangiography was performed. The excised anastomosis was examined for breaking strength and collagen content.

Results

Standard liver parameters were not significantly affected by the surgery, and cholangiography showed no signs of extrahepatic stenosis or intrahepatic dilatation. Breaking strength showed a decrease for the initial 3 postoperative days (PODs), then an increase to a stable level on PODs 6 to 14. Collagen content per volume showed a rise on PODs 0 to 1, then no change until POD 4, followed by a gradual rise until day 6. Subsequently a stable level was reached until POD 14. Two pigs were excluded due to minor cholascos.

Conclusions

The present study on pigs shows that choledocho-choledochostomies, judged by breaking strength and collagen content, regain a stable level of strength 6 days after operation.

     

Outcome of hepaticojejunostomy without access loop for repair of iatrogenic bile duct injury at laparoscopic cholecystectomy

Background Purpose

Roux-en-Y hepaticojejunostomy is the accepted treatment for transectional biliary injury at cholecystectomy. Many authors advocate leaving a long redundant jejunal access loop to facilitate subsequent access. Reasoning that percutaneous access can be achieved transhepatically in patients with stenosis, this study reports the outcome of a policy of biliary repair without the use of a jejunal access loop.

Methods

Eleven patients undergoing biliary reconstruction over a 5-year period constituted the study population. Three (27%) were male, and the median (range) age at injury was 53 (26–75) years. Median delay from injury to repair was 2 (1–48) months. Bismuth stage was: stage I, 4; stage II, 5; and stage III, 2. Four patients had concomitant arterial injury. All underwent surgical repair by Roux-en-Y hepaticojejunostomy without an access loop.

Results

The median follow-up was 13 (1–64) months. The principal postoperative complication was a hepatic abscess in one patient. There was one death during follow-up, from acute myeloid leukemia. One patient (9%) with a type III injury presented with a symptomatic recurrent biliary stricture 6 months after repair, and was successfully managed by percutaneous biliary dilatation, using a combination of transhepatic and jejunal loop puncture.

Conclusions

Successful biliary reconstruction can be performed without a routine jejunal access loop.

     

Green-tea polyphenol (-)-epigallocatechin-3-gallate provides resistance to apoptosis in isolated islets

Background/Purpose

Apoptosis resulting from disruption of the normal cell-matrix relationship (anoikis) during islet isolation, and the reactive oxygen and nitrogen species generated following hypoxia/reoxygenation (H/R) can lead to a loss of islet tissue in culture and the reduced survival of transplanted pancreatic islets. The aim of this study was to investigate the effect of (-)-epigallocatechin-3-gallate (EGCG), a well-known antiapoptotic agent, on inhibiting anoikis and H/R injury in an in vitro islet culture system.

Methods

Islets were isolated from F344 rats and cultured under normal or H/R condition with/without EGCG.

Results

EGCG inhibited apoptosis and lactate-dehydrogenase leakage from anoikis and H/R in a dose-dependent manner. Further, EGCG prevent increases in 8-hydroxy-2′-deoxyguanosine content and inhibited the decline of insulin secretory function induced by H/R.

Conclusions

These results suggest that the addition of EGCG to an islet culture system may improve the survival rate of isolated islets and reduce the loss of functional islet mass that compromises the stable reversal of diabetes after islet transplantation.

     

Right hepatopancreatoduodenectomy: improvements over 23 years to attain acceptability

Background/Purpose

Right hepatopancreatoduodenectomy (rt-HPD), a demanding procedure associated with high morbidity and mortality, remains the only curative option for some patients with biliary cancer. We retrospectively analyzed our progress over 23 years in making this operation safer.

Methods

Fifty-eight patients who had undergone rt-HPD were enrolled. Gallbladder cancer was present in 33 patients and bile duct cancer in 25 patients. Comparisons of short-term results after surgery were made between the 1980s (16 patients), 1990s (28 patients), and 2000 to 2004 (14 patients).

Results

Intraoperative blood loss decreased progressively and significantly. The incidence of pancreatic fistula, and leakage of pancreatojejunostomy and hepaticojejunostomy also decreased, as did the occurrence of liver failure. Infection varied little by decade, but some recent progress may be underway. Mortality decreased, although not significantly.

Conclusions

Refinements in techniques, imaging, and perioperative management have improved the outlook for patients requiring HPD for cure, but much more remains to be achieved. Our results are not satisfactory, but they may be acceptable, considering the lack of alternative curative treatment.

     

Gallstone pancreatitis: positive correlation between severe pancreatitis and passed stone

Background/Purpose

Little is known about whether the severity of pancreatitis depends upon persistent stone impaction or stone passage into the duodenum, and the role of endoscopic sphincterotomy (ES) has remained controversial.

Methods

This study reviewed our experience of 183 patients with gallstone pancreatitis, with special attention paid to the relationship between the severity of pancreatitis, the severity of coexisting biliary pathology, and the outcome.

Results

Sixteen patients (9%) had severe pancreatitis (SP) and the remaining 167 (91%) had mild pancreatitis (MP). All of the SP patients had pancreatic necrosis, and 6 of them developed multiple organ failure (MOF). No SP patients had stones impacted at the papilla of Vater or persistent stones and purulent bile in the bile duct (severe cholangitis). Most SP patients (94%) had stones in the gallbladder alone, suggesting stone passage into the duodenum. Of the 167 MP patients, on the other hand, 58 (35%) had severe cholangitis. Four patients (25%) with SP died of MOF. There were four deaths in the MP group (2%) and all in patients with coexisting severe cholangitis, 2 of whom were in septic shock at the time of admission.

Conclusions

None of the SP patients had severe cholangitis. The positive correlation between SP and passed stone suggests that early ES should not be advocated for SP patients. MP patients with coexisting severe cholangitis are likely to benefit from ES.