No-touch isolation technique in emergency pancreaticoduodenectomy for neoplastic hemorrhage: Two case reports and review of literature

BACKGROUND Emergency pancreaticoduodenectomy(EPD)is a rare event for complex periam-pullary etiology.Increased intraoperative blood loss is correlated with poor post-operative outcomes.CASE SUMMARY Two patients underwent EPD using a no-touch isolation technique,in which all arteries supplying the pancreatic head region were ligated and divided before manipulation of the pancreatic head and duodenum.The operative times were 220 and 239 min,and the blood loss was 70 and 270 g,respectively.The patients were discharged on the 14^(th) and 10^(th) postoperative day,respectively.Thirty-two patients underwent EPD for the treatment of neoplastic bleeding.The mean operative time was 361.6 min,and the mean blood loss was 747.3 g.The comp-lication rate was 37.5%.The in-hospital mortality rate was 9.38%.CONCLUSION The no-touch isolation technique is feasible,safe,and effective for reducing intraoperative blood loss in EPD.

Laparoscopy in the management of hilar cholangiocarcinoma

The use of minimally invasive surgery has become widely accepted in many gastrointestinal fields,even in patients with malignancy.However,performing laparoscopic resection for the treatment of hilar cholangiocarcinoma is still not universally accepted as an alternative approach to open surgery,and only a limited number of such procedures have been reporteddue to the difficulty of performing oncologic resection and the lack of consensus regarding the adequacy of this approach.Laparoscopy was initially limited to staging,biopsy and palliation.Recent technological developments and improvements in endoscopic procedures have greatly expanded the applications of laparoscopic liver resection and lymphadenectomy,and some reports have described the use of laparoscopic or robot-assisted laparoscopic resection for hilar cholangiocarcinoma as being feasible and safe in highly selected cases,with the ability to obtain an adequate surgical margin.However,the benefits of major laparoscopic surgery have yet to be conclusively proven,and carefully selecting patients is essential for successfully performing this procedure.

Prognostic value of KRAS and BRAF mutations in curatively resected colorectal cancer

AIM: To investigate the prognostic role of KRAS and BRAF mutations after adjustment for microsatellite instability(MSI) status in Japanese colorectal cancer(CRC) population.METHODS: We assessed KRAS and BRAF mutations and MSI status in 813 Japanese patients with curatively resected, stage Ⅰ-Ⅲ CRC and examined associations of these mutations with disease-free survival(DFS) and overall survival(OS) using uni- and multivariate Cox proportional hazards models.RESULTS: KRAS and BRAF mutations were detected in 312(38%) of 812 and 40(5%) of 811 tumors, respectively. KRAS mutations occurred more frequently in females than in males(P = 0.02), while the presence of BRAF mutations was significantly associated with the female gender(P = 0.006), proximal tumor location(P < 0.001), mucinous or poorly differentiated histology(P < 0.001), and MSI-high tumors(P < 0.001). After adjusting for relevant variables, including MSI status, KRAS mutations were associated with poorer DFS(HR = 1.35; 95%CI: 1.03-1.75) and OS(HR = 1.46; 95%CI: 1.09-1.97). BRAF mutations were poor prognostic factors for DFS(HR = 2.20; 95%CI: 1.19-4.06) and OS(HR = 2.30; 95%CI: 1.15-4.71). Neither the BRAF by MSI interaction test nor the KRAS by MSI interaction test yielded statistically significant results for DFS and OS.CONCLUSION: KRAS and BRAF mutations are associated with inferior survival, independent of MSI status, inJapanese patients with curatively resected CRC.

Factors affecting the quality of life of patients after gastrectomy as assessed using the newly developed PGSAS-45 scale: A nationwide multi-institutional study

AIM To identify certain clinical factors other than the type of gastrectomy which affect the postoperative quality of life(QOL) of patients after gastrectomy.METHODS The postgastrectomy syndrome assessment scale(PGSAS)-45 was designed to assess the severity of symptoms, the living status and the QOL of gastrectomized patients. It consists of 45 items, of which 22 are original items while 23 were retrieved from the SF-8 and Gastrointestinal Symptoms Rating Scale questionnaires with permission. A nationwide surveillance study to validate PGSAS was conducted and 2368 gastric cancer patients who underwent various types of gastrectomy at 52 medical institutions were enrolled. Of these, 1777 patients who underwent total gastrectomy(TG) reconstructed with Roux-Y(n = 393), distal gastrectomy(DG) reconstructed with Billroth-I(n = 909), or DG reconstructed with Roux-Y(n = 475) were evaluated in the current study. The influence of the type of gastrectomy and other clinical factors such as age, sex, duration after surgery, the symptom severity, the degree of weight loss, dietary intake, and the ability for working on the postoperative QOL(i.e., dissatisfaction for daily life subscale, physical component summary and mental component summary of the SF-8) were examined by multiple regression analysis(MRA). In addition, importance of various symptoms such as esophageal reflux, abdominal pain, meal-related distress, indigestion, diarrhea, constipation and dumping on the postoperative living status and QOL were also appraised by MRA.RESULTS The postoperative QOL were significantly deteriorated in patients who underwent TG compared to those after DG. However, the extent of gastrectomy was not an influential factor on patients' QOL when adjusted by the MRA. Among various clinical factors, the symptom severity, ability for working, and necessity for additional meals were the most influential factorsto the postoperative QOL. As for the individual symptoms, meal-related distress, dumping, abdominal pain, and esophageal reflux significantly affected the postoperative QOL in that order, while the influence of indigestion, diarrhea and constipation was insignificant. CONCLUSION Several clinical factors such as the symptom severity(especially in meal-related distress and dumping), ability for working and necessity for additional meals were the main factors which affected the patients' wellbeing after gastrectomy.

Quality of life after total vs distal gastrectomy with Rouxen-Y reconstruction: Use of the Postgastrectomy Syndrome Assessment Scale-45

AIM To investigate the detrimental impact of loss of reservoir capacity by comparing total gastrectomy(TGRY) and distal gastrectomy with the same Rouxen-Y(DGRY) reconstruction. The study was conducted using an integrated questionnaire, the Postgastrectomy Syndrome Assessment Scale(PGSAS)-45, recently developed by the Japan Postgastrectomy Syndrome Working Party.METHODS The PGSAS-45 comprises 8 items from the Short Form-8, 15 from the Gastrointestinal Symptom Rating Scale, and 22 newly selected items. Uni-and multivariate analysis was performed on 868 questionnaires completed by patients who underwent either TGRY(n = 393) or DGRY(n = 475) for stage I gastric cancer(52 institutions). Multivariate analysis weighed of six explanatory variables, including the type of gastrectomy(TGRY/DGRY), interval after surgery, age, gender, surgical approach(laparoscopic/open), and whether the celiac branch of the vagus nerve was preserved/divided on the quality of life(QOL).RESULTS The patients who underwent TGRY experienced the poorer QOL compared to DGRY in the 15 of 19 main outcome measures of PGSAS-45. Moreover, multiple regression analysis indicated that the type of gastrectomy, TGRY, most strongly and broadly impaired the postoperative QOL among six explanatory variables. CONCLUSION The results of the present study suggested that TGRY had a certain detrimental impact on the postoperative QOL, and the loss of reservoir capacity could be a major cause.

Postoperative inflammation as a possible cause of portal vein thrombosis after irreversible electroporation for locally advanced pancreatic cancer

Portal vein thrombosis(PVT) is a rare but serious postoperative complication associated with irreversible electroporation(IRE). We report a case of postoperative PVT in a 54-year-old woman who underwent IRE for locally advanced pancreatic cancer. Drain removal and discharge of the patient from the hospital were scheduled on postoperative day(POD) 7; however, a magnetic resonance imaging scan revealed the presence of PVT. We suspected postoperative inflammation in the pancreas as the main cause of PVT. However, the patient did not undergo any medical treatment because she did not have any clinical symptoms, and she was discharged on POD 8.

Predictive factors for body weight loss and its impact on quality of life following gastrectomy

To determine the predictive factors and impact of body weight loss on postgastrectomy quality of life (QOL). METHODSWe applied the newly developed integrated questionnaire postgastrectomy syndrome assessment scale-45, which consists of 45 items including those from the Short Form-8 and Gastrointestinal Symptom Rating Scale instruments, in addition to 22 newly selected items. Between July 2009 and December 2010, completed questionnaires were received from 2520 patients with curative resection at 1 year or more after having undergone one of six types of gastrectomy for Stage I gastric cancer at one of 52 participating institutions. Of those, we analyzed 1777 eligible questionnaires from patients who underwent total gastrectomy with Roux-en-Y procedure (TGRY) or distal gastrectomy with Billroth-I (DGBI) or Roux-en-Y (DGRY) procedures. RESULTSA total of 393, 475 and 909 patients underwent TGRY, DGRY, and DGBI, respectively. The mean age of patients was 62.1 ± 9.2 years. The mean time interval between surgery and retrieval of the questionnaires was 37.0 ± 26.8 mo. On multiple regression analysis, higher preoperative body mass index, total gastrectomy, and female sex, in that order, were independent predictors of greater body weight loss after gastrectomy. There was a significant difference in the degree of weight loss (P < 0.001) among groups stratified according to preoperative body mass index (< 18.5, 18.5-25 and > 25 kg/m2). Multiple linear regression analysis identified lower postoperative body mass index, rather than greater body weight loss postoperatively, as a certain factor for worse QOL (P < 0.0001) after gastrectomy, but the influence of both such factors on QOL was relatively small (R2, 0.028-0.080). CONCLUSIONWhile it is certainly important to maintain adequate body weight after gastrectomy, the impact of body weight loss on QOL is unexpectedly small.

Background factors influencing postgastrectomy syndromes after various types of gastrectomy

BACKGROUND Postgastrectomy syndromes(PGS) after curative gastrectomy for gastric cancer are influenced by not only gastrectomy type but also by background factors. Recently, a nationwide PGS study was performed using the Postgastrectomy Syndrome Assessment Scale-45(PGSAS-45) questionnaire.AIM To determine the influence of each background factor on PGS for each gastrectomy type using PGS assessment study(PGSAS) data as an additional analysis. METHODS The data of 2368 patients were obtained from the PGSAS. This included patients undergoing distal gastrectomy(DG) with Billroth I reconstruction, DG with Roux-en-Y reconstruction, total gastrectomy with Roux-en-Y, proximal gastrectomy, pylorus-preserving gastrectomy(PPG), and local resection. Multiple regression analysis was performed to explore the independent effects of each background factor on the main outcome measures(MOMs) of PGSAS-45 for each gastrectomy type. The background factors included postoperative period, age, sex, surgical approach(laparoscopic or open), and the status of the celiac branch of the vagal nerve.RESULTS The MOMs of DG and PPG were highly affected by background factors, whereas those of total gastrectomy with Roux-en-Y, proximal gastrectomy, and local resection were not. Worse PGS were found in females, whereas a longer postoperative period alleviated some of the MOMs. For DG and PPG, a laparoscopic approach and preservation of the celiac branch improved several MOMs.CONCLUSION Various background factors affected PGS, and their influence varied with the type of gastrectomy performed. Laparoscopic surgery and celiac branch preservation can improve PGS in patients undergoing DG and PPG.

Histological analysis of human pancreatic carcinoma following irreversible electroporation in a nude mouse model

AIM To determine changes in the morphology and function of pancreatic cancer cells after irreversible electroporation(IRE) treatment, and to explore the clinical significance of IRE treatment for pancreatic cancer providing an experimental basis for the clinical application of IRE treatment. METHODS IRE was carried out in an athymic nude mouse model of pancreatic carcinoma generated with human pancreatic cancer cells 1. In therapy groups, IRE electrodes were inserted with 90 pulses per second at 800 V/cm applied to ablate the targeted tumor tissues. Histological assessment of the affected tissue was performed by hematoxylin and eosin staining(HE). Quantification of cell proliferation and apoptosis was performed by evaluating Ki67 and caspase-3 levels, respectively. Flow cytometry was used to assess cell apoptosis. Ultrasound imaging was carried out to evaluate IRE treatment results. Pathological correlation studies showed IRE is effective for the targeted ablation of pancreatic tumors in an orthotopic mouse model.RESULTS IRE was efficacious in removing tumors in the orthotopic mouse model. The IRE-ablated zone displays characteristics of nude mouse models at different time-points as assessed by hematoxylin and eosin staining. Immunohistochemical analysis of samples from the pancreatic cancer models showed significantly enhanced caspase-3 cleavage and Ki67. Flow cytometry data corroborated the above findings that apoptosis in tumor cells was observed immediately on the first postoperative day, and with time the middle and late stages of apoptosis were observed. For ultrasound imaging studies, the IRE ablation zone became a hyperechoic area due to increasing inflammatory and immunologic cellular contents. CONCLUSION IRE is a promising new approach for pancreatic cancer, with many potential advantages over conventional ablation techniques.

Defecation disorders are crucial sequelae that impairs the quality of life of patients after conventional gastrectomy

BACKGROUND Defecation disorders are obscure sequelae that occurs after gastrectomy,and its implication on daily lives of patients have not been sufficiently investigated.AIM To examine the features of defecation disorders after gastrectomy and to explore its implication on daily lives of patients in a large cohort using the Postgast rectomy Syndrome Assessment Scale(PGSAS)-45.METHODS We conducted a nationwide multi-institutional study using PGSAS-45 to examine the prevalence of postgastrectomy syndrome and its impact on daily lives of patients after various types of gastrectomy.Data were obtained from 2368 eligible patients at 52 institutions in Japan.Of these,1777 patients who underwent total gastrectomy(TG;n=393)or distal gastrectomy(DG;n=1384)were examined.The severity of defecation disorder symptoms,such as diarrhea and constipation,and their correlation with other postgastrectomy symptoms were examined.The importance of defecation disorder symptoms on the living states and quality of life(QOL)of postgastrectomy patients,and those clinical factors that affect the severity of defecation disorder symptoms were evaluated using multiple regression analysis.RESULTS Among seven symptom subscales of PGSAS-45,the ranking of diarrhea was 4th in TG and 2nd in DG.The ranking of constipation was 5th in TG and 1st in DG.The symptoms that correlated well with diarrhea were dumping and indigestion in both TG and DG;while those with constipation were abdominal pain and mealrelated distress in TG,and were meal-related distress and indigestion in DG.Among five main outcome measures(MOMs)of living status domain,constipation significantly impaired four MOMs,while diarrhea had no effect in TG.Both diarrhea and constipation impaired most of five MOMs in DG.Among six MOMs of QOL domain,diarrhea impaired one MOM,whereas constipation impaired all six MOMs in TG.Both diarrhea and constipation equally impaired all MOMs in DG.Male sex,younger age,division of the celiac branch of vagus nerve,and TG,independently worsened diarrhea,while female sex worsened constipation.CONCLUSION Defecation disorder symptoms,particularly constipation,impair the living status and QOL of patients after gastrectomy;therefore,we should pay attention and adequately treat these relatively modest symptoms to improve postoperative QOL.

Complete response with sorafenib and transcatheter arterial chemoembolization in unresectable hepatocellular carcinoma

Patients with advanced hepatocellular carcinoma(HCC) showing portal vein tumor thrombosis(PVTT) have an extremely poor prognosis. According to treatment guidelines, the only option for HCC patients with PVTT is sorafenib chemotherapy. However, in Asia, various treatments have been attempted and possible prolongation of overall survival has been repeatedly reported. We herein report the first case of a patient with an initially unresectable advanced HCC with PVTT who underwent curative hepatectomy after sorafenib and transcatheter arterial chemoembolization(TACE) showing complete histological response. Two months after induction with sorafenib, a significant decrease in serum alpha-fetoprotein level was observed and computed tomography imaging showed a significant decrease in tumor size. Because of remaining PVTT, TACE and curative resection were performed. The combination of sorafenib and TACE may be an effective treatment for HCC patients with PVTT.

Impaired liver function attenuates liver regeneration and hypertrophy after portal vein embolization

AIM To clarify the clinical factors associated with liver regeneration after major hepatectomy and the hypertrophic rate after portal vein embolization(PVE).METHODS A total of 63 patients who underwent major hepatectomy and 13 patients who underwent PVE in a tertiary care hospital between January 2012 and August 2015 were included in the analysis.We calculated the remnant liver volume following hepatectomy using contrast-enhanced computed tomography(CT) performed before and approximately 3-6 mo after hepatectomy.Furthermore,we calculated the liver volume using CT performed 2-4 wk after PVE.Preoperative patient characteristics and laboratory data were analyzed to identify factors affecting postoperative liver regeneration or hypertrophy rate following PVE.RESULTS The remnant liver volume/total liver volume ratio negatively correlated with the liver regeneration rate after hepatectomy(ρ =-0.850,P < 0.001).The regeneration rate was significantly lower in patients with an indocyanine green retention rate at 15 min(ICG-R15) of ≥ 20% in the right hepatectomy group but not in the left hepatectomy group.The hypertrophic rate after PVE positively correlated with the regeneration rate after hepatectomy(ρ = 0.648,P = 0.017).In addition,the hypertrophic rate after PVE was significantly lower in patients with an ICG-R15 ≥ 20% and a serum total bilirubin ≥ 1.5 mg/d L.CONCLUSION The regeneration rate after major hepatectomy correlated with hypertrophic rate after PVE.Both of them were attenuated in the presence of impaired liver function.

Monitoring salivary amylase activity is useful for providing timely analgesia under sedation

AIM:To detect the criteria and cause of elevated salivary amylase activity(sAMY)in patients undergoing endoscopic submucosal dissection(ESD)under sedation.METHODS:A total of 41 patients with early gastric cancer removed via ESD under deep sedation(DS)were enrolled.The perioperative sAMY,which was shown as sympathetic excitements(SE),was measured.The time at which a patient exhibited a relatively increased rate of sAMY compared with the preoperative baseline level(IR,%)≥100%(twice the actual value)was assumed as the moment when the patient received SE.Among the 41 patients,we focused on 14 patients who exhibited an IR≥100% at any time that was associated with sAMY elevation during ESD(H-group)and examined whether any particular endoscopic procedures can cause SE by simultaneously monitoring the sAMY level.If a patient demonstrated an elevated sAMY level above twice the baseline level,the endoscopic procedure was immediately stopped.In the impossible case of discontinuance,analgesic medicines were administered.This study was performed prospectively.RESULTS:A total of 26 episodes of sAMY eruption were considered moments of SE in the H-group.The baseline level of sAMY significantly increased in association with an IR of>100% at 5 min,with a significant difference(IR immediately before elevation/IR at elevation of sAMY=8.72±173/958±1391%,P<0.001).However,effective intervention decreased the elevated sAMY level immediately within only 5 min,with a significant difference(IR at sAMY elevation/immediately after intervention=958±1391/476±1031,P<0.001).The bispectral indices,systolic blood pressure and pulse rates,which were measured at the same time,remained stable throughout the ESD.Forceful endoscopic insertion or over insufflation was performed during 22 of the 26 episodes.Release of the gastric wall tension and/or the administration of analgesic medication resulted in the immediate recovery of the elevated sAMY level,independent of body movement.CONCLUSION:By detecting twice the actual sAMY based on the preoperative level,the release of the gastric wall tension or the administration of analgesic agents should be considered.