Surgical treatment of gallbladder cancer:An eight-year experience in a single center

BACKGROUND Gallbladder cancer(GBC)is the most common biliary malignancy and has the worst prognosis,but aggressive surgeries[e.g.,resection of the extrahepatic bile duct(EHBD),major hepatectomy and lymph node(LN)dissection]may improve long-term survival.GBC may be suspected preoperatively,identified intraoperatively,or discovered incidentally on histopathology.AIM To present our data together with a discussion of the therapeutic strategies for GBC.METHODS We retrospectively investigated nineteen GBC patients who underwent surgical treatment.RESULTS Nearly all symptomatic patients had poor outcomes,while suspicious or incidental GBCs at early stages showed excellent outcomes without the need for two-stage surgery.Lymph nodes around the cystic duct were reliable sentinel nodes in suspicious/incidental GBCs.Intentional LN dissection and EHBD resection prevented metastases or recurrence in early-stage GBCs but not in advanced GBCs with metastatic LNs or invasion of the nerve plexus.All patients with positive surgical margins(e.g.,the biliary cut surface)showed poor outcomes.Hepatectomies were performed in sixteen patients,nearly all of which were minor hepatectomies.Metastases were observed in the left-sided liver but not in the caudate lobe.We may need to reconsider the indications for major hepatectomy,minimizing its use except when it is required to accomplish negative bile duct margins.Only a few patients received neoadjuvant or adjuvant chemoradiation.There were significant differences in overall and disease-free survival between patients with stages≤IIB and≥IIIA disease.The median overall survival and disease-free survival were 1.66 and 0.79 years,respectively.CONCLUSION Outcomes for GBC patients remain unacceptable,and improved therapeutic strategies,including neoadjuvant chemotherapy,optimal surgery and adjuvant chemotherapy,should be considered for patients with advanced GBCs.

Do liver metastases from gastric cancer contraindicate aggressive surgical resection?A 14-year single-center experience

BACKGROUND Advanced gastric cancer(GC)with liver metastasis is often characterized by multiple and bilobular metastases and may also be associated with extrahepatic metastatic lesions.Hence,many physicians consider that radical surgeries are contraindicated for liver metastases from GC(LMGC).According to the 2017 Japanese treatment guideline for GC,a smaller number of liver metastases without unresectable factors may be an indication for liver resection(LR)with curability.The actual 5-year overall survival(OS)rate ranges from 0 to 0.37.AIM To present the institutional indications for LR for LMGC and identify important factors for prognostic outcomes.METHODS In total,30 patients underwent LR for LMGC during a 14-year period,and we evaluated the clinical,surgical,and oncological findings.In all patients,radical surgery with intentional lymphadenectomy was performed for the primary GC.The median follow-up duration after the initial LR was 33.7 mo,and three patients with no recurrence died of causes unrelated to the LMGC.The OS and recurrence-free survival rates after the initial LR were assessed.RESULTS Seventeen patients had metachronous LMGC.The initial LR achieved curability in 29 patients.Perioperative chemotherapy was introduced in 23 patients.The median greatest LMGC dimension was 30 mm,and the median number of LMGC was two.Twenty-two patients had unilobular LMGC.The 5-year OS and recurrence-free survival rates were 0.48 and 0.28,respectively.The median survival duration and recurrence-free duration after the initial LR were 16.8 and 8.6 mo,respectively.Twenty-one patients developed recurrence after the initial LR.Additional surgeries for recurrence were performed in nine patients,and these surgeries clearly prolonged the patients’survival.Pathological serosal invasion was an independent predictor of a poor prognostic outcome after the initial LR.Aggressive LR may be indicated for carefully selected patients with LMGC.CONCLUSION Our results of LR for LMGC seem acceptable.Additional surgeries for recurrence after the initial LR might prolong OS.Pathological serosal invasion is important for poor prognostic outcomes.

Impact of continuous local lavage on pancreatic juice-related postoperative complications: Three case reports

BACKGROUND Postoperative pancreatic leakage readily results in intractable pancreatic fistula and subsequent intraperitoneal abscess.This refractory complication can be fatal;therefore,intensive treatment is important.Continuous local lavage (CLL) has recently been reevaluated as effective treatment for severe infected pancreatitis,and we report three patients with postoperative intractable pancreatic fistula successfully treated by CLL.We also discuss our institutional protocol for CLL for postoperative pancreatic fistula.CASE SUMMARY The first patient underwent subtotal stomach-preserving pancreaticoduodenectomy,and pancreatic leakage was observed postoperatively.Intractable pancreatic fistula led to intraperitoneal abscess,and CLL near the pancreaticojejunostomy site was instituted from postoperative day (POD) 8.The abscess resolved after 7 d of CLL.The second patient underwent distal pancreatectomy.Pancreatic leakage was observed,and intractable pancreatic fistula led to intraperitoneal abscess near the pancreatic stump.CLL was instituted from POD 9,and the abscess resolved after 4 d of CLL.The third patient underwent aneurysmectomy and splenectomy with wide exposure of the pancreatic parenchyma.Endoscopic retrograde pancreatic drainage was performed on POD 15 to treat pancreatic fistula;however,intraperitoneal abscess was detected on POD 59.We performed CLL endoscopically via the transgastric route because the percutaneous approach was difficult.CLL was instituted from POD 63,and the abscess resolved after 1 wk of CLL.CONCLUSION CLL has therapeutic potential for postoperative pancreatic fistula.

Fatal arterial hemorrhage after pancreaticoduodenectomy:How do we simultaneously accomplish complete hemostasis and hepatic arterial flow?

BACKGROUND Although arterial hemorrhage after pancreaticoduodenectomy(PD)is not frequent,it is fatal.Arterial hemorrhage is caused by pseudoaneurysm rupture,and the gastroduodenal artery stump and hepatic artery(HA)are frequent culprit vessels.Diagnostic procedures and imaging modalities are associated with certain difficulties.Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD.Although complete hemostasis may be obtained by endovascular treatment(EVT)or surgery,liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur.We herein discuss therapeutic options for fatal arterial hemorrhage after PD.AIM To present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.METHODS We retrospectively investigated 16 patients who developed arterial hemorrhage after PD.The patients’clinical characteristics,diagnostic procedures,actual treatments[transcatheter arterial embolization(TAE),stent-graft placement,or surgery],clinical courses,and outcomes were evaluated.RESULTS The frequency of arterial hemorrhage after PD was 5.5%.Pancreatic leakage was observed in 12 patients.The onset of hemorrhage occurred at a median of 18 d after PD.Sentinel bleeding was observed in five patients.The initial EVT procedures were stent-graft placement in seven patients,TAE in six patients,and combined therapy in two patients.The rate of technical success of the initial EVT was 75.0%,and additional EVTs were performed in four patients.Surgical approaches including arterioportal shunting were performed in eight patients.Liver infarction was observed in two patients after TAE.Two patients showed a poor outcome even after successful EVT.These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT.Fourteen patients were successfully treated.CONCLUSION Transcatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.