Background/purpose This study was performed to evaluate the outcomes of laparoscopic distal pancreatectomy (LDP) and laparoscopic pancreatoduodenectomy (LPD) compared with the open method using meta-analysis. Methods A literature search was performed to identify comparative studies of laparoscopic versus open pancreatectomy. Perioperative outcomes were evaluated by meta-analysis using a fixed effect model and random effects model. Results Twenty-four studies of LDP and three studies of LPD matched the selection criteria, including 2,904 patients of DP and 109 patients of PD. Compared with ODP, LDP showed statistically significant differences with respect to less blood loss, lower transfusion rates, lower wound infection rates, lower morbidity rates, and shorter hospital stays. LPD showed significantly longer operative times compared with OPD. There was no significant difference in oncological outcomes between laparoscopic pancreatectomy and the open technique. Conclusions This meta-analysis included the largest number of patients and number of articles comparing LDP and ODP, and LDP showed significantly better perioperative outcomes. This meta-analysis suggests that LDP is a reasonable operative method for benign tumors and some ductal carcinomas in the pancreas.
OBJECTIVE:Microsurgical techniques, initially used for hepatic artery reconstruction, have been extended to biliary reconstruction to decrease biliary complications. The routine use of microsurgical biliary reconstruction in pediatric living donor liver transplantation (LDLT) has not been elucidated.METHODS:Sixty-seven pediatric patients underwent primary LDLT. All biliary reconstructions were performed by a single microsurgeon using microsurgical techniques. A biliary stent was not used. The minimum follow-up was 12 months. Thirty-four patients had a minimum follow-up of 36 months. The outcomes of those who underwent microsurgical biliary reconstruction were compared with the outcomes of a cohort of 67 patients who underwent conventional biliary reconstruction.RESULTS:The demographical and clinical profiles of the two groups were not significantly different. There were 5 anastomotic complications in the conventional and 2 anastomotic complications in the microsurgical reconstruction groups. All complications developed within 90 days after transplant. There were no late biliary complications. Further analysis showed that conventional reconstruction increased the risk of biliary complications by 2.4 times (relative risk: 2.42; attributable risk: 4.5).CONCLUSION:The routine use of microsurgical biliary reconstruction in pediatric LDLT is a technical innovation that led to decreased anastomotic biliary complications.
This paper describes typical diseases and morbidities classified in the category of miscellaneous etiology of cholangitis and cholecystitis. The paper also comments on the evidence presented in the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG 07) published in 2007 and the evidence reported subsequently, as well as miscellaneous etiology that has not so far been touched on. (1) Oriental cholangitis is the type of cholangitis that occurs following intrahepatic stones and is frequently referred to as an endemic disease in Southeast Asian regions. The characteristics and diagnosis of oriental cholangitis are also commented on. (2) TG 07 recommended percutaneous transhepatic biliary drainage in patients with cholestasis (many of the patients have obstructive jaundice or acute cholangitis and present clinical signs due to hilar biliary stenosis or obstruction). However, the usefulness of endoscopic naso-biliary drainage has increased along with the spread of endoscopic biliary drainage procedures. (3) As for biliary tract infections in patients who underwent biliary tract surgery, the incidence rate of cholangitis after reconstruction of the biliary tract and liver transplantation is presented. (4) As for primary sclerosing cholangitis, the frequency, age of predilection and the rate of combination of inflammatory enteropathy and biliary tract cancer are presented. (5) In the case of acalculous cholecystitis, the frequency of occurrence, causative factors and complications as well as the frequency of gangrenous cholecystitis, gallbladder perforation and diagnostic accuracy are included in the updated Tokyo Guidelines 2013 (TG13).Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
Background It is still unknown whether laparoscopic liver resection is suitable for recurrent hepatocellular carcinoma (HCC) after previous curative hepatic resection. Method The perioperative outcomes of 40 patients treated with second surgery for recurrent HCC by partial hepatectomy were studied retrospectively. The second surgery was performed under laparotomy in 20 patients (laparotomy group) and under laparoscopy in 20 patients (laparoscopy group). Results Intraoperative blood loss ( p < 0.0001) and the incidence of postoperative complications ( p = 0.0004) were lower in the laparoscopy group than in the laparotomy group. The incidence rates of surgical site infection and intractable ascites were significantly higher in the laparotomy group than in the laparoscopy group ( p = 0.0202, p = 0.0436, respectively). The proportion of patients classified as Clavien grade IIIa was higher in the laparotomy group than in the laparoscopy group ( p = 0.0033). The duration of the postoperative hospital stay was significantly shorter in the laparoscopy group than in the laparotomy group ( p < 0.0001). Conclusions Postoperative morbidity has been decreased by the introduction of laparoscopic liver resection in patients with recurrent HCC after curative hepatic resection. As a result, the duration of the postoperative stay is shorter.
BACKGROUND:The discovery of practical biomarkers is important to realize personalized medicine for patients with malignant neoplasias, including colorectal cancer (CRC).PURPOSE:The aim of this study was to determine reliable prognostic biomarkers by the analysis of patients with resectable colorectal liver metastases (CRLM).METHODS:Genomic DNA was obtained from the CRLM tissues of a cohort of 126 patients with CRLM with curative hepatic resection. The KRAS/BRAF mutation spectrum and microsatellite instability (MSI) status were successfully analyzed in 100 of the 126 CRLM tissues and these findings were examined in relation to the patients' clinical outcomes.RESULTS:The cohort of 100 CRLM patients consisted of 46 with synchronous and 54 with metachronous liver metastasis. Overall survival and disease-free survival at 5 years were 57.4 and 24.9 %, respectively. MSI analysis revealed that none of the 100 CRLM specimens showed any evidence of MSI. By KRAS/BRAF mutation analysis, the analyzed CRLM patients were divided into 3 groups; KRAS-mutant (KRAS-Mt; n = 27), BRAF-mutant (BRAF-Mt; n = 3), and wild-types of both genes (Wild-type; n = 70). In the survival analysis, both KRAS-Mt and BRAF-Mt patients showed significantly poorer prognoses compared with Wild-type patients. Furthermore, although the population with the BRAF mutation was small, this mutation had a significant negative impact on disease-free survival.CONCLUSIONS:In this study, all tumors in the cohort of CRLM patients were non-MSI tumors, suggesting MSI cancer in primary CRC would rarely reveal metastatic potential. KRAS and BRAF mutations are suggested to be poor prognostic factors in CRLM. Genetic information has an essential role as a prognostic marker and could contribute to the decisions on treatment strategy for CRLM.
BACKGROUND:Neo-adjuvant chemotherapy (CHT) has gained increasing importance in resectable and borderline resectable pancreatic cancer leading to a better performing surgery when we look at negative resection margins and selection of patients with less aggressive disease. We apply this principle to patients with Stage III (LAC) pancreatic cancer undergoing RFA and try to select patients who may benefit from a local treatment.METHODS:All patients affected by LAC were treated with RFA for a stable disease after a short CHT. Postoperative morbidity and mortality were evaluated together with overall survival (OS) and disease specific survival (DSS).RESULTS:We consecutively treated 57 patients affected by LAC. Median duration of CHT before RFA was 5 months. The postoperative mortality rate was zero. Overall morbidity was 14 % with RFA-related morbidity of 3.5 %. The OS and DSS were 19 months and when compared to a similar population who received RFA as up front treatment, there was no difference.CONCLUSIONS:Our results do not support the adoption of a short CHT as a way to identify patients to treat with RFA with the most benefit. Based on this and by knowing the role of immune modulation after RFA and its specific involvement in pancreatic carcinoma, we can propose RFA as upfront treatment.
Pancreatic cancer is the fourth leading cause of cancer death in our society, with a mortality that virtually parallels its incidence, a median survival of <12 months even with maximal therapy, and a 5-year survival rate of <5 %. The diversity of clinical outcomes and the molecular heterogeneity of histopathologically similar cancer types, incomplete knowledge of the genomic aberrations that drive carcinogenesis and the lack of therapeutics that specifically target most known genomic aberrations necessitates large-scale detailed analysis of cancer genomes to identify novel potential therapeutic strategies. As part of the International Cancer Genome Consortium (ICGC), the Australian Pancreatic Cancer Genome Initiative (APGI) used exomic sequencing and copy number analysis to define genomic aberrations that characterize a large, clinically focused, prospectively accrued cohort of patients with pancreatic cancer. The cohort consisted of early (clinical stages I and II) non-pre-treated patients with pancreatic ductal adenocarcinoma who underwent operative resection with curative intent. We devised approaches to adjust for low epithelial content in primary tumours and to define the genomic landscape of pancreatic cancer to identify novel candidate driver genes and mechanisms. We aim to develop stratified, molecular phenotype-guided therapeutic strategies using existing therapeutics that are either rescued, repurposed, in development, or are known to be effective in an undefined subgroup of PC patients. These are then tested in primary patient-derived xenografts and cell lines from the above deeply characterized cohort. In addition, we return information to treating clinicians that influences patient care and are launching a clinical trial called IMPaCT (Individualized Molecular Pancreatic Cancer Therapy). This umbrella design trial randomizes patients with metastatic disease to either standard first-line therapy with gemcitabine, or a molecular phenotype-guided approach using next-generation sequencing strategies to screen for actionable mutations defined through the ICGC effort.
Since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07), diagnostic criteria and severity assessment criteria for acute cholangitis have been presented and extensively used as the primary standard all over the world. However, it has been found that there are crucial limitations in these criteria. The diagnostic criteria of TG07 do not have enough sensitivity and specificity, and its severity assessment criteria are unsuitable for clinical use. A working team for the revision of TG07 was organized in June, 2010, and these criteria have been updated through clinical implementation and its assessment by means of multi-center analysis. The diagnostic criteria of acute cholangitis have been revised as criteria to establish the diagnosis where cholestasis and inflammation demonstrated by clinical signs or blood test in addition to biliary manifestations demonstrated by imaging are present. The diagnostic criteria of the updated Tokyo Guidelines (TG13) have high sensitivity (87.6 %) and high specificity (77.7 %). TG13 has better diagnostic capacity than TG07. Severity assessment is classified as follows: Grade III: associated with organ failure; Grade II: early biliary drainage should be conducted; Grade1: others. As for the severity assessment criteria of TG07, separating Grade II and Grade I at the time of diagnosis was impossible, so they were unsuitable for clinical practice. Therefore, the severity assessment criteria of TG13 have been revised so as not to lose the timing of biliary drainage or treatment for etiology. Based on evidence, five predictive factors for poor prognosis in acute cholangitis--hyperbilirubinemia, high fever, leukocytosis, elderly patient and hypoalbuminemia--have been extracted. Grade II can be diagnosed if two of these five factors are present. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
In 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were first published in the Journal of Hepato-Biliary-Pancreatic Surgery. The fundamental policy of TG07 was to achieve the objectives of TG07 through the development of consensus among specialists in this field throughout the world. Considering such a situation, validation and feedback from the clinicians' viewpoints were indispensable. What had been pointed out from clinical practice was the low diagnostic sensitivity of TG07 for acute cholangitis and the presence of divergence between severity assessment and clinical judgment for acute cholangitis. In June 2010, we set up the Tokyo Guidelines Revision Committee for the revision of TG07 (TGRC) and started the validation of TG07. We also set up new diagnostic criteria and severity assessment criteria by retrospectively analyzing cases of acute cholangitis and cholecystitis, including cases of non-inflammatory biliary disease, collected from multiple institutions. TGRC held meetings a total of 35 times as well as international email exchanges with co-authors abroad. On June 9 and September 6, 2011, and on April 11, 2012, we held three International Meetings for the Clinical Assessment and Revision of Tokyo Guidelines. Through these meetings, the final draft of the updated Tokyo Guidelines (TG13) was prepared on the basis of the evidence from retrospective multi-center analyses. To be specific, discussion took place involving the revised new diagnostic criteria, and the new severity assessment criteria, new flowcharts of the management of acute cholangitis and cholecystitis, recommended medical care for which new evidence had been added, new recommendations for gallbladder drainage and antimicrobial therapy, and the role of surgical intervention. Management bundles for acute cholangitis and cholecystitis were introduced for effective dissemination with the level of evidence and the grade of recommendations. GRADE systems were utilized to provide the level of evidence and the grade of recommendations. TG13 improved the diagnostic sensitivity for acute cholangitis and cholecystitis, and presented criteria with extremely low false positive rates adapted for clinical practice. Furthermore, severity assessment criteria adapted for clinical use, flowcharts, and many new diagnostic and therapeutic modalities were presented. The bundles for the management of acute cholangitis and cholecystitis are presented in a separate section in TG13.Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
Background Laparoscopic cholecystectomy is now accepted as a surgical procedure for acute cholecystitis when it is performed by an expert surgeon. There are several lines of strong evidence, such as randomized controlled trials (RCTs) and meta-analyses, supporting the introduction of laparoscopic cholecystectomy for patients with acute cholecystitis. The updated Tokyo Guidelines 2013 (TG13) describe the surgical treatment for acute cholecystitis according to the grade of severity, the timing, and the procedure used for cholecystitis in a question-and-answer format using the evidence concerning surgical management of acute cholecystitis. Methods and materials Forty-eight publications were selected for a careful examination of their full texts, and the types of surgical management of acute cholecystitis were investigated using this evidence. The items concerning the surgical management of acute cholecystitis were the optimal surgical treatment for acute cholecystitis according to the grade of severity, optimal timing for the cholecystectomy, surgical procedure used for cholecystectomy, optimal timing of the conversion of cholecystectomy from laparoscopic to open surgery, and the complications of laparoscopic cholecystectomy. Results There were eight RCTs and four meta-analyses concerning the optimal timing of the cholecystectomy. Consequently, it was found that cholecystectomy is preferable early after admission. There were three RCTs and two meta-analyses concerning the surgical procedure, which concluded that laparoscopic cholecystectomy is preferable to open procedures. Literature concerning the surgical treatment according to the grade of severity could not be quoted, because there have been no publications on this topic. Therefore, the treatment was determined based on the general opinions of professionals. Conclusion Surgical management of acute cholecystitis in the updated TG13 is fundamentally the same as in the Tokyo Guidelines 2007 (TG07), and the concept of a critical view of safety and the existence of extreme vasculobiliary injury are added in the text to call the surgeon’s attention to the need to reduce the incidence of bile duct injury. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html .
Endoscopic biliary stenting is a well-established palliative treatment for unresectable malignant biliary strictures, for which plastic tube stents (PSs) and self-expandable metallic stents (SEMSs) are most commonly used. The efficacy of these stents has been extensively described in distal biliary strictures, but not in hilar biliary strictures. The present study aimed to compare the efficacy of PSs and SEMSs for unresectable malignant hilar biliary strictures.
BACKGROUND:Minimally invasive surgical techniques for pancreatic cancer are being applied with increasing frequency. With support of the literature, the location of the tumor within the pancreas is the factor which determines if these techniques can be safely used routinely by pancreatic surgeons.METHODS:Literature supporting minimally invasive techniques for all types of resections for pancreatic cancer was reviewed.RESULTS:Multiple meta-analysis regarding laparoscopic distal pancreatectomy all support the routine use of laparoscopy for these lesions. There are several case series describing the safety and efficacious use of laparoscopy in pancreaticoduodenectomy, and results have been promising in these highly specialized centers.CONCLUSIONS:The location of the tumor within the pancreas remains the most critical factor in the use of laparoscopy as the standard of care. Lesions in the body and tail, which are readily resected with a distal or subtotal pancreatectomy should be performed laparoscopically unless there is a clear reason why not to do so. Lesions in the head of the pancreas have been shown to be removed safely and effectively with laparoscopy. However, the technical skills necessary and the ability to teach these to trainees are the limiting factors to widespread use. Further series are necessary to assess if the laparoscopic approach to pancreaticoduodenectomy will play a similar role as the one it plays in the surgical treatment for distal lesions.
While referring to the evidence adopted in the Tokyo Guidelines 2007 (TG07) as well as subsequently obtained evidence, further discussion took place on terminology, etiology, and epidemiological data. In particular, new findings have accumulated on the occurrence of symptoms in patients with gallstones, frequency of severe cholecystitis and cholangitis, onset of cholecystitis and cholangitis after endoscopic retrograde cholangiopancreatography and medications, mortality rate, and recurrence rate. The primary etiology of acute cholangitis/cholecystitis is the presence of stones. Next to stones, the most significant etiology of acute cholangitis is benign/malignant stenosis of the biliary tract. On the other hand, there is another type of acute cholecystitis, acute acalculous cholecystitis, in which stones are not involved as causative factors. Risk factors for acute acalculous cholecystitis include surgery, trauma, burn, and parenteral nutrition. After 2000, the mortality rate of acute cholangitis has been about 10 %, while that of acute cholecystitis has generally been less than 1 %. After the publication of TG07, diagnostic criteria and severity assessment criteria were standardized, and the distribution of cases according to severity and comparison of clinical data among target populations have become more subjective. The concept of healthcare-associated infections is important in the current treatment of infection. The treatment of acute cholangitis and cholecystitis substantially differs from that of community-acquired infections. Cholangitis and cholecystitis as healthcare-associated infections are clearly described in the updated Tokyo Guidelines (TG13). Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.
Laparoscopic liver resection remains limited to a relatively small number of institutions because of insufficient hepatic and laparoscopic surgical experience and few training opportunities. The aim of this study was to assess the feasibility and safety of an improved laparoscopic left lateral sectionectomy technique as a training procedure for new surgeons.Twenty-four laparoscopic left lateral sectionectomies (LLLSs) were retrospectively reviewed. Patients were divided into 3 groups with 8 patients in each: those undergoing surgery by expert surgeons prior to 2008 (Group A); those undergoing surgery by expert surgeons after 2008, when a standardized LLLS technique was adopted (Group B); and those undergoing LLLS by junior surgeons being trained (Group C).The median operative time was significantly shorter for Group B (103 min; range, 99-109 min) and C (107 min; range, 85-135 min) patients than for Group A (153 min; range, 95-210 min) patients. There were no significant differences in blood loss or hospital stay. In Groups B and C, no conversions to open laparotomy or complications occurred.The standardized LLLS procedure was both safe and feasible as a technique for training surgeons in laparoscopic hepatectomy.
INTRODUCTION:We report our experience with laparoscopic major liver resection in Korea based on a multicenter retrospective study.MATERIALS AND METHODS:Data from 1,009 laparoscopic liver resections conducted from 2001 to 2011 were retrospectively collected. Twelve tertiary medical centers with specialized hepatic surgeons participated in this study.RESULTS:Among 1,009 laparoscopic liver resections, major liver resections were performed in 265 patients as treatment for hepatocellular carcinoma, metastatic tumor, intrahepatic duct stone, and other conditions. The most frequently performed procedure was left hemihepatectomy (165 patients), followed by right hemihepatectomy (53 patients). Pure laparoscopic procedure was performed in 190 patients including 19 robotic liver resections. Hand-assisted laparoscopic liver resection was performed in three patients and laparoscopy-assisted liver resection in 55 patients. Open conversion was performed in 17 patients (6.4 %). Mean operative time and estimated blood loss in laparoscopic major liver resection was 399.3 ± 169.8 min and 836.0 ± 1223.7 ml, respectively. Intraoperative transfusion was required in 65 patients (24.5 %). Mean postoperative length of stay was 12.3 ± 7.9 days. Postoperative complications were detected in 53 patients (20.0 %), and in-hospital mortality occurred in two patients (0.75 %). Mean number and mean maximal size of resected tumors was 1.22 ± 1.54 and 40.0 ± 27.8 mm, respectively. R0 resection was achieved in 120 patients with hepatic tumor, but R1 resection was performed in eight patients. Mean distance of safe resection margin was 14.6 ± 15.8 mm.CONCLUSIONS:Laparoscopic major liver resection has become a reliable option for treatment of liver disease in Korea.
Background The incidence of surgical site infections (SSIs) is high after pancreaticoduodenectomy (PD). Methods We divided 116 consecutive patients who underwent PD into an early group ( n = 58) and a later group ( n = 58) according to time of surgery. In both groups, endoscopic retrograde biliary drainage was mainly employed for the patients with obstructive jaundice. In the later group, prophylactic antibiotics were selected according to the susceptibility of microorganisms isolated from SSIs in the early group. The incidence of SSIs was compared between the groups. Results The background characteristics (including methods of preoperative biliary drainage and microorganisms in the bile obtained before or during operation) of the patients were not significantly different between the groups, except for the serum albumin level, which was lower in the later group than in the early group ( P = 0.0026). The incidence of SSIs was significantly lower in the later group (24.1 %) than in the early group (46.6 %) ( P = 0.0116). Belonging to the later group was one independent negative risk factor for SSI. Conclusions Selection of prophylactic antibiotics on the basis of microorganisms isolated from SSIs in the early group contributed to the reduced incidence of SSIs in the later group after PD.
A multicenter survey was conducted to explore the role of adjuvant surgery for initially unresectable pancreatic cancer with a long-term favorable response to non-surgical cancer treatments.
Pancreatic cancer is still a highly lethal disease with a 5-year survival rate of approximately 5 %. Early detection offers one of the best hopes for improving survival. Previous cohort studies and case-control studies showed that 4-10 % of pancreatic cancers have a hereditary basis, and individuals with a family history have an increased risk of developing pancreatic and extra-pancreatic malignancies. Since individuals with a family history of pancreatic cancer and those with a known genetic syndrome that predisposes to pancreatic cancer will be the first to benefit from early detection tests as they become available, familial pancreatic cancer (FPC) registries have been established in the US and Europe, but not yet in Japan. Such registries form the basis for epidemiological studies, clinical trials, and basic research on familial pancreatic cancer. There is a need for FPC registries in Japan as cancer risk varies among different populations and discoveries made in Western populations may not translate to the Japanese population. These registries in Japan will align with ongoing international efforts and add to a better understanding of the natural history, risk factors, screening strategies, and responsible genes, for improving survival of this dismal disease.
BACKGROUND/PURPOSE:Recent studies suggest that there is no significant benefit and that there may be significantly higher morbidity rates in pancreatic cancer patients who undergo preoperative plastic stent placement for obstructive jaundice. This review attempts to define the role of stenting in patients with pancreatic cancer and malignant obstructive jaundice. The latter includes patients unresectable for cure, those who are too frail to withstand an operation, the occasional patient who presents with cholangitis, and those patients who will have a significant delay in surgery because of preoperative neoadjuvant therapy.METHODS:Literature review. A therapeutic endoscopy team member of a multidisciplinary team which evaluates and treats >250 pancreatic cancer patients yearly.RESULTS:There are 5 historical randomized controlled trials (RCTs) and 1 current RCT demonstrating no significant benefit in preoperatively decompressing jaundiced patients with pancreatic malignancy with percutaneously placed tubes or endoscopically inserted plastic stents. There are 5 RCTs defining a longer patency rate with self-expandable metal stents (SEMS) compared to plastic prostheses suggesting that in the setting of palliation as well as the use of neoadjuvant therapy for resectable or borderline resectable patients, SEMS placement is preferable.CONCLUSIONS:Despite data demonstrating lack of efficacy and potential harm in decompressing the biliary tree as opposed to early surgery in jaundiced patients with pancreatic malignancy, endoscopic retrograde cholangiopancreatography with SEMS insertion remains an invaluable palliative modality in non-resectable patients as well as those in whom contemplated resection is delayed in order to give neoadjuvant therapy.
