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Background: Systemic inflammation before surgery, as evidenced by the Glasgow prognostic score (GPS), predicts postoperative complications and cancer-specific survival in various types of cancer. The aim of this study was to evaluate the significance GPS in hepatic resection for hepatocellular carcinoma (HCC)., Patients and Methods: Sixty-six patients who underwent elective hepatic resections for HCC were include in the study. Patients were classified into three groups: GPS 0 [C-reactive protein (CRP)≤1.0 mg/dl and serum albumin ≥3.5 g/dl, n = 54], GPS 1 [CRP >1.0 mg/dl or serum albumin <3.5 g/dl, n = 11], and GPS 2 [CRP>1.0 mg/dl and serum albumin <3.5 g/dl, n = 1]. We retrospectively examined the association between GPS (0 or 1) and perioperative clinical variables and outcome., Results: In univariate analysis, GPS 0 patients had significantly better preoperative the retention rate of indocyanine green at 15 minutes (ICGR15) (p=0.0418), Child-Pugh classification (p = 0.0075) and model for end-stage liver disease score (p = 0.0007) than did GPS 1 patients. In multivariate analysis, blood loss and GPS 1 were independent risk factors for pulmonary complications (p = 0.0118 for blood loss, p = 0.0143 for GPS 1), red blood cell concentration transfusion (p = 0.0036 for blood loss, p = 0.0117 for GPS 1) and flesh frozen plasma transfusion (p = 0.0020 for blood loss, p = 0.0044 for GPS 1). Albumin product transfusion, duration of operation (p = 0.0478), blood loss (p = 0.0420) and GPS 1 (p = 0.0111) were independent risk factors. Disease-free and overall survival of GPS 0 and GPS 1 patients were comparable., Conclusion: GPS reflects preoperative patient status, and is associated with blood transfusion and pulmonary complications in elective hepatic resection for HCC.

Background: In spite of improvements in surgical management, hepatocellular carcinoma (HCC) still recurs after operation in 60-70% of patients. Therefore, we investigated the relation between perioperative change in white blood cell count (WBC) and tumor recurrence as well as survival in patients with HCC after hepatic resection., Methods: Subjects were 53 patients who underwent elective hepatic resection for HCC. We retrospectively examined the relation between perioperative change in WBC and recurrence of HCC as well as overall survival., Results: Advanced tumor stage and increasing of WBC on postoperative day (POD) 1 were positively associated with worse disease-free survival rate on both univariate and multivariate analysis (P < 0.05). Advanced tumor stage, increasing of WBC on POD 1, and blood transfusion were positively associated with worse overall survival rate on univariate analysis (P < 0.05), while change in WBC was the only independent factor on multivariate analysis (P < 0.05)., Conclusions: Perioperative change in WBC after elective hepatic resection for HCC is positively associated with recurrence and worse survival.

Relief of adverse events induced by chemotherapy is an important issue for patients, especially those with a poor prognosis, such as with pancreatic cancer. There are no reports of the relationship between gastroesophageal reflux disease (GERD) and chemotherapy, so we investigated the incidence of chemotherapy-induced GERD in patients undergoing treatment with gemcitabine or S-1 for pancreatic cancer and the effect of sodium rabeprazole (RPZ), a proton-pump inhibitor. GERD was diagnosed in 40% of the patients according to the Frequency Scale for Symptoms of GERD score, and RBZ therapy significantly improved their symptoms.

The prognosis of pancreatic cancer remains poor, and the standard first-line chemotherapy with gemcitabine (GEM) has a response rate of less than 20%. Since expression of deoxycytidine kinase (dCK) seems important for improvement of GEM sensitivity, overexpression of dCK was investigated using pancreatic cancer cell lines (Panc-1, MIAPaCa-2 and BxPC-3). dCK gene was introduced into the cell lines by retrovirus and changes in IC50 were examined. Sensitivity of two pancreatic cancer cell lines to GEM elevated dramatically in comparison with control cells, but change of sensitivity remained at 1.8 times in BxPC-3. Since addition of tetrahydro uridine (THU), an inhibitor of deoxycytidine deaminase (CDA), increased the sensitivity 54-fold, overexpression of CDA seems to be the mechanism for improvement of the sensitivity. In conclusion, dCK is a key enzyme of GEM, but resistance of GEM is not improved in all pancreatic cancer cells by overexpression of dCK. Combination treatment based on expression of GEM metabolism-related gene may become an effective therapy in the future.

Background: In perioperative management of hepatic resection for hepatocellular carcinoma, excessive blood loss and blood transfusion greatly influence postoperative complications and prognosis of the patients. We evaluated the influence of blood products use on postoperative recurrence and prognosis of patients with hepatocellular carcinoma., Methods: The subjects were 66 patients who underwent elective hepatic resection for hepatocellular carcinoma without concomitant microwave or radiofrequency ablation therapy nor other malignancies between January 2001 and June 2006. We retrospectively investigated the influence of the use of blood products including red cell concentration and fresh frozen plasma on recurrence of hepatocellular carcinoma and overall survival., Results: In multivariate analysis, the dose of blood products transfusion was a significant predictor of disease-free and overall survival. Both disease-free and overall survival rates of those who were given blood products were significantly worse than those who did not receive. On the other hand, in univariate analysis of disease-free and overall survival after hepatic resection and clinical variables, the amount of blood loss was not a significant predictor of recurrence or death., Conclusion: Transfusion of blood products is associated with increased recurrence rate and worse survival after elective hepatic resection for patients with hepatocellular carcinoma.

Purpose: Gemcitabine is currently the standard first-line chemotherapeutic agent for pancreatic cancer. However, chemoresistance to gemcitabine because of gemcitabine-induced nuclear factor-kappaB (NF-kappaB) activation has been reported. We previously reported that the synthetic serine protease inhibitor nafamostat mesilate inhibited NF-kappaB activation and induced apoptosis of pancreatic cancer cells. In this study, whether or not nafamostat mesilate could enhance the anticancer effect of gemcitabine was investigated., Materials and Methods: NF-kappaB activation in pancreatic cancer cells treated with various agents was examined by electrophoretic mobility shift assay (in vitro) and immunohistochemistry by investigating the location of p65 in cancer cells (in vivo). Apoptosis of the cancer cells treated with agents was examined by flow cytometry., Results: Nafamostat mesilate inhibited gemcitabine-induced NF-kappaB activation, enhanced apoptosis by gemcitabine and suppressed pancreatic tumor growth. Interestingly, the combination treatment improved the body weight loss of mice induced by gemicitabine., Conclusion: This combination chemotherapy could be a potential novel strategy for pancreatic cancer.

Background: In perioperative management after hepatectomy, some patients require fresh frozen plasma (FFP) to treat coagulopathy associated with blood loss. However, several studies have suggested a correlation between blood products and pulmonary complications or surgical-site infection (SSI)., Methods: The subjects were 99 patients who underwent hepatectomy for hepatocellular carcinoma without plasma exchange for postoperative liver failure in the Department of Surgery, Jikei University Hospital, between January 2000 and December 2006. We investigated the association of 16 factors including age; gender; preoperative ICG(R15); type of resection; concomitant resection of other digestive organs; duration of operation; blood loss; hepatitis virus status; postoperative minimum platelet count, maximum serum total bilirubin (max T-Bil), minimum serum albumin, or minimum prothrombin time; and the dose of red-blood-cell concentration (RC), FFP, platelet concentration, or albumin given in relation to postoperative pulmonary complications and SSI., Results: In univariate analysis, pulmonary complications were correlated with gender (P = 0.012), max T-Bil (P = 0.043), dose of RC given (P = 0.007), dose of FFP given (P < 0.001), and dose of albumin given (P < 0.001). In multivariate analysis, pulmonary complications were correlated with FFP given (P = 0.031) and albumin given (P = 0.020), while the incidence of SSI was not correlated with any factors., Conclusion: Excessive FFP and albumin administration may cause pulmonary complications after hepatectomy.

Background/purpose: The most common cause of conversion to laparotomy (open splenectomy) during laparoscopic splenectomy (LS) is bleeding from the splenic hilar vessels. Recently, the efficacy of Ligasure (a vessel-sealing system) as a safety device for sealing vessels and reducing intraoperative blood loss has been reported with various laparoscopic procedures. The objective of this report was to describe our techniques for minimizing bleeding during LS, characterized by the application of Ligasure (which reduces the number of clips and staples, and reduces unnecessary bleeding) and a splenic hilum hanging maneuver with a Diamond-Flex flexible retractor to obtain optimal exposure of the splenic hilum., Methods: We have performed 87 LSs since February 1993, and have employed the Ligasure instead of metal clips and staplers since September 2003. We have also introduced the splenic hilum hanging maneuver paired with Ligasure use. We have performed this new LS in 30 consecutive adult patients presenting with idiopathic thrombocytopenic purpura (n = 14), benign splenic tumor (n = 5), lymphoma (n = 4), hereditary spherocytosis (n = 2), liver cirrhosis (n = 2), and other pathologies (n = 3). The splenic ligaments and vessels, including the splenic artery and vein, were divided using a 5-mm Ligasure instead of a clip or stapler. The splenic hilum was encircled and elevated, using a Diamond-Flex, to ensure better exposure in all patients., Results: LS was successfully completed in 29 patients (97%), with only one conversion to open splenectomy. Mean blood loss for all patients with completed LS was only 21.6 ml (range 0-250 ml). Moreover, blood loss was not determinable (considered as 0 ml in this study) in 15 patients (52%). Mean spleen weight and operating time were 319.4 g (range 80-1605 g) and 143.4 min (range 90-180 min), respectively. No postoperative mortalities were encountered. Two patients experienced complications, including grade B pancreatic fistula and atelectasis, for an overall morbidity rate of 6.7%. Mean postoperative stay was 6.5 days (range 3-14 days)., Conclusions: LS using a Ligasure in combination with the splenic hilum hanging maneuver may reduce intraoperative blood loss.

Although postoperative liver metastasis for pancreatic adenocarcinoma is a major problem that directly influences patient outcome, there is no useful predictor reported to date. We reviewed 174 surgically resected pancreatic tubular adenocarcinomas for their clinicopathological data and time for the appearance of postoperative liver metastasis to occur, using the Cox proportional hazards model. Multivariate analysis revealed three independent risk factors for postoperative liver metastasis: G3 histological grading, venous system invasion, and increased preoperative carbohydrate antigen 19-9. Furthermore, the additive effect of these three variables for predicting postoperative liver metastasis was evaluated. Two-year disease-free survival rate for the liver in patients without any factor was 82%, which was significantly higher than that of those with one, two, or three factors (35%, 33%, or 0%, respectively). Our data suggest that these three conventional clinicopathological variables are useful to predict postoperative liver metastasis in patients with pancreatic cancer.

A 61-year-old man was admitted to our hospital with epigastric pain and vomiting. Enhanced abdominal computed tomography revealed inflammatory change of the pancreatic groove and focal wall thickening of the second portion of the duodenum with several cystic lesions around the head of the pancreas. We diagnosed atypical type of groove pancreatitis. The patient made a satisfactory recovery by conservative medication treatment for acute on chronic pancreatitis and cystic lesions disappeared in parallel with pancreatitis. Groove pancreatitis is a rare form of chronic pancreatitis, and to the best of our knowledge, our patient is the first case in the English literature of groove pancreatitis with cystic lesions around the head of the pancreas, which disappeared after conservative treatment for pancreatitis.

Background/objective: Postoperative pancreatic fistula remains a major complication after pancreatic surgeries. To prevent pancreatic fistula, one of the employed management strategies is pancreatic duct stenting. The purpose of this study was to evaluate the efficacy and safety of preoperative pancreatic stenting to prevent pancreatic fistula after surgery., Methods: Subjects comprised 18 consecutive patients who underwent pancreatic surgeries. Patients were divided into 2 groups: stenting group (n=7); and non-stenting group (n=11). Complications after stent placement were analyzed. Compared parameters between groups included background, incidence and grading of pancreatic fistula as judged by international study group of pancreatic fistula (ISGPF) criteria, duration until drain removal, and mean maximum level of drain amylase., Results: Two patients displayed mild pancreatitis with high serum amylase levels after stenting. No significant differences in background or any other compared parameters to assess drainage effect were identified between stenting and non-stenting groups. Complications related to placement of the stent tube occurred in 4 patients with tube occlusion or cholestasis., Conclusions: Although drainage effect in the stenting group was compared with that in the non-stenting group, no obvious effect was obtained. This procedure seems to require further investigation on indications for postoperative drainage to decrease the incidence of pancreatic fistula.

Background/aims: The purpose of this study was to introduce our procedure of limited pancreatic resection with preoperative pancreatic duct stenting to prevent complications., Patients and Methods: Subjects comprised 6 patients with neoplasm who underwent preoperative pancreatic stenting. Pancreatic stents were placed within 7 days before elective surgery. After intraoperative ultrasonography, the relationship between the main pancreatic duct (MPD) and the lesion was confirmed by measuring the distance. Partial resection was surrendered if a sufficient margin of excised tumor was not obtained or injury to the MPD was likely to occur. Branches of pancreatic duct recognized were ligated as much as possible., Results: Mild pancreatitis was present after stenting in 2 patients. Three patients actually underwent partial resection. In patients with partial resection, enhanced visualization of the MPD was useful for deciding the operative procedure and prevented iatrogenic injury to the MPD during dissection., Conclusions: Pancreatic duct stenting prior to pancreatic surgery seems useful as a guide for determining the feasibility of limited pancreatic resection and to prevent missing injury to the MPD., ((c) 2008 S. Karger AG, Basel.)

Background Purpose: Although carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9) 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.

Background: The indications for metallic stents have widened from primary hepatobiliary cancers to the other diseases such as lymph node metastases from distant organs. The present study aimed to evaluate the results and establish the efficacy of metallic stenting in patients with obstructive jaundice due to metastatic lymph nodes., Methods: Stent patency, survival and cost per patient until death were retrospectively compared between patients with primary carcinoma of the biliary tract (PC group; n = 71) and lymph node metastases from the gastric and colorectal carcinomas. (LN group; n = 26)., Results: Stent occlusion occurred in 17 patients in the PC group (24%). In contrast, stent occlusion was significantly more frequent in the LN group (P = 0.0293), occurring in 13 patients (50%). Cumulative stent patency was also significantly shorter in the LN group than that in the PC group (P = 0.0016). However, survival was almost the same between the two groups. The mean medical fee was 27% higher for the LN group than for the PC group, which was attributable to additional treatment for stent occlusion., Discussion: The indications for metallic stent placement for biliary obstruction caused by lymph node metastases from the gastrointestinal tract seem limited. Further investigation of the treatments alternative to metallic stents would be required., ((c) 2006 Wiley-Liss, Inc.)