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A stent often is placed across the pancreaticojejunostomy. However, there is no report compared between internal drainage and external drainage. We conducted a prospective randomized trial ( NCT00628186 registered at http://ClinicalTrials.gov) with 100 patients who underwent pancreaticoduodenectomy and we compared the effects on postoperative course. The incidence of pancreatic fistula according to the International Study Group on Pancreatic Fistula criteria was not different (external, 20%; vs internal, 26%), and the incidence of the other complications was similar between stent types. The median postoperative hospital stay was 21 days (range, 8–163 d) in the internal drainage group, which was shorter than the median stay of 24 days (range, 21–88 d) in the external drainage group ( P = .016). Both internal drainage and external drainage were safety devices for pancreaticojejunostomy. Internal drainage simplifies postoperative managements and it might shorten postoperative stay for pancreaticoduodenectomy.

Background The most important problem in pancreatic fistula is whether one can distinguish clinical pancreatic fistula, grade B + C fistula by the International Study Group on Pancreatic Fistula (ISGPF), from transient pancreatic fistula (grade A), in the early period after pancreaticoduodenectomy (PD). It remains unclear what predictive risk factors can precisely predict which clinical relevant or transient pancreatic fistula when diagnosed pancreatic fistula on POD3 by ISGPF criteria. Methods We analyzed the predictive factors of clinical pancreatic fistula by logistic regression analysis in 244 consecutive patients who underwent PD. Pancreatic fistula was classified into three categories by ISGPF. Results The rate of pancreatic fistula was 69 of 244 consecutive patients (28%) who underwent PD. Of these, 47 (19%) had grade A by ISGPF criteria, 17 patients (7.0%) had grade B, and five patients (2.0%) had grade C. The independent risk factor of incidence of pancreatic fistula is soft pancreatic parenchyma. However, soft pancreatic parenchyma did not predict underlying clinically relevant pancreatic fistula. The independent predictive factors of clinically relevant pancreatic fistula were serum albumin level ≤3.0 g/dl on postoperative day (POD) 4 and leukocyte counts >9,800 mm −3 on POD 4. Positive predictive value of the combination of two predictive factors for clinical relevant pancreatic fistula was 88%. Conclusions The combination of two factors on POD4, serum albumin level ≤3.0 g/dl and leukocyte counts >9,800 mm −3 , is predictive of clinical relevant pancreatic fistula when diagnosed pancreatic fistula on POD 3 by ISGPF criteria.

Inctroduction A central pancreatectomy is a parenchyma-sparing procedure that is performed to reduce long-term endocrine and exocrine insufficiency. Method In this study, we analyzed the perioperative course, the frequency of postoperative onset of diabetes mellitus, and long-term change of body weight in patients undergoing a central pancreatectomy, in comparison to the patients undergoing a distal pancreatectomy for low-grade neoplasms including cystic neoplasms and neuroendocrine tumors. Results and Discussion The rate of postoperative complications including grade B/C pancreatic fistula was no different between both groups. Only one patient undergoing a central pancreatectomy (4.7%) developed new onset of mild diabetes, whereas 35% in the distal pancreatectomy group developed new onset or worsening diabetes ( p  = 0.0129). The body weight in the distal pancreatectomy group was significant lower than that in the central pancreatectomy group at 1 and 2 years after surgery (1 year; P  < 0.0001, 2 years; P  = 0.0055), and the body weight in the patients undergoing a central pancreatectomy improved to preoperative values within 2 years after surgery. Conclusion A central pancreatectomy is a safe procedure for the treatment of low-grade malignant neoplasms in the pancreatic body; the rate of onset of diabetes is minimal, and the body weight improves early in the postoperative course.

Lymph node metastasis (LNM) is the most important prognostic factor in patients undergoing surgical resection of pancreatic ductal adenocarcinoma (PDAC). In this study, we aimed to identify molecular markers associated with LNM in PDAC using genome‐wide expression profiling. In this study, laser microdissection and genome‐wide transcriptional profiling were used to identify genes that were differentially expressed between PDAC cells with and without LNM obtained from 20 patients with PDAC. Immunohistochemical staining was used to confirm the clinical significance of these markers in an additional validation set of 43 patients. In the results, microarray profiling identified 46 genes that were differently expressed between PDAC with and without LNM with certain significance. Four of these biomarkers were validated by immunohistochemical staining for association with LNM in PDAC in an additional validation set of patients. In 63 patients with PDAC, significant LNM predictors in PDAC elucidated from multivariate analysis were low expression of activating enhancer binding protein 2 (AP2α) (P = 0.012) and high expression of mucin 17 (MUC17) (P = 0.0192). Furthermore, multivariate analysis revealed that AP2α‐low expression and MUC17‐high expression are independent prognostic factors for poor overall survival (P = 0.0012, 0.0001, respectively). In conclusion, AP2α and MUC17 were independent markers associated with LNM of PDAC. These two markers were also associated with survival in patients with resected PDAC. We demonstrate that AP2α and MUC17 may serve as potential prognostic molecular markers for LNM in patients with PDAC. (Cancer Sci 2009)

Background The indication for a hepatopancreatoduodenectomy (HPD) in patients with advanced biliary tract cancer is still controversial, because this aggressive surgery might be associated with high mortality and morbidity rates. In this study, we review our experience with HPD for advanced biliary tract cancer, and seek to define the indication for HPD. Methods Eleven patients with biliary tract cancer underwent HPD at Wakayama Medical University Hospital between 1986 and 2004. Univariate analysis was used to assess independent variables of the mortality and morbidity associated with HPD. Results The rates of mortality and morbidity were 18% and 82%, respectively. Univariate analysis showed that the total serum bilirubin level before surgery and the hepatic parenchymal resection of more than two Healey’s segments correlated significantly with an increased risk of severe complications (P = 0.044, 0.0152, respectively). The 1‐, 2‐, and 3‐year survival rates were 44%, 33%, and 11%, respectively. Conclusions Hepatopancreatoduodenectomy might offer a chance of long survival by yielding a tumor‐free margin in selected patients who are able to tolerate such an aggressive operation, but the indication for this aggressive surgery should be carefully considered.

Background No previous reports have prospectively discussed an operative approach to reducing intraoperative bleeding during pancreaticoduodenectomy (PD). We have established the preoperative CT image-assessed ligation of inferior pancreaticoduodenal artery (IPDA) method (CLIP), which uses a preoperative three-dimensional computed tomographic (3D-CT) image to precisely detect the IPDA root intraoperatively and ligates the IPDA before the pancreas head is isolated. The aim of this study was to clarify whether the new operative approach reduces intraoperative bleeding compared with classical PD. Method Between October 2003 and May 2005, classical PD was performed ( n  = 48), and from June 2005 to September 2006, PD with the CLIP method was prospectively performed ( n  = 48) at Wakayama Medical University Hospital. The perioperative status of the patients in the two groups, including intraoperative bleeding, was compared. Results Median intraoperative bleeding in patients with the CLIP method was significantly reduced compared with classical PD (867 ml versus 728 ml; p  = 0.026). Moreover, operative time, red blood cell transfusion (units), and red blood cell transfusion in patients with the CLIP method were significantly reduced compared with classical PD ( p  = 0.033, 0.042, 0.014, respectively). There were no differences in length from the SMA to the IPDA root when the preoperative measurement by 3D-CT image (37.9 ± 8.9 mm) and the intraoperative findings (38.0 ± 8.8 mm) were compared ( p  = 0.6283). Conclusions The CLIP method is a useful and reliable operative technique for reducing intraoperative bleeding in PD.

This study was conducted retrospectively to examine the efficacy of Traverso reconstruction compared with Billroth I reconstruction after pylorus‐preserving pancreaticoduodenectomy, in the prevention of several complications. Pylorus‐preserving pancreaticoduodenectomy is an aggressive surgery, and insufficiency of the pancreaticoenterostomy plays an important role in the postoperative progression. However, reports examining the correlation between pancreatic fistula and the type of reconstruction after pylorus‐preserving pancreaticoduodenectomy have been limited. Sixty‐four patients who underwent pylorus‐preserving pancreaticoduodenectomy (33 reconstructed by the Traverso technique and 31 reconstructed by the Billroth I technique) were entered into this study to investigate whether the complications were related to the type of reconstruction procedure employed. Insufficiency of the pancreaticojejunostomy, including major leakage and pancreatic fistula, occurred in 18.2% of the reconstructions by Billroth I and 0% of the reconstructions by Traverso (p < 0.05). In addition, jejunal obstruction by recurrent tumor in the remnant pancreas was observed in 3 patients reconstructed by Billroth I, and required palliative bypass surgery. Reconstruction by the Traverso procedure after pylorus‐preserving pancreaticoduodenectomy is a safe surgical method and has an advantage for advanced pancreatic cancer, which has high risk of jejunal obstruction by recurrent tumor in the remnant pancreas.