Publications by authors named "Tatsuma Sakaguchi"

37 Publications

Validation of the triple-checked criteria for drain management after pancreatectomy.

J Hepatobiliary Pancreat Sci 2021 Jul 30. Epub 2021 Jul 30.

Department of Surgery, Kansai Medical University, Hirakata, Japan.

Background: Drain management is important for the detection and treatment of clinically relevant postoperative pancreatic fistula (CR-POPF). We previously established the triple-checked criteria for drain removal: drain fluid amylase (DFA) <5000 U/L on postoperative day (POD) 1 and DFA <3000 U/L on POD 3, or C-reactive protein <15 mg/dL on POD 3. This study aimed to validate the efficacy of the triple-checked criteria.

Methods: In this study, 681 patients who underwent pancreatectomy were included. Drains were removed according to our previous criteria (sequentially checked criteria: DFA <5000 U/L on POD 1 and DFA <3000 U/L on POD 3) from 2012 to 2016 (control group) and the triple-checked criteria from 2017 to 2019 (intervention group).

Results: The control group included 406 patients, and the intervention group included 275 patients. Significantly more patients (n = 237, 86.2%) met the triple-checked criteria in the intervention group, relative to the sequentially checked criteria for early drain removal policy (n = 309, 76.1%; P = .001). Sensitivity, accuracy, and negative predictive value were significantly higher in the intervention group than in the control group (P < .001). The incidence of CR-POPF was not significantly different (11.1% vs 13.8%, P = .285).

Conclusions: The triple-checked criteria contributed to effective drain removal after pancreatectomy without increasing CR-POPF.
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http://dx.doi.org/10.1002/jhbp.1030DOI Listing
July 2021

Hepatic actinomycosis after total pancreatectomy: A case report.

Int J Surg Case Rep 2021 Aug 20;85:106212. Epub 2021 Jul 20.

Department of Surgery, Kansai Medical University, Osaka, Japan.

Introduction And Importance: Hepatic actinomycosis (HA) is a rare infection mimicking a malignancy. HA after total pancreatectomy for a pancreatic tumor has not been reported.

Case Presentation: A 70-year-old woman with a history of gastrectomy and sigmoidectomy for benign lesions, underwent a total pancreatectomy for a non-invasive, intraductal papillary mucinous carcinoma (IPMC). She required partial resection of the transverse colon due to insufficient blood flow and had an anastomotic failure. Four months later, she developed a fever and effusion from the upper abdominal midline incision. No bacteria were cultured from the effusion. Contrast-enhanced computed tomography demonstrated an 80-mm iso-vascular liver mass. A slightly high-signal intensity on T2-weighted magnetic resonance imaging was demonstrated. Positron emission tomography (PET) showed a standardized uptake value of 11.9 at the liver mass. The percutaneous liver biopsy did not establish a diagnosis. Because a malignancy could not be ruled out, an exploratory laparotomy was performed. A tissue sample revealed aggregates of branched filamentous microorganisms; actinomycosis was diagnosed. Oral amoxicillin for 4 months resolved the mass.

Clinical Discussion: This patient had several causative factors for HA, including multiple surgical procedures involving the gastrointestinal tract, reconstruction of the biliary tract, anastomotic failure of the transverse colon, and diabetes mellitus following total pancreatectomy. Based on the past treatment history for IPMC and PET findings mimicking a malignancy, a laparotomy was performed to biopsy the lesion. Typically, penicillin is recommended for >6 months.

Conclusion: A rare case of HA mimicking a malignancy after a total pancreatectomy for IPMC is presented.
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http://dx.doi.org/10.1016/j.ijscr.2021.106212DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8335620PMC
August 2021

A simple risk score for detecting radiological occult metastasis in patients with resectable or borderline resectable pancreatic ductal adenocarcinoma.

J Hepatobiliary Pancreat Sci 2021 Jul 27. Epub 2021 Jul 27.

Department of Surgery, Kansai Medical University, Osaka, Japan.

Background: We advocated carbohydrate antigen (CA) 19-9 ≥ 150 U/mL and tumor size ≥30 mm as "high-risk markers" for predicting unresectability among patients with radiologically resectable (R) or borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC). The main aim is to establish a risk scoring system for occult abdominal metastasis (OAM) in R/BR PDAC.

Methods: Predictors of OAM were investigated retrospectively in an experiment cohort from 2006 to 2018. The proposed risk scoring system was validated in another cohort from 2019 to 2020.

Results: Five hundred and thirteen eligible patients were divided into the experimental (405 patients; OAM, 22%) and validation cohorts (108 patients). Multivariate analysis identified tumor location of body/tail (odds ratio [OR] 4.45, P < .0001) and "high-risk markers" (OR 2.07, P = .011) as independent predictors of OAM. A scoring system consisting of body/tail (yes: 1, no: 0) and "high-risk markers" (yes: 1, no: 0) was constructed. In the validation cohort, when staging laparoscopy (SL) was performed for patients with scores 1/2, the eligibility for SL, sensitivity, and negative predictive value of OAM were 55%, 91%, and 96%, respectively.

Conclusions: Tumor location of body/tail and "high-risk markers" were independent predictors of OAM, composing our simple and reproducible risk scoring system.
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http://dx.doi.org/10.1002/jhbp.1026DOI Listing
July 2021

Nutritional impact of active hexose-correlated compound for patients with resectable or borderline-resectable pancreatic cancer treated with neoadjuvant therapy.

Surg Today 2021 Jun 4. Epub 2021 Jun 4.

Department of Surgery, Kansai Medical University, 2-5-1 Shin-machi, Hirakata-City, Osaka, 573-1010, Japan.

Active hexose-correlated compound (AHCC) is a standardized extract from cultured Lentinula edodes mycelia, used as a potent biological response modifier in cancer treatment. We evaluated the nutritional effect of AHCC, given during neoadjuvant therapy, to patients with pancreatic ductal adenocarcinoma (PDAC). Thirty patients with resectable or borderline-resectable PDAC received neoadjuvant therapy with gemcitabine plus S-1. We compared, retrospectively, the outcomes of 15 patients who received AHCC combined with neoadjuvant therapy with those of 15 patients who did not receive AHCC combined with neoadjuvant therapy. The median changes of the neutrophil-to-lymphocyte ratio (NLR) and prognostic nutrition index (PNI) were significantly better in the AHCC group. The relative dose intensity of neoadjuvant therapy was also significantly higher in the AHCC group. Thus, AHCC may improve the nutritional status during neoadjuvant therapy of patients with pancreatic ductal adenocarcinoma. To validate these results and examine the long-term impact of AHCC, a prospective phase II study for PDAC is ongoing.
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http://dx.doi.org/10.1007/s00595-021-02308-3DOI Listing
June 2021

Does direct invasion of peripancreatic lymph nodes impact survival in patients with pancreatic ductal adenocarcinoma? A retrospective dual-center study.

Pancreatology 2021 Aug 19;21(5):884-891. Epub 2021 Mar 19.

Department of Surgery, Nara Medical University School of Medicine, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan.

Background: Pancreatic ductal adenocarcinoma can directly invade the peripancreatic lymph nodes; however, the significance of direct lymph node invasion is controversial, and it is currently classified as lymph node metastasis. This study aimed to identify the impact of direct invasion of peripancreatic lymph nodes on survival in patients with pancreatic ductal adenocarcinoma.

Methods: A total of 411 patients with resectable/borderline resectable pancreatic ductal adenocarcinoma who underwent pancreatic resection at two high-volume centers from 2006 to 2016 were evaluated retrospectively.

Results: Sixty (14.6%) patients had direct invasion of the peripancreatic lymph nodes without isolated lymph node metastasis (N-direct group), 189 (46.0%) had isolated lymph node metastasis (N-met group), and 162 (39.4%) had neither direct invasion nor isolated metastasis (N0 group). There was no significant difference in median overall survival between the N-direct group (35.0 months) and the N0 group (45.6 month) (p = 0.409), but survival was significantly longer in the N-direct compared with the N-met group (25.0 months) (p = 0.003). Similarly, median disease-free survival was similar in the N-direct (21.0 months) and N0 groups (22.7 months) (p = 0.151), but was significantly longer in the N-direct compared with the N-met group (14.0 months) (p < 0.001). Multivariate analysis identified resectability, adjuvant chemotherapy, and isolated lymph node metastasis as independent predictors of overall survival. However, direct lymph node invasion was not a predictor of survival.

Conclusion: Direct invasion of the peripancreatic lymph nodes had no effect on survival in patients undergoing pancreatic resection for pancreatic ductal adenocarcinoma, and should therefore not be classified as lymph node metastasis.
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http://dx.doi.org/10.1016/j.pan.2021.03.008DOI Listing
August 2021

Para-sacral approach followed by laparoscopic low anterior resection of a gastrointestinal stromal tumour at the anterior wall of the lower rectum.

Colorectal Dis 2021 06 9;23(6):1579-1583. Epub 2021 Mar 9.

Department of Urology and Andrology, Kansai Medical University Hospital, Hirakata, Japan.

Aim: We present a para-sacral approach followed by a laparoscopic low anterior resection of gastrointestinal stromal tumours located between the urethra and the low rectum.

Method: Case 1 is a 56-year-old male patient whose tumour (37 × 28 mm) was located 3.0 cm above the anal verge between the anterior wall of the rectum and the urethra; he underwent surgery after 14 months' administration of imatinib mesylate (400 mg/day). Case 2 is a 68-year-old male patient who presented with dysuria; a tumour (89 × 84 mm) was detected between the urethra and the anterior wall of the low rectum by MRI. He underwent surgery after 5 months' administration of imatinib mesylate (400 mg/day). In order to perform sphincter-preserving surgery and avoid injury not only to the tumour capsule but also to the urethra, a para-sacral approach followed by laparoscopic low anterior resection was adopted in these patients. Restoration of bowel continuity was done by coloanal anastomosis in case 1 and the double stapling technique in case 2. The postoperative course of the patients was uneventful. In case 2, tumour dissection from the urethra caused injury to the posterior wall of the urethra, which could be repaired easily under direct vision. The urethral catheter was removed after 117 postoperative days, and the diverting stoma was closed after 143 postoperative days.

Conclusion: The para-sacral approach followed by a laparoscopic low anterior resection of an extraluminal gastrointestinal stromal tumour located between the urethra and anterior wall of the low rectum enables R0 resection of the tumour and an appropriate reconstruction of the rectum.
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http://dx.doi.org/10.1111/codi.15597DOI Listing
June 2021

Surgical indication for and desirable outcomes of conversion surgery in patients with initially unresectable pancreatic ductal adenocarcinoma.

Ann Gastroenterol Surg 2020 Jan 29;4(1):6-13. Epub 2019 Oct 29.

Department of Surgery Kansai Medical University Hirakata-City Japan.

Aim of this review is to propose an acceptable surgical indication for conversion surgery in patients with initially unresectable (UR) pancreatic ductal adenocarcinoma (PDAC) by considering desirable outcomes, including resectability, overall survival (OS), and disease-free survival (DFS). A comprehensive literature search of PubMed was conducted through July 15, 2019. Eligible studies were those reporting on patients with UR-PDAC who underwent surgery. We excluded case reports with fewer than 10 patients, insufficient descriptions of survival data, and palliative surgery. When patients with UR-PDAC with no progression after chemo(radiation) therapy were offered surgical exploration, resectability and median survival time (MST) of those who underwent conversion surgery ranged from 20% to 69% (median, 52%) and from 19.5 to 33 months (median, 21.9 months), respectively. When conversion surgery was carried out in patients with expected margin-negative resection or with clinical response by Response Evaluation Criteria In Solid Tumors (RECIST), resectability and MST ranged from 18% to 27% (median, 20%) and from 21 to 35.3 months (median, 30 months), respectively. Among patients who underwent conversion surgery based on clinical response and decreased CA19-9 level after multimodal treatment, resectability and MST ranged from 2% to 24% (median, 4.1%) and from 24.1 to 64 months (median, 36 months), respectively. Decreased CA19-9 level was a predictor of resectability, OS and DFS by multivariate analysis. In conclusion, decision-making for conversion surgery based on clinical response and decreased CA19-9 level after multimodal treatment may be appropriate. With regard to desirable outcomes of OS and DFS, conversion surgery may provide improved survival for patients with initial UR-PDAC.
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http://dx.doi.org/10.1002/ags3.12295DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6992681PMC
January 2020

The past, present, and future status of multimodality treatment for resectable/borderline resectable pancreatic ductal adenocarcinoma.

Surg Today 2020 Apr 28;50(4):335-343. Epub 2020 Jan 28.

Department of Surgery, Kansai Medical University, 2-3-1, Shin-machi, Hirakata, Osaka, 573-1191, Japan.

A multimodal approach to treating pancreatic ductal adenocarcinoma (PDAC) is now widely accepted. Improvements in radiological assessment have enabled us to define resectability in detail. Multimodality treatment is essential for patients, especially for those with PDAC in the borderline resectable (BR) stage. Even for disease in a resectable (R) stage, adjuvant and neoadjuvant therapies have demonstrated beneficial outcomes in several trials and analyses. Thus, there is growing interest in optimization of the perioperative therapeutic strategy. We discuss the transition of resectability criteria and the global standard of adjuvant and neoadjuvant treatments for patients with R/BR-PDAC.
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http://dx.doi.org/10.1007/s00595-020-01963-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098925PMC
April 2020

Bile Duct Stones Predict a Requirement for Cholecystectomy in Older Patients.

World J Surg 2020 03;44(3):721-729

Department of Surgery, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan.

Background: The requirement for elective cholecystectomy in older patients is unclear. To determine predictors for requiring elective cholecystectomy in older patients, a prospective cohort study was performed.

Methods: All patients with gallstone disease who presented to our department from 2006 to 2018 were included if they met the following criteria: (1) age 75 years or older, (2) presentation for elective cholecystectomy, and (3) preoperative diagnosis of cholecystolithiasis. Two therapeutic options, elective surgery and a wait-and-see approach, were offered at their initial visit. Enrolled patients were assigned to one arm of the study according to their choice of the therapeutic options. The primary endpoint was the incidence of gallstone-related complications. The endpoint was compared between patients who underwent cholecystectomy (CH group) and those who chose a wait-and-see approach (No-CH group).

Results: During the study period, there were 344 patients in the CH group and 161 in the No-CH group. Among patients with a history of bile duct stones, the incidence of gallstone-related complications in the No-CH group was significantly higher (45% within 3 years, including two gallstone-related deaths) than that in the CH group (RR 2.66, 95% confidence interval 1.50-4.77, p = 0.0009). Among patients with no history of bile duct stones, the incidence of gallstone-related complications in the No-CH group reached only 10% over the 12 years.

Conclusion: Cholecystectomy is recommended for older patients with both histories of cholecystolithiasis and bile duct stones, whereas a wait-and-see approach is preferable for patients with no bile duct stone history. A history of bile duct stones is a good predictor for cholecystectomy in older patients.
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http://dx.doi.org/10.1007/s00268-019-05241-2DOI Listing
March 2020

Levosimendan pretreatment improves survival of septic rats after partial hepatectomy and suppresses iNOS induction in cytokine-stimulated hepatocytes.

Sci Rep 2019 09 16;9(1):13398. Epub 2019 Sep 16.

Department of Surgery, Kansai Medical University, Hirakata, Osaka, Japan.

We evaluated the survival effects and biochemical profiles of levosimendan in septic rats after partial hepatectomy and investigated its effects in cultured hepatocytes. Thirty-two rats underwent 70% hepatectomy and were randomised equally into four groups, followed by lipopolysaccharide (LPS) injection (250 µg/kg, i.v.) after 48 h. Levosimendan was given (i.p.) 1 h before LPS injection [group (A) levosimendan 2 mg/kg; (B) 1; (C) 0.5; (D) vehicle]. Survival at 7 days was increased significantly in group A compared with that in group D [A: 63%; B: 38%; C: 13%; D: 0%]. In serum, levosimendan decreased the level of tumour necrosis factor-α, interleukin (IL)-1β, IL-6 and nitric oxide (NO). In remnant livers, levosimendan inhibited inducible nitric oxide synthase (iNOS) gene expression. In primary cultured rat hepatocytes stimulated by IL-1β, levosimendan suppressed NO production by inhibiting iNOS promoter activity and stability of its mRNA.
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http://dx.doi.org/10.1038/s41598-019-48792-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6746814PMC
September 2019

Surgical treatment of metastatic pancreatic ductal adenocarcinoma: A review of current literature.

Pancreatology 2019 Jul 7;19(5):672-680. Epub 2019 Jun 7.

Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Denver, USA.

Background: There is no international consensus concerning the role of surgical treatment of metastatic pancreatic ductal adenocarcinoma (mPDAC), but favorable prognoses can be expected for highly selected patients.

Methods: A comprehensive literature search of the PubMed and Cochrane databases was conducted using combinations of keywords to 4 July 2018. Eligible studies were those reporting on patients with histologically confirmed mPDAC undergoing surgery with curative intent. We excluded case reports with fewer than five patients, insufficient descriptions of survival data, and palliative or cytoreductive surgery as well as studies that assessed para-aortic lymph node metastasis or peritoneal washing cytology.

Results: Thirteen studies were deemed eligible, and six studies were identified from their references. The studies involved 428 patients who underwent surgical resection for liver metastases (n = 343), lung metastases (n = 57), and peritoneal dissemination (n = 28). Median overall survival (OS) in patients with synchronous liver metastases who underwent conversion surgery following favorable response to initial chemotherapy was 27 or 34 months, and peritoneum metastases was 28 months. Median OS after the initial treatment was varied from 51 to 121 months in metachronous lung metastasis and from 24 to 40 months in metachronous liver metastasis, respectively.

Conclusion: Encouraging OS was indicated in patients with synchronous mPDAC of liver and peritoneum who underwent conversion surgery. Metastasectomy for metachronous lung and liver oligometastases could be considered a practical treatment option.
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http://dx.doi.org/10.1016/j.pan.2019.05.466DOI Listing
July 2019

Active Hexose Correlated Compound Has Protective Effects in Ischemia-Reperfusion Injury of the Rat Small Intestine.

J Surg Res 2019 11 26;243:265-273. Epub 2019 Jun 26.

Department of Surgery, Kansai Medical University, Hirakata, Osaka, Japan; Research Organization of Science and Technology, Ritsumeikan University, Kusatsu, Shiga, Japan.

Background: Ischemia-reperfusion (IR) injury of the small intestine is a serious problem in abdominal aortic aneurysm surgery or small intestine transplantation. Active hexose correlated compound (AHCC) is a popular anti-inflammatory drug in complementary and alternative medicine. The aim of this study was to examine whether pretreatment with AHCC reduces intestinal IR injury.

Methods: Rats were given a normal diet (IR group) or normal diet supplemented with 2% AHCC (IR + AHCC group) ad libitum for 10 d. After 1 d of fasting, the superior mesenteric artery was occluded by clipping for 45 min. Intestinal and blood samples were collected for 1-6 h after reperfusion. The messenger RNA (mRNA) and protein levels of inflammatory factors were analyzed.

Results: The IR + AHCC group had reduced mucosal abrasion and significantly increased mucosal thickness of the intestinal tissues 6 h after reperfusion, compared with the IR group. AHCC decreased mRNA expression of inducible nitric oxide synthase (iNOS), cytokine-induced neutrophil chemoattractant 1 and interleukin 6 in the mucosa of the small intestine. AHCC also decreased expression of iNOS protein. Serum levels of cytokine-induced neutrophil chemoattractant 1 and tumor necrosis factor α were decreased in the IR + AHCC group compared with the IR group. Electrophoretic mobility shift assay of mucosal nuclear extracts revealed that AHCC inhibited the activation of nuclear factor kappa B. AHCC also inhibited the expression of iNOS antisense transcript, which stabilizes iNOS mRNA.

Conclusions: Our findings suggest that AHCC reduces expression of inflammatory mediators, in part, by inhibiting nuclear factor kappa B activation. AHCC may have anti-inflammatory effect in patients with intestinal IR injury.
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http://dx.doi.org/10.1016/j.jss.2019.05.047DOI Listing
November 2019

Clinical impact of the sequentially-checked drain removal criteria on postoperative outcomes after pancreatectomy: a retrospective study.

J Hepatobiliary Pancreat Sci 2019 Sep 23;26(9):426-434. Epub 2019 Jul 23.

Department of Surgery, Kansai Medical University, Hirakata, Japan.

Background: Strict criteria for impeccably safe drain management following pancreatectomy have not yet been developed. We evaluated the utility of the sequentially-checked drain removal criteria by comparison with conventional criteria.

Methods: Postoperative outcomes of 801 patients who underwent pancreatectomy, including 395 patients for whom drain fluid amylase (DFA) < 375U/l on postoperative day (POD) 3 (control group), were used and 406 patients for whom the sequentially-checked criteria of DFA <5,000 U/l on POD 1 and DFA <3,000 U/l on POD 3 (sequentially-checked group) were used and were retrospectively evaluated.

Results: DFA on POD 3 and fistula risk score did not differ between groups. Significantly more patients in the sequentially-checked group met the criteria (control, 63.8% vs. sequentially-checked, 76.1%, P < 0.001). The incidences of clinically relevant postoperative pancreatic fistula (CR-POPF) (17.0% vs. 11.1%), intra-abdominal abscess (21.0% vs. 9.1%) were significantly lower in the sequentially-checked group (all P < 0.05). Multivariate analysis revealed that use of the sequentially-checked criteria was significantly associated with CR-POPF (odds ratio 0.601, 95% confidence interval [CI] 0.389-0.929; P = 0.022). C-reactive protein <15 mg/dl at POD 3 was identified as an independent predictive factor for false positive CR-POPF results in the sequentially-checked group (odds ratio 0.872, 95% CI 0.811-0.939; P < 0.001); thus, this criterion was added to create the new triple-checked criteria.

Conclusions: The sequentially-checked criteria can provide safe drain management and improve postoperative outcomes.
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http://dx.doi.org/10.1002/jhbp.649DOI Listing
September 2019

Loss of skeletal muscle mass in patients with chronic liver disease is related to decrease in bone mineral density and exercise tolerance.

Hepatol Res 2018 Apr 7;48(5):345-354. Epub 2017 Dec 7.

Department of Nutritional Medicine, Graduate School of Human Life Science, Osaka City University, Osaka, Japan.

Aim: This study aimed to identify the relationship between loss of skeletal muscle mass and clinical factors such as osteoporosis in patients with chronic liver disease.

Methods: The subjects were 112 patients (85 men and 27 women) with hepatocellular carcinoma who were scheduled to undergo hepatectomy. Skeletal muscle reduction was diagnosed according to the cut-off level of the skeletal mass index (SMI) for Asians (men <7.0 kg/m , women <5.4 kg/m ). Osteoporosis was diagnosed according to T-score ≤-2.5 standard deviation. The SMI and T-score were assessed using the results of dual-energy X-ray absorption. Peak oxygen consumption (PeakVO ), an index of exercise tolerance, was evaluated using the cardiopulmonary exercise test. The characteristics of patients with low SMI (low SMI group) were compared with those of patients whose SMI was not low (control group). Outcomes are presented as median (interquartile range).

Results: The T-score was significantly lower in the low SMI group (control vs. low SMI -1.1 [1.8] vs. -1.6 [1.9], P = 0.049). T-score positively correlated with SMI (r = 0.409, P < 0.0001). PeakVO was significantly decreased in the low SMI group (17.7 [6.3] vs. 14.4 [4.5], P = 0.006). In multivariate logistic regression analysis, T-score (odds ratio [OR], 3.508; 95% confidence interval [CI], 1.074-11.456; P = 0.038) and PeakVO (OR, 3.512; 95% CI, 1.114-11.066; P = 0.032) were significantly related to SMI, independent of age and sex.

Conclusions: Skeletal muscle reduction in chronic liver disease is closely related to exercise tolerance and osteoporosis, and these factors are believed to be associated with physical inactivity in daily life.
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http://dx.doi.org/10.1111/hepr.13000DOI Listing
April 2018

Laparoscopic management for spontaneous jejunal perforation caused by nonspecific ulcer: A case report.

Int J Surg Case Rep 2017 1;39:309-312. Epub 2017 Sep 1.

Department of Surgery, Kansai Medical University, 10-15 Fumizonocho, Moriguchi, Osaka, 570-8507, Japan. Electronic address:

Introduction: Nonspecific small bowel ulcers are rare and there have been limited reports. We applied laparoscopic surgery successfully for the perforation caused by this disease of jejunum.

Presentation Of Case: A 70-year-old man visited to our hospital with complaint of abdominal pain and fever. He was diagnosed abdominal peritonitis with findings of intraperitoneal gas and fluid. Emergency laparoscopic surgery was performed. A perforation 5mm in diameter was recognized in jejunum opposite side of mesentery. Partial resection of jejunum with end-to-end anastomosis and peritoneal lavage were performed. Pathologically, an ulcer was recognized around the blowout perforation without specific inflammation. He was discharged uneventfully 12days after surgery.

Conclusion: Laparoscopic surgery has diagnostic and therapeutic advantages because of its lower invasion with a good operation view, and in case of the small bowel, it is easy to shift extra-corporeal maneuver.
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http://dx.doi.org/10.1016/j.ijscr.2017.08.048DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5602819PMC
September 2017

Laparoscopic surgery for colon cancer with intestinal malrotation in adults: Two case reports and review of literatures in Japan.

Int J Surg Case Rep 2017 13;38:86-90. Epub 2017 Jul 13.

Department of Surgery, Kansai Medical University, 10-15 Fumizonocho, Moriguchi, Osaka 570-8507, Japan. Electronic address:

Introduction: Intestinal malrotation is a congenital anomaly, and its occurrence in adults is rare. Colon cancer with intestinal malrotation is far more rare. We herein report two cases of colon cancer with intestinal malrotation treated with laparoscopic surgery and reviewed the literatures in Japan.

Presentation Of Cases: Case 1 involved a 78-year-old man. Abdominal enhanced computed tomography (CT) showed that the tumor was located in the sigmoid colon. Intraoperatively, the cecum and ascending colon were located along the midline and the small intestine occupied the right side of the abdomen. The tumor was located in the cecum, and the patient was diagnosed with cecal cancer with intestinal malrotation. We performed laparoscopy-assisted ileocecal resection. Case 2 involved a 81-year-old man. Colonoscopy revealed a laterally spreading tumor in the cecum. Intraoperatively, the position of the small intestine and the ascending colon was similar to case 1, and Ladd's band was found in front of the duodenum. Thus, we diagnosed the patient with a laterally spreading cecal tumor with intestinal malrotation and performed laparoscopy-assisted ileocecal resection.

Discussion: A review of the literature revealed 49 cases of colon cancer with intestinal malrotation and laparoscopic surgery performed at 30.6%. If laparoscopic mesenteric excision for colon cancer with intestinal malrotation is unsafe because of the abnormalities of the artery, mesenteric excision should be performed outside the body.

Conclusion: If the intestinal malrotation is diagnosed preoperatively, 3D-CT angiography should be used to reveal the vascular anatomic anomalies for safe performance of laparoscopic surgery.
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http://dx.doi.org/10.1016/j.ijscr.2017.07.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5524425PMC
July 2017

Duodenogastric regurgitation in hepaticoduodenostomy after excision of congenital biliary dilatation (choledochal cyst).

J Pediatr Surg 2017 Oct 5;52(10):1621-1624. Epub 2017 Apr 5.

Division of Pediatric Surgery, Department of Surgery, Kansai Medical University, Hirakata City, Osaka, Japan.

Purpose: We examined the clinical significance of duodenogastric regurgitation (DGR) as a late complication in the long-term follow-up after hepaticoduodenostomy (HD) as a reconstruction surgery for congenital biliary dilatation (CBD).

Methods: Seventeen patients with CBD were retrospectively analyzed for late complications (mean follow-up, 16.8 years). All patients had undergone total resection of the extrahepatic bile duct followed by HD. DGR was identified using endoscopic examination, intraluminal bile monitoring, and liver scanning.

Results: DGR was found in all 17 patients by endoscopic examination and intraluminal bile monitoring. Fourteen of the 17 (82.4%) patients with DGR had experienced abdominal symptoms since a mean of 6.9 years postoperatively. Liver scanning also revealed apparent DGR in all 14 symptomatic patients. We converted 7 of the 14 patients to hepaticojejunostomy reconstruction at a mean of 13.0 years after the initial excisional surgery. Their symptoms were completely relieved postoperatively.

Conclusions: DGR is an important complication after HD. Examination of patients for the development of DGR is an essential part of long-term follow-up in patients with CBD who have undergone HD as a reconstruction surgery. Conversion surgery is recommended in patients with DGR accompanied by long-term abdominal symptoms.

Levels Of Evidence: Level IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.03.063DOI Listing
October 2017

Phase I Study of Sorafenib in Combination with Intermittent Hepatic Arterial Infusion Chemotherapy for Unresectable Hepatocellular Carcinoma.

Cancer Invest 2017 Apr 8;35(4):271-276. Epub 2017 Mar 8.

a Department of Surgery , Kansai Medical University , Osaka , Japan.

Objectives: We conducted a phase I study of sorafenib and intermittent hepatic arterial infusion chemotherapy using cisplatin for unresectable hepatocellular carcinoma.

Methods: Sorafenib was administered continuously, whereas cisplatin was administered once every 3 weeks. We estimated the safety and efficacy.

Results: Fifteen patients were enrolled into this study. The dose-limiting toxicities occurred at sorafenib 800 mg and cisplatin 20 mg/m. The recommended dose was at sorafenib 400 mg and cisplatin 30 mg/m. The disease control rate was 73.3%.

Conclusions: This treatment is feasible for unresectable hepatocellular carcinoma. Further evaluation of the regimen in a randomized controlled trial is warranted.
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http://dx.doi.org/10.1080/07357907.2017.1289382DOI Listing
April 2017

Intraoperative Detection of Superficial Liver Tumors by Fluorescence Imaging Using Indocyanine Green and 5-aminolevulinic Acid.

Anticancer Res 2016 Apr;36(4):1841-9

Department of Surgery, Hirakata Hospital, Kansai Medical University, Hirakata, Osaka, Japan.

Background/aim: Indocyanine green (ICG) and the porphyrin precursor 5-aminolevulinic acid (5-ALA) have been approved as fluorescence imaging agents in the clinical setting. This study evaluated the usefulness of fluorescence imaging with both ICG and 5-ALA for intraoperative identification of latent small liver tumors.

Patients And Methods: There were 48 patients who had main tumors within 5 mm of the liver surface. 5-ALA hydrochloride was orally administered to patients 3 h before surgery. ICG had been intravenously injected within 14 days prior to surgery. Intraoperatively, after visual inspection, manual palpation and ultrasonography fluorescence images of the liver surface were obtained with ICG and 5-ALA prior to resection.

Results: With ICG, the sensitivity, specificity and accuracy for detecting the preoperatively identified main tumors were 96%, 50% and 94%, respectively. Twelve latent small tumors were newly detected on the liver surface using ICG, five of which proved to be carcinomas. With 5-ALA, the sensitivity, specificity and accuracy for detecting the main tumors were 57%, 100% and 58%, respectively. Five latent small tumors were newly detected using 5-ALA; all were carcinomas. Overall, five new tumors were detected by both ICG and 5-ALA fluorescence imaging; two were hepatocellular carcinomas (HCCs) and three were metastases of colorectal cancer. The sensitivity and specificity of ICG fluorescence imaging for main tumor detection were relatively high and low, respectively, but the opposite was true of 5-ALA imaging.

Conclusion: Fluorescence imaging using 5-ALA may provide greater specificity in the detection of surface-invisible malignant liver tumors than using ICG fluorescence imaging alone.
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April 2016

Evaluation of fluorescence imaging with indocyanine green in hepatocellular carcinoma.

Cancer Imaging 2016 Apr 6;16. Epub 2016 Apr 6.

Department of Surgery, Hirakata Hospital, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1010, Japan.

Background: We hypothesized that indocyanine green (ICG) fluorescence patterns using Clairvivo OPT in resected liver specimens could confirm hepatocellular carcinoma (HCC) better than earlier commercial imaging systems. This preclinical trial evaluated the effectiveness of fluorescence imaging as an intraoperative cancer navigation tool.

Methods: ICG fluorescence images of resected specimens from 190 patients with HCC were classified into two groups according to whether high fluorescence was seen in the HCC (high cancerous [HC] group) or in the surrounding liver tissue (high surrounding [HS] group). The HC and HS groups were sub-classified into whole and partial types and whole and ring types, respectively.

Results: The HC group had significantly higher prevalence of esophageal or gastric varices, and worse liver function than patients in the HS group. The HC group also had a higher percentage of limited resection cases than did the HS group. Cirrhotic liver histology was significantly more common in the HC group than in the HS group. Multivariate analysis revealed that the HC group was a predictive factor for cirrhosis in HCC patients. Among the HC patients, a higher percentage of well-differentiated HCC cases were seen in the partial-type subgroup than in the whole-type subgroup (23/48 (48 %) vs. 7/68 (10 %)). In the HS group, the ring-type subgroup had a higher percentage of poorly differentiated HCC cases than did the whole-type subgroup (6/37 (16 %) vs. 0/37 (0 %)).

Conclusion: Tumor differentiation and fibrosis in the non-cancerous liver parenchyma could affect ICG fluorescence imaging in HCC. ICG fluorescence imaging may be a good indication for fibrosis stage. In future, we will try to evaluate fluorescence imaging with ICG for intraoperative cancer navigation in HCC, using a portable near-infrared fluorescence imaging system.
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http://dx.doi.org/10.1186/s40644-016-0064-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4823845PMC
April 2016

[A Case of Local Recurrence of Bile Duct Cancer Completely Responding to Chemoradiotherapy with S-1].

Gan To Kagaku Ryoho 2015 Nov;42(12):1576-8

Dept. of Surgery and Gastroenterological Surgery, Osaka Saiseikai Izuo Hospital.

An 80-year-old man with common bile duct cancer was treated by pancreaticoduodenectomy with D2 lymph node dissection in October 2005. The patient presented with frequent episodes of bloody-mucous rectal discharge in July 2009. An abdominal CT demonstrated local recurrence at the hepatoduodenal ligament. We treated him with concurrent chemoradiotherapy (CRT) with single-dose S-1 chemotherapy. After 6 months, we diagnosed a complete response (CR) by follow-up CT. The patient was treated with S-1 for 3 years after the diagnosis of a CR. He is alive without disease 6 years after the diagnosis of the recurrence. Concurrent CRT with S-1 chemotherapy may be the therapy of choice for recurrence of bile duct cancer.
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November 2015

[OBJECTIVE ASSESSMENT OF POSTOPERATIVE PAIN AFTER DIGESTIVE TRACT SURGERY].

Nihon Geka Gakkai Zasshi 2015 Jul;116(4):243-8

Pain is a sensation associated with subjective factors, making it difficult to measure and assess. Currently, there is no widely accepted method of objectively assessing pain, and therefore subjective assessments such as the Visual Analogue Scale (VAS) are generally used. The PainVision system has been developed for the quantitative analysis of pain and comparison of postoperative pain intensity. In this study, we investigated whether postoperative pain could be objectively assessed using this system in digestive tract surgery patients. Pain scores were measured with the VAS, the PainVision system, and the short-form McGill Pain Questionnaire in patients undergoing open or laparoscopic hepatectomy, open or laparoscopic gastrectomy, and laparoscopic cholecystectomy. As measured using the PainVision system, postoperative pain intensity was lower in patients who underwent laparoscopic surgery compared with open hepatectomy. In open hepatectomy patients, pain intensity measured by the PainVision system was significantly lower on postoperative days (POD) 7 and 10 than on POD 1. Preemptive use of nonsteroidal antiinflammatory drugs significantly reduced postoperative pain in open hepatectomy patients. The results showed that PainVision effectively quantifies pain intensity after digestive tract surgery. Objective assessment of postoperative pain may lead to earlier mobility and improved quality of life.
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July 2015

Segmental dilatation of the intestine: results of a nationwide survey in Japan.

Pediatr Surg Int 2015 Nov 5;31(11):1073-6. Epub 2015 Sep 5.

Department of Pediatric Surgery, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashiku, Fukuoka, Japan.

Purpose: To clarify the status of segmental dilatation of the intestine (SD) using a nationwide retrospective cohort survey.

Methods: Supported by the Ministry of Health, Labour and Welfare in Japan, preliminary questionnaires requesting the numbers of SD cases from 2000 to 2009 were sent to 161 Japanese major institutes of pediatric surgery and gastroenterology. We present the results of our analysis of the data from secondary questionnaires.

Results: Twenty-eight cases of SD were reported, including 19 males and 9 females. The average gestational age was 30.2 weeks and the average birth weight was 2.319 g. The period of onset was neonatal in 18 cases and infancy in 6 cases, including 7 cases diagnosed prenatally. The dilated segment was ileum in 14 cases and colon in 10 cases, and symptoms included abdominal distention, vomiting, and chronic constipation. Concurrent intestinal malformation such as malrotation, intestinal atresia, and anal atresia were present in 4 cases and 27 of 28 cases were successfully treated by surgical resection. Histologically, abnormal muscle layers were found in three cases and ectopic tissue in two cases.

Conclusion: We determined the clinical features of SD based on data from 28 cases occurring over 10 years.
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http://dx.doi.org/10.1007/s00383-015-3788-7DOI Listing
November 2015

Low-grade mucinous neoplasia in a cecal diverticulum: A case report.

Int J Surg Case Rep 2015 20;15:66-9. Epub 2015 Aug 20.

Department of Surgery, Kansai Medical University, 10-15 Fumizonocho, Moriguchi, Osaka 570-8507, Japan. Electronic address:

Introduction: Low-grade mucinous neoplasia is an uncommon benign tumor that develops in the appendix. The development of mucocele disease has never been reported in a colonic diverticulum. We present a case developing low-grade mucinous neoplasia in a cecal diverticulum.

Presentation Of Case: A tumor in the ileocecal region was found during a medical examination of a 66-year-old woman. Three months later, the tumor was still present and the patient developed abdominal pain. Laparoscopic ileocecal resection with D2 lymph node dissection was performed. Histopathological examination revealed a low-grade mucinous neoplasm in a cecal diverticulum.

Discussion: Colonic mucoceles reportedly originate from the appendix. There are no previous reports of mucocele disease in a colonic diverticulum worldwide. This report reviews and discusses the management of the appendiceal mucoceles.

Conclusion: The incidence of colonic diverticula has recently begun to increase in Japan. The possibility of a mucocele within a colonic diverticulum should be considered in patients with submucosal colonic tumors.
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http://dx.doi.org/10.1016/j.ijscr.2015.08.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4601971PMC
October 2015

Effect of Intramuscular Adipose Tissue Content on Prognosis in Patients Undergoing Hepatocellular Carcinoma Resection.

J Gastrointest Surg 2015 Jul 12;19(7):1315-23. Epub 2015 May 12.

Department of Surgery, Hirakata Hospital, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1191, Japan,

Background: It has recently been reported that myosteatosis, the infiltration of fat in skeletal muscle, is associated with insulin resistance and type 2 diabetes mellitus. The present study investigated the effect of skeletal muscle fat accumulation on short- and long-term outcomes following partial hepatectomy for hepatocellular carcinoma (HCC) and aimed to identify prognostic factors.

Methods: The records of 141 HCC patients who underwent hepatectomy were retrospectively reviewed. Clinicopathological and outcome data from 71 patients with high intramuscular adipose tissue content (IMAC) were compared with those from 70 patients with low IMAC.

Results: The 5-year overall survival rate was 46% among patients with high IMAC and 75% among those with low IMAC. The 5-year disease-free survival rates in these groups were 18 and 38%, respectively. Multivariate analysis revealed that high IMAC was predictive of an unfavorable prognosis. High IMAC was significantly correlated with liver dysfunction, higher intraoperative blood loss, the need for blood transfusion, and comorbid diabetes mellitus.

Conclusions: Greater fat accumulation in skeletal muscle was predictive of worse overall survival after partial hepatectomy in patients with HCC, even with adjustment for other known predictors. The identification of patients with greater skeletal muscle fat accumulation before hepatectomy could permit early preventive strategies to maintain muscle quality and thus improve prognosis and patient selection for hepatectomy.
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http://dx.doi.org/10.1007/s11605-015-2838-8DOI Listing
July 2015

[A novel technique of laparoscopic hepatectomy].

Gan To Kagaku Ryoho 2014 Nov;41(12):1494-6

Dept. of Surgery, Kansai Medical University.

We report a novel technique of laparoscopic hepatectomy (lap-HT) performed at our hospital and the outcomes.Lap -HT was performed in 90 cases at our hospital, including 38 cases of anatomical resection of the liver.After mobilization of the right lobe with the patient in the half-lateral position, we resected the liver tissue using cavitron ultrasonic surgical aspirator (CUSA) and AquamantysTM Bipolar®.This surgical instrument is useful for laparoscopic anatomical resection of the liver because it is based on vessel sealing technology.In the 90 cases in which lap-HT was performed, the mean duration of surgery and mean blood loss were 332.9 minutes and 381 mL, respectively. The mean duration of hospitalization after surgery was 12.1 days, and postoperative complications were noted in 5 cases(5.6%). Comparison of the clinical factors and short-term performance of the surgery between liver cirrhosis patients who underwent open hepatectomy and lap-HT revealed that blood loss was significantly lower and the hospital stay duration was significantly shorter in patients who underwent lap-HT. Our findings suggest that laparoscopic anatomical resection of the liver can be safely performed using this novel technique and surgical instrument.
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November 2014

Comparison of a flexible-tip laparoscope with a rigid straight laparoscope for single-incision laparoscopic cholecystectomy.

Am Surg 2014 Dec;80(12):1245-9

Department of Surgery, Kansai Medical University, Osaka, Japan.

This study assessed whether a flexible-tip laparoscope improves operative outcomes including operative length while performing single-incision laparoscopic cholecystectomy (SILC) compared with the use of a conventional straight laparoscope. The flexible-tip laparoscope decreased the operative time compared with the straight laparoscope. Although SILC has potential benefits, surgeons experience problems for in-line viewing through a laparoscope and from contact of instruments with the laparoscope, resulting in longer operative times and the need for additional ports. The aim of this study was to determine whether a flexible-tip laparoscope improves operative outcomes, including operative length and the rate of insertion of additional ports, while performing SILC compared with the use of a conventional rigid straight laparoscope. We reviewed data on patients for whom we performed SILC at the Department of Surgery, Kansai Medical University, for the period from November 1, 2009, to February 28, 2013. The information was assessed with respect to patient characteristics, types of laparoscope used, operative data as well as postoperative outcomes. Operating time for SILC using the flexible-tip laparoscope was significantly shorter than with the straight laparoscope (81.5 ± 23.2 vs 94.4 ± 21.1 minutes) as a result of a better view of the operating field without contact with working instruments. Although a trend was shown toward a reduced rate of the need for extra ports in the flexible-tip laparoscope group, the difference did not reach statistical significance. Using the flexible-tip laparoscope solved the problem of in-line viewing and decreased the operative time for SILC.
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December 2014

Influence of Rictor and Raptor Expression of mTOR Signaling on Long-Term Outcomes of Patients with Hepatocellular Carcinoma.

Dig Dis Sci 2015 Apr 5;60(4):919-28. Epub 2014 Nov 5.

Department of Surgery, Hirakata Hospital, Kansai Medical University, 2-5-1 Shinmachi, Hirakata, Osaka, 573-1191, Japan,

Background: Aberrant signaling mediated by the mammalian target of rapamycin (mTOR) occurs at high frequency in hepatocellular carcinoma (HCC), indicating that mTOR is a candidate for targeted therapy. mTOR forms two complexes called mTORC1 (mTOR complexed with raptor) and mTORC2 (mTOR complexed with rictor). There are minor studies of the expression kinetics of mTORC1 and mTORC2 in HCC.

Methods: We studied 62 patients with HCC who underwent curative resection. We used univariate and multivariate analyses to identify factors that potentially influence disease and overall survival after hepatectomy. The mRNA and protein levels of mTOR, rictor and raptor in cancer and non-cancer tissues were analyzed using quantitative RT-PCR, immunohistochemistry and Western blotting.

Results/conclusion: High ratio of the levels of rictor and raptor mRNAs in tumors was identified as independent prognostic indicators for disease-free survival. Low and high levels of preoperative serum albumin and mTOR mRNA in the tumor, respectively, were identified as independent indicators of overall survival. HCC is likely to recur early after hepatic resection in patients with high levels of mTOR and rictor mRNAs and high rictor/raptor ratios in cancer tissues. We conclude that analysis of mTOR expression in cancer tissues represents an essential strategy to predict HCC recurrence after curative treatment.
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http://dx.doi.org/10.1007/s10620-014-3417-7DOI Listing
April 2015

High survival in patients operated for small isolated liver metastases from gastric cancer: a multi-institutional study.

World J Surg 2014 Oct;38(10):2692-7

Department of General and Gastroenterological Surgery, Osaka Medical College Hospital, Takatsuki, 2-7 Daigaku-machi, Takatsuki City, Osaka, 569-8686, Japan,

Background: Although several studies have reported the outcomes of surgery for the treatment of liver metastases of gastric cancer (GLM), indications for liver resection for gastric metastases remain controversial. This study was designed to identify prognostic determinants that identify operable hepatic metastases from gastric cancer and to evaluate the actual targets of surgical therapy.

Methods: Retrospective analysis was performed on outcomes for 24 consecutive patients at five institutions who underwent gastrectomy for gastric cancer followed by curative hepatectomy for GLM between 2000 and June 2012.

Results: Overall 5-year survival and median survival were 40.1 % and 22.3 months, respectively. Uni- and multivariate analyses showed that liver metastatic tumour size less than 5 cm was the most important predictor of overall survival (OS, p = 0.03). Four patients survived >5 years. Repeat hepatectomy was performed in three patients. Two of these patients have remained disease-free since the repeat hepatectomy.

Conclusions: GLM patients with metastatic tumour diameter less than 5 cm maximum are the best candidates for hepatectomy. Hepatic resection should be considered as an option for gastric cancer patients with liver metastases.
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http://dx.doi.org/10.1007/s00268-014-2608-xDOI Listing
October 2014
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