Hiroyuki Kato

Background: The main etiology of NAFLD and NASH after pancreatic resection is still unclear, and the therapeutic strategy has yet to be established. The focus of this review is how predict and prevent NAFLD/NASH after pancreaticoduodenectomy.Methods: From April 2005 to October 2008, 54 patients who underwent pancreaticoduodenectomy in our institution were enrolled in this study. From the pre‐, intra‐ and postoperative risk factors, we identified the most influential risk factors of postoperative NAFLD by uni‐ and multivariate analyses. Moreover, a postoperative NAFLD scoring system was proposed based on these risk factors.Results: The incidence of postoperative NAFLD was 37.0% (20/54). Of these, 10% (2/20) of patients were diagnosed as having NASH by percutaneous liver biopsy. By multivariate analysis, pancreatic adenocarcinoma (p < 0.05), pancreatic resection line (p < 0.01) and postoperative diarrhea (p < 0.01) were identified as the most influential factors concerning postoperative NAFLD. Based on these results, we proposed a postoperative NAFLD scoring system (0–10) and evaluated the correlation between the score and decreasing rates of CT values, revealing a significant correlation (r = 0.829p < 0.001). The prevalence of postoperative NAFLD in the patients with our scores of 0–3, 4–6 and 7–10 points was 0 (0/22), 35 (6/17) and 93% (14/15), respectively.Conclusions: In conclusion, NAFLD develops frequently in patients who undergo PD, and some patients even progress to NASH. A postoperative NAFLD scoring system makes it possible to predict the occurrence of NAFLD after PD, and aggressive nutrition support is needed for patients with high scores.

The poor prognosis of patients with intrahepatic cholangiocarcinoma (ICC) or hilar cholangiocarcinoma is well known. Herein, we described the first reported case of severe locally advanced ICC in which radical surgery was successfully achieved based on the marked effect of neoadjuvant chemoradiation therapy (NCRT) using gemcitabine. A 54-year-old man was admitted to our institution with obstructive jaundice. Abdominal computed tomography (CT) showed a large low-density mass in the caudate lobe, extensively involving the inferior vena cava and main portal vein. Moreover, nodal involvements of the hepatoduodenal ligament were detected concurrently. We therefore regarded this tumor as a severe locally advanced ICC and attempted to initiate combined treatment with gemcitabine (800 mg/m² biweekly) and three-dimensional conformation radiation (45 Gy/25 days). After completion of NCRT, this patient underwent a left trisegmentectomy with combined resection of the portal vein and inferior vena cava. Postoperative microscopic findings surprisingly revealed that more than 90% of tumor cells had disappeared with extensive fibrosis, achieving tumor downstaging and tumor volume reduction which were related to the radical resection. In conclusion, ICC showed a favorable histological response to chemoradiation therapy using gemcitabine. Further studies are needed to conclusively assess the effect of NCRT on locally advanced ICC.

Laparoscopic surgery is the main treatment method for patients with gastrointestinal malignant tumors. Although laparoscopic surgery is minimally invasive, its tool stimulation and pneumoperitoneum pressure often cause strong stress reactions in patients. On the other hand, gastrointestinal surgery can cause stronger pain in patients, compared to other surgeries. Transversus abdominis plane block (TAPB) can effectively inhibit the transmission of nerve impulses caused by surgical stimulation, alleviate patient pain, and thus alleviate stress reactions. Remazolam is an acting, safe, and effective sedative, which has little effect on hemodynamics and is suitable for most patients. TAPB combined with remazolam can reduce the dosage of total anesthetic drugs, reduce adverse reactions, reduce stress reactions, and facilitate the rapid postoperative recovery of patients.