Prognosis of Pancreatic Cancer Based on Resectability: A Single Center Experience

Although conversion surgery has increasingly been performed for initially unresectable advanced pancreatic ductal adenocarcinoma (PDAC), the rate of conversion, including that for patients who do not undergo resection, remains unclear. Patients with PDAC who were treated between January 2013 and December 2018 were classified into three groups: resectable (R), borderline resectable (BR), and unresectable (UR). We analyzed patient outcomes, including the rate of surgical resection and survival, in each of these groups. In total, 211 patients (R, 118; BR, 22; UR, 81) were selected. Among them, 117 (99%), 18 (82%), and 15 (19%) patients in the R, BR, and UR groups, respectively, underwent surgical resection. R0 resection rates were 88, 78, and 67%, whereas median overall survival (OS) from treatment initiation were 31, 18, and 11 months (p < 0.0001) in the R, BR, and UR groups, respectively. In patients who underwent surgical resection, relapse-free survival (RFS) and OS were similar among the three groups (R vs. BR vs. UR; median RFS (months), 17 vs. 13 vs. 11, p = 0.249; median OS (months), 31 vs. 26 vs. 32, p = 0.742). Lymph node metastases and incomplete adjuvant chemotherapy were identified as independent prognostic factors for OS. Although the surgical resection rate was low, particularly in the BR and UR groups, the prognosis of patients who underwent surgical resection was similar irrespective of the initial resectability status.

Prognostic significance of regional lymph node metastasis according to station in ampullary carcinoma

BACKGROUND

The TNM (Tumor, Node, Metastasis) classification of the 8th Union for International Cancer Control and the 6th Japanese classification of biliary tract cancer were made on the premise that the prognostic effect of each regional lymph node station is similar. However, some studies have reported different effects of lymph node metastasis location on post-resection prognosis. This study aimed to investigate outcome following radical resection of ampullary carcinoma according to station of lymph node metastasis.

METHODS

Patients who underwent surgical resection for ampullary carcinoma between January 2007 and December 2017 at two separate Japanese institutions were included. Regional lymph nodes were subclassified as follows: Pancreatoduodenal lymph nodes (PD) and others (OT).

RESULTS

Of the 101 patients analyzed, 34 had regional lymph node metastasis. OT metastasis was found in eight patients. Significant differences were found in relapse-free survival (RFS) and overall survival (OS) between the three study groups (no nodal metastasis, only PD metastasis and OT metastasis; P < .001 for both). OT metastasis was an independent prognostic factor in the multivariate analysis for RFS (hazard ratio [HR] 17.14; 95% confidence interval [CI], 6.33-43.93) and OS (HR 11.06; 95% CI, 3.7-32.99).

CONCLUSION

The poor prognosis of ampullary carcinoma patients with OT metastasis suggests that regional lymph nodes should not be categorized equally into one group.

Primary Tumor Histology Affects Oncological Outcomes Independently of the Anatomical Extent of Disease in Colorectal Liver Metastasis

Introduction

Growing evidence indicates the prognostic importance of the crosstalk between cancer cells and stroma through the induction of epithelial-mesenchymal transition (EMT). This study aimed to clarify the prognostic value of evaluating primary tumor histology with the anatomical extent of disease in patients with colorectal liver metastasis (CRLM).

Methods

Prognostic analyses were performed in 411 CRLM patients who underwent hepatectomy at two institutions. Tumors were graded into one of three histological categories based on integrated assessment of EMT-associated histology (Histology^EMT) in primary tumors, i.e., poorly differentiated clusters (PDCs) and desmoplastic reaction (DR).

Results

A prognostic grouping system for the anatomical extent of disease (N stage, liver metastasis number and size, and extrahepatic disease; Grade^anatomical) stratified patients into three groups with different five-year relapse-free survival (RFS) rates after hepatectomy: A, 31% (191 patients); B, 15% (124 patients); and C, 6% (96 patients; P < 0.0001). Histology^EMT (A, G1 PDC and mature-type DR; C, G3 PDC and immature-type DR; and B, others) identified 49, 120, and 242 patients with 46%, 5%, and 22% five-year RFS, respectively (P < 0.0001). Among prognostic factors, the Akaike information criterion was most favorable in Grade^anatomical, followed by Histology^EMT. Multivariate analysis demonstrated that these two factors independently impacted RFS; two-year RFS after hepatectomy in different patient groups had a wide range (10%-76%).

Conclusions

Histological assessment of dedifferentiation and the stromal environment of primary tumors contributed to effective risk stratification of early relapse after hepatectomy, which could be useful to determine clinical management for CRLM patients.

Prognostic Impact of Budding Grade in Patients With Residual Liver Recurrence of Colorectal Cancer After Initial Hepatectomy

BACKGROUND

Many patients undergoing hepatectomy for colorectal liver metastases (CRLM) experience recurrence. However, no criteria for screening candidates to undergo repeat hepatectomy (RH) for CRLM have been established. Budding, one form by which colorectal carcinoma malignancies are expressed, is a new pathologic index. This study aimed to analyze prognostic factors, including budding, and to provide criteria for screening candidates to undergo RH for recurrent CRLM.

METHODS

Data of 186 consecutive patients who underwent hepatectomy for CRLM between April 2008 and December 2015 were collected. Survival was calculated using the Kaplan-Meier method. Uni- and multivariate analyses were performed to determine factors significantly affecting mortality.

RESULTS

Of 186 patients, 131 experienced recurrence after hepatectomy, with 83 of the 131 patients showing recurrence in the liver, and 52 of these 83 patients undergoing primary surgery at the authors' institution and having information on budding grade. In the univariate analysis, preoperative chemotherapy, budding grade, extrahepatic metastases, and number of liver metastases at the time of recurrence were associated with overall survival (OS) for the 52 patients. In the multivariate analysis, budding grade and number of liver metastases at the time of recurrence were associated with OS.

CONCLUSION

The study examined simple prognostic factors that could help to screen patients better for RH. Repeat hepatectomy improved the prognosis for patients with recurrent CRLM. The independent prognostic factors for OS were number of liver metastases at recurrence as a conventional factor and budding grade as a new pathologic factor. With budding used as an index, patients who could benefit from hepatectomy can be screened more precisely.

Nutritional benefit of laparoscopic jejunostomy during neoadjuvant chemotherapy for obstructing esophageal cancer

Neoadjuvant chemotherapy (NAC) confers a survival benefit in esophageal carcinoma, but it is difficult to perform in patients who cannot receive enteral feeding due to an esophageal obstruction. In the current study, the nutritional benefit of laparoscopic jejunostomy (Lap-J) was evaluated in patients with NAC for obstructing esophageal cancer. A total of 91 patients with esophageal cancer who received NAC between 2009 and 2017 were included in the present study. Lap-J was performed prior to NAC in 15 patients (16.5%) with an obstructing tumor. Patients with NAC without Lap-J were used as the control group (n=76). Nutritional parameters and surgical outcomes of the two groups were compared retrospectively. In the patients with Lap-J, 14 of the 15 patients (93.3%) did not experience any procedure-associated complications. No mortalities were associated with Lap-J. Significant decreases in total serum protein, albumin, hemoglobin concentrations and prognostic nutritional index (PNI) occurred following NAC in the control but not in the Lap-J group. Serum albumin and the improved modified Glasgow prognostic score increased significantly after NAC in the Lap-J group but not in the control group. In conclusion, perioperative nutritional support with Lap-J was safe and effective in patients with NAC for obstructing esophageal cancer.

Successful resection of a granulocyte colony-stimulating factor-producing carcinoma of the pancreas: A case report

Granulocyte colony-stimulating factor (G-CSF) is a naturally occurring glycoprotein that stimulates the proliferation of precursor cells in the bone marrow and their maturation into fully differentiated neutrophils. G-CSF-producing cancers rarely occur in the digestive system, particularly the pancreas. Herein we report the rare case of a G-CSF-producing pancreatic carcinoma associated with severe anemia due to bleeding in the duodenum, which was successfully treated with surgery. A 79 year-old man presented with epigastralgia and anemia at our institution. Esophagogastroduodenoscopy revealed a duodenal tumor, which was diagnosed as a poorly differentiated adenocarcinoma. To control breeding, subtotal stomach-preserving pancreaticoduodenectomy was performed. The excised tumor measured 86×55×54 mm. It was primarily located in the pancreas and compressed the pancreatic parenchyma and main bile duct. It comprised poorly differentiated adenocarcinoma, and prominent neutrophil infiltration was noted around the tumor. Immunohistochemical examination revelaed that the tumor was positive for G-CSF expression. Based on these results, a final diagnosis of G-CSF-producing primary pancreatic cancer was made. At 18 months following surgery, the patient was alive without recurrence.

Laparoscopic fenestration for a large ruptured splenic cyst combined with an elevated serum carbohydrate antigen 19-9 level: a case report

Background

Non-parasitic splenic cysts are associated with elevated serum carbohydrate antigen (CA) 19–9 levels. We report a case in which a 23-year-old female exhibited a large ruptured splenic cyst and an elevated serum CA19–9 level.

Case presentation

The patient, who experienced postprandial abdominal pain and vomiting, was transferred to our hospital and was found to have a large splenic cyst during an abdominal computed tomography (CT) scan. On physical examination, her vital signs were stable, and she demonstrated rebound tenderness in the epigastric region. An abdominal CT scan revealed abdominal fluid and a low-density region (12 × 12 × 8 cm) with enhanced margins in the spleen. The patient’s serum levels of CA19–9 and CA125 were elevated to 17,580 U/mL and 909 U/mL, respectively. A cytological examination of the ascitic fluid resulted in it being categorized as class II. Finally, we made a diagnosis of a ruptured splenic epidermoid cyst and performed laparoscopic splenic fenestration. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 5. The cystic lesion was histopathologically diagnosed as a true cyst, and the epithelial cells were positive for CA19–9. Follow-up laboratory tests performed at 4 postoperative months showed normal CA19–9 (24.6 U/L) and CA125 (26.8 U/L) levels. No recurrence of the splenic cyst was detected during the 6 months after surgery.

Conclusion

Laparoscopic fenestration of a ruptured splenic cyst was performed to preserve the spleen, after the results of abdominal fluid cytology and MRI were negative for malignancy.

The effect of neoadjuvant chemotherapy with gemcitabine and S-1 for resectable pancreatic cancer (randomized phase II/III trial; Prep-02/JSAP-05)

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Background: Despite recent progress of adjuvant chemotherapy for resected pancreatic ductal adenocarcinoma (PDAC), its survival remains limited. We conducted a randomized controlled trial to compare neoadjuvant chemotherapy (NAC) with upfront surgery (UP-S) for patients with resectable PDAC. Methods: Patients with resectable PDAC, all confirmed cytologically or histologically were enrolled. Patients received 2 cycles of gemcitabine and S-1 regimen (GS) followed by surgery (NAC) or UP-S after randomization (1:1). Patients in both arms received adjuvant chemotherapy using S-1 for 6 months after surgical resection. The primary endpoint was overall survival (OS); secondary endpoints included adverse events, resection rate, recurrence-free survival, residual tumor status, nodal metastases, and tumor marker kinetics. Results: A total 362 patients were randomly assigned to NAC-GS (n=182) or UP-S (n=180) for 3 years (2013-16). The median OS was 36.7 months in NAC-GS and 26.6 months in UP-S; HR 0.72 (p=0.015, stratified log-rank test) at 2.5 year after final enrollment. Crude resection rate for NAC and UP-S were 77%, 72% respectively. There was no operative mortality in both groups. Although G3/4 adverse events were observed frequently (73%) during NAC, no significant difference for both groups was observed for perioperative outcomes including blood loss, operation time, R0 resection rate and post-operative morbidity. Significant decrease of pathological nodal metastases in NAC was noted compared to those in UP-S by pathological evaluation for resected patients(p<0.01). Although significant decrease of viable tumor cells was observed in primary tumor after NAC compared to UP-S (p<0.01), Evans IIb or more was found in only 14 % of resected patients in NAC. Hepatic recurrence after surgery was significantly reduced in NAC (30.0%) compared to UP-S (47.5%) in observed period. Conclusions: The strategy of NAC showed significant longer survival compared to that of UP-S with acceptable feasibility. The effect of NAC might imply the control of subdiagnostic liver metastases before surgery for resectable PDAC. Clinical trial information: UMIN000009634.

Long-term outcome following sentinel node navigation surgery for cT1 gastric cancer

Sentinel node navigation surgery (SNNS) has become a standard procedure for early-stage melanoma and breast cancer. However, very few studies have evaluated the long-term clinical outcomes following SNNS for gastric cancer. The present study analyzed 51 patients with cT1 gastric cancer who underwent SNNS at our hospital. Sentinel nodes (SNs) were identified using the dual tracer method. Patients underwent limited gastrectomy with SN station dissection when the SNs were reported as pathologically negative during surgery. When SNs were pathologically positive, standard gastrectomy with D2 lymphadenectomy was performed. Out of the 51 cases, 42 cases (82%) were pathologically diagnosed as SN-negative using a frozen section. The surgical procedures included segmental gastrectomy (n=33) and local resection (n=9). A total of 9 patients (18%) had lymph node metastasis in SNs. The mean observation period was 3,125±167 days, and the 5-year overall survival rate was 98%. There was no recurrence, and body weight loss was minimal following the SNNS. Remnant gastric cancer developed in 4 (8%) of the 50 patients except total gastrectomy. Thus, SNNS was a useful procedure for cT1 gastric cancer from the long-term clinical outcomes, though metachronous gastric cancer should paid further attention to.

Pathomorphological features of metastatic lymph nodes as predictors of postoperative prognosis in pancreatic cancer

To investigate the pathological features of metastatic lymph nodes (LN) in pancreatic ductal adenocarcinoma (PDAC) and to determine factors with prognostic implications.Metastatic LN status is a proven significant factor for predicting postoperative prognosis in pancreatic cancer patients. However, the effective prognostic criteria regarding metastatic LNs for such disease remain unknown.We retrospectively reviewed 98 patients with R0/1 resection for PDAC. All metastatic LNs were evaluated for the pathomorphological features of metastasis and analyzed in terms of postoperative outcomes. Various morphological patterns of metastasis were assessed in 440 positive LNs and then classified into 4 groups: common type, direct type (continuously invaded by the main tumor), scatter type (multiple tumor clusters among the normal LN tissues), and isolated tumor cell (ITC).The pathological stage was defined as stage IIA in 10% and IIB in 90% patients. Common-type metastasis was noted in 55% positive LNs of 75% node-positive patients; direct type in 36% LNs of 69% patients; scatter type in 5% LNs of 14% patients; and ITCs in 5% LNs of 18% patients. Significant difference was noted only in recurrence-free survival (RFS) but not in overall survival (OS) in the common-type; only in OS but not in RFS for the scatter type; and neither in RFS nor OS for both direct type and ITC. Multivariate analysis revealed that only LN ratio and curability were independent predictive factors of poor.The tumor distribution patterns in metastatic LNs are the postoperative prognostic factors in pancreatic cancer.

Randomized phase II/III trial of neoadjuvant chemotherapy with gemcitabine and S-1 versus upfront surgery for resectable pancreatic cancer (Prep-02/JSAP-05)

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Background: Despite improvements of postoperative adjuvant therapy for resected pancreatic ductal adenocarcinoma (PDAC), its prognosis remains poor. A randomized controlled trial has begun to compare neoadjuvant chemotherapy using gemcitabine and S1 (NAC-GS) with upfront surgery (Up-S) for patients with PDAC planned resection. Methods: Patients were enrolled after the diagnosis of resectable PDAC with histological confirmation. They were randomly assigned as either NAC-GS or Up-S. In NAC-GS, gemcitabine was provided at a dose of 1 g/m2 on day 1 and 8 and oral S-1 was administered at a dose of 40 mg/m2 twice daily on 1-14 days. Patients received 2 cycles of this regimen. S-1 adjuvant for 6 months was administered for the patients with curative resection and fully recovered within 10 weeks after surgery in both arms. The primary endpoint for the phase III part was overall survival (OS); secondary endpoints included adverse events, resection rate, recurrence-free survival, residual tumor status, nodal metastases, and tumor marker kinetics. The target sample size required 163 patients (α-error 0.05; power 0.8) in each arm. The trial was conducted by the Health Labor Sciences Research Grant (H22-009) of Japan and registered with the UMIN Clinical Trials Registry as UMIN000009634. Results: From January 2013 to January 2016, 364 patients were enrolled in 57 centers (182 to NAC-GS and 182 to Up-S). Of these, two were excluded because of ineligibility, therefore 182 patients in NAC-GS and 180 in Up-S constituted the ITT analysis-set. The median OS was 36.7 months in NAC-GS and 26.6 months in Up-S; HR 0.72 (95% confidential interval 0.55-0.94; p=0.015 [stratified log-rank test]). Grade 3 or 4 adverse events frequently (72.8%) observed in NAC-GS were leukopenia or neutropenia. However, the resection rate, R0 resection rate, and morbidity of the operation were equivalent in the two groups. There was no perioperative mortality in either group. Conclusions: This phase III study demonstrated the significant survival benefits of NAC-GS treatment. Therefore, the results indicated that neoadjuvant chemotherapy could be a new standard for patients with resectable PDAC. Clinical trial information: UMIN000009634.

A case of intrahepatic cholangiocarcinoma that was difficult to diagnose prior to surgery: A case report

The present study reports a case of mass-forming intrahepatic cholangiocarcinoma (ICC), which mimicked cholangiocellular carcinoma (CoCC) during imaging and a needle biopsy examination. A 51-year-old female with no relevant medical history was referred to the National Defense Medical College hospital with an intrahepatic tumor. Computed tomography demonstrated non-homogeneous enhancement in the early arterial phase and persistent enhancement in the portal and equilibrium phases, together with notable swelling of the para-aortic lymph nodes. Gadolinium-ethoxybenzyl diethylenetriamine-pentaacetic acid-enhanced magnetic resonance imaging revealed low signal intensity in the hepatobiliary phase. The liver tumor and lymph nodes exhibited increased radiotracer uptake (maximum standardized uptake value=14.0) with positron emission tomography. A histological examination of a percutaneous needle biopsy specimen of the liver tumor indicated a diagnosis of CoCC. The patient underwent left hepatectomy and lymphadenectomy. The surgical specimen contained a poorly differentiated adenocarcinoma with anaplastic changes, which was immunohistochemically positive for epithelial membrane antigen (at the luminal membrane), cytokeratins 7 and 19, and negative for α-fetoprotein, hepatocyte-specific antigen, cluster of differentiation 56 and KIT. Based on these histopathological and immunohistochemical findings, the patient was diagnosed with ICC.

Hepatic portal venous gas related to appendicitis

BACKGROUND

Hepatic portal venous gas (HPVG) is rare with high mortality. There are few reports on HPVG's association with appendicitis. Here we report a case of HPVG associated with appendicitis. Case presentation: A 79-year-old man presented with acute abdominal pain. Physical examination suggested peritoneal irritation. Blood tests indicated acute inflammation, metabolic acidosis, renal dysfunction and disseminated intravascular coagulation. Contrast-enhanced abdominal computed tomography revealed HPVG, a contrast defect in the small intestine, and minor ascites around the intestine. Urgent laparotomy was performed as intestinal ischemia was suspected. There were no findings of intestinal ischemia, but the appendix was discolored with wall thickening. We confirmed a clinical diagnosis of peritonitis caused by gangrenous appendicitis. We performed appendectomy and abdominal drainage. After surgery, the patient needed intensive care for septic shock. He left the ICU 7 days after the surgery and was discharged 10 days later. Conclusion: Thus, appendicitis may cause HPVG.

Mechanisms of sepsis-induced immunosuppression and immunological modification therapies for sepsis

Surgical injury can be a life-threatening complication, not only due to the injury itself, but also due to immune responses to the injury and subsequent development of infections, which readily result in sepsis. Sepsis remains the leading cause of death in most intensive care units. Unfavorable outcomes of several high-profile trials in the treatment of sepsis have led researchers to state that sepsis studies need a new direction. The immune response that occurs during sepsis is characterized by a cytokine-mediated hyper-inflammatory phase, which most patients survive, and a subsequent immunosuppressive phase. Therefore, therapies that improve host immunity might increase the survival of patients with sepsis. Many mechanisms are responsible for sepsis-induced immunosuppression, including apoptosis of immune cells, increased regulatory T cells and expression of programmed cell death 1 on CD4+ T cells, and cellular exhaustion. Immunomodulatory molecules that were recently identified include interleukin-7, interleukin-15, and anti-programmed cell death 1. Recent studies suggest that immunoadjuvant therapy is the next major advance in sepsis treatment.

Prognostic Value of Preoperative Systemic Immunoinflammatory Measures in Patients with Esophageal Cancer

BACKGROUND

It is reported that several systemic immunoinflammatory measures, including systemic immune-inflammatory index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio, and C-reactive protein (CRP)-to-albumin ratio (CAR), are associated with survival in patients with various types of cancer.

OBJECTIVE

The aim of the present study was to clear which systemic immunoinflammatory measures had the greatest prognostic values. In addition, we examined which component had the greatest prognostic power in patients with esophageal cancer.

METHODS

Preoperative systemic immunoinflammatory measures were evaluated in 143 patients undergoing esophageal resection for esophageal cancer from 2009 to 2014. Univariate and multivariate analyses were performed to determine the prognostic significance of these markers. Receiver operating characteristic (ROC) curves were plotted, and the area under the ROC curves (AUROCs) were compared to verify the accuracy of each measure in predicting overall survival (OS).

RESULTS

In univariate analysis, preoperative SII, NLR, and CAR were the predictors of OS in patients who underwent esophagectomy for esophageal cancer (p < 0.05, respectively), whereas in multivariate analysis, CAR and pathological tumor depth were the significant predictors of OS (hazard ratio [HR] 1.994, p = 0.03 vs. HR 1.967, p = 0.02, respectively). According to AUROC, the CRP (0.66) and albumin levels (0.66) were more important systemic immunoinflammatory measures than neutrophil (0.58), lymphocyte (0.63), and platelet (0.56) levels.

CONCLUSION

Among systemic immunoinflammatory measures, CAR was the most significant predictor of OS in patients with esophageal cancer. CRP and albumin levels were more important components of systemic immunoinflammatory measures.

Vitamin A-coupled liposome system targeting free cholesterol accumulation in hepatic stellate cells offers a beneficial therapeutic strategy for liver fibrosis

AIM

Liver fibrosis is a life-threatening disorder for which no approved therapy is available. Recently, we reported that mouse hepatic stellate cell (HSC) activation increased free cholesterol (FC) accumulation, partly by enhancing signaling through sterol regulatory element-binding protein 2 (SREBP2) and microRNA-33a (miR-33a), which resulted in HSC sensitization to transforming growth factor-β (TGFβ)-induced activation in a "vicious cycle" of liver fibrosis.

METHODS

Human HSCs were isolated from surgical liver specimens from control patients and patients with liver fibrosis. C57BL/6 mice were treated with carbon tetrachloride for 4 weeks and concurrently given SREBP2-siRNA- or anti-miR-33a-bearing vitamin A-coupled liposomes.

RESULTS

In human activated HSCs obtained from patients with liver fibrosis, FC accumulation was enhanced independently of serum cholesterol levels through increased signaling by both SREBP2 and miR-33a. This increased FC accumulation enhanced Toll-like receptor 4 (TLR4) protein levels and lowered the TGFβ-pseudoreceptor Bambi (bone morphogenetic protein and activin membrane-bound inhibitor) mRNA levels in HSCs. Notably, in a mouse liver fibrosis model, reduction of FC accumulation, specifically in activated HSCs by suppression of SREBP2 or miR-33a expression using SREBP2-siRNA- or anti-miR-33a-bearing vitamin A-coupled liposomes, downregulated TLR4 signaling, increased Bambi expression, and consequently ameliorated liver fibrosis.

CONCLUSIONS

Our results suggest that FC accumulation in HSCs, as an intracellular mediator promoting HSC activation, contributes to a vicious cycle of HSC activation in human and mouse liver fibrosis independent of serum cholesterol levels. Targeting FC accumulation-related molecules in HSCs through a vitamin A-coupled liposomal system represents a favorable therapeutic strategy for liver fibrosis.

Relationship between desmoplastic pattern and lymphocytes infiltration in pancreatic cancer

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Background: The proposed histologic desmoplastic reaction (DR) categorization and lymphocyte infiltration (LI) directly reflects tumor behavior in a modulating stromal environment and could provide valuable prognostic information for colorectal cancer patients, but the prognostic role of DR and LI has not been investigated in pancreatic cancer patients. Methods: A total of 87 pancreatic cancer patients who underwent potentially curative surgery for their tumors in our hospital (2008 to 2013) were included. DR was classified as mature, intermediate, or immature on the basis of the existence of keloid-like collagen and myxoid stroma-distinctive histologic products of extracellular matrix remodeling. LI was classified as Pattern I; circumferential lymphocytes zone without disruptions around tumor, Pattern II; lymphocytes zone with partial disruptions and thinning around tumor, Pattern III; focal lymphocytes foci around tumor at most invasive border without lymphocyte zone, and Pattern IV; no lymphocyte foci around tumor. Results: With regard to DR, 0, 23, and 64 patients were classified as mature, intermediate, and immature, respectively. Five-year overall survival rates (#%) were higher in immature group (p=0.0040) than those of intermediate group (#%). Multivariate analysis revealed that DR was an independent prognostic factor along with residual tumor (p=0.0300). With regard to LI, 0, 6, 70, and 11 patients were classified as Pattern I, Pattern II, Pattern III, and Pattern IV, respectively. There was no relationship between DR and LI. Conclusions: The DR categorization seemed to reflect tumor behavior and could provide valuable prognostic information for pancreatic cancer patients. We did not show any relationship between DR and LI in pancreatic cancer.

Impact of angiotensin-converting enzyme 2 levels on postoperative pneumonia after esophagectomy

BACKGROUND

Pulmonary complications after esophagectomy are often fatal. The prediction of postoperative pulmonary complications remains a challenge. Accumulating evidence demonstrates a physiological and pathological role for angiotensin-converting enzyme 2 (ACE2) in the respiratory system. The purpose of this study was to evaluate the predictive value of ACE2 levels for the development of postoperative pneumonia.

METHODS

To evaluate the association between serum ACE2 levels and pneumonia after esophagectomy, we retrospectively reviewed the medical records of 80 patients who underwent thoracoscopic esophagectomy for esophageal cancer from 2009 to 2014.

RESULTS

Nineteen patients (23.8%) developed pneumonia after esophagectomy. Patients with pneumonia had significantly higher levels of ACE2 from the preoperative day to postoperative day (POD) 3, white blood cell count (POD7), and C-reactive protein (POD3, POD5, and POD7) than patients without pneumonia. Patients with postoperative pneumonia had higher serum ACE2 levels on POD3 than patients without pneumonia.

CONCLUSIONS

The elevation of ACE2 levels on POD3 may predict the incidence of pneumonia.

A case of pneumatosis intestinalis during neoadjuvant chemotherapy with cisplatin and 5-fluorouracil for esophageal cancer†

Pneumatosis intestinalis (PI) is a relatively rare disease. A 70-year-old man with stage II squamous cell carcinoma of the middle thoracic esophagus was administered cisplatin plus 5-fluorouracil (CF) therapy as neoadjuvant chemotherapy. On Day 14 of the first course of CF therapy, he complained of acute abdominal pain. Computed tomography (CT) revealed PI of the entire colon and a small air bubble in the mesentery. A colonoscopy revealed that there was no finding suggestive of ischemia. Because there was no sign of peritoneal irritation, conservative treatment was selected. On Day 7 after PI diagnosis, CT indicated the disappearance of PI. The patient underwent a radical esophagectomy. Intraoperative laparoscopic findings showed the serosa of the colon to be intact. The patient was discharged without any complications. It is important to take into account that CF therapy may cause PI and that PI can be treated conservatively.

In vivo imaging of hepatic hemodynamics and light scattering property during ischemia-reperfusion in rats based on spectrocolorimetry

A red-green-blue camera-based imaging method is proposed for estimating spatial maps of concentrations of oxyhemoglobin (C_HbO), deoxyhemoglobin (C_HbR), total hemoglobin (C_HbT), tissue oxygen saturation (StO₂), and scattering power (b) in liver tissue. Hemodynamic responses to hepatic ischemia-reperfusion of in vivo rat liver tissues induced by portal triad occlusion were evaluated. Upon portal triad occlusion, this method yielded images of decreased C_HbO, C_HbT, StO₂, and b, and increased C_HbR followed by a progressive increase in C_HbO and StO₂ during reperfusion. Time courses of the changes in C_HbO, C_HbR, C_HbT, and StO₂ over different regions of interest (ROI_s) revealed that ischemia results in an abrupt significant (P<0.05) reduction in C_HbO, C_HbT, and StO₂ with a simultaneous increase in C_HbR compared to the baseline level, indicative of the hemodynamic responses during hepatic ischemia-reperfusion. Upon reperfusion, there was a gradual increase in C_HbO and StO₂, and decrease in C_HbR. The change in average scattering power b implies the presence of morphological alterations in the cellular and subcellular structures induced by ischemia or anoxia. This study shows the potential of monitoring spatiotemporal changes in hemodynamic parameters and morphological changes in studies of hepatic pathophysiology.

Weekly paclitaxel therapy for gastric cancer in patients with renal dysfunction: A case report

A 57-year-old woman was admitted to National Defense Medical College hospital for treatment of gastric cancer with pyloric stenosis. She had been diagnosed with chronic kidney disease (CKD) 10 years prior, but received no hemodialysis. Because of peritoneal dissemination, a palliative distal gastrectomy was performed. In consideration of renal dysfunction, we decided for chemotherapy with paclitaxel, but not S-1 plus cisplatin regimen which is renal toxic agents. On the 29th postoperative day, chemotherapy using paclitaxel was initiated at a dose of 80 mg/m². Paclitaxel was administered weekly on days 1, 8, and 15 on a 28-day cycle. The patient tolerated 13 courses of this treatment without any severe adverse effect, such as exacerbation of renal function. Despite the gradual increase in the level of tumor markers, metastases were not detected via radiography during the clinical course. Moreover, renal function was maintained for the duration of the clinical course. To date, standard chemotherapeutic treatment for patients with CKD has not been established. We conclude that weekly paclitaxel is a suitable treatment regimen for patients with renal failure requiring chemotherapy for advanced gastric cancer.

•

In Japan, the standard therapy for unresectable advanced gastric cancer is S-1 and cisplatin combination chemotherapy. However, the pharmacodynamics of these agents in patients with renal dysfunction remains unclear.

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We herein present a case of chronic kidney disease (CKD) in which the patient was safely given paclitaxel to treat gastric cancer with peritoneal dissemination.

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Weekly paclitaxel therapy is feasible and effective for patients with advanced gastric cancer and renal impairment.

Successful laparoscopic repair of an incarcerated Bochdalek hernia associated with increased intra-abdominal pressure during use of blow gun: A case report

BACKGROUND

Bochdalek hernia is a congenital diaphragmatic hernia, and adult cases are rare, with a reported frequency of 0.17%-6% among all diaphragmatic hernias.

PRESENTATION OF CASE

A 78-year-old man was referred to our hospital with a sudden onset of whole abdominal pain after playing with a blow gun. Chest radiography and computed tomography revealed diaphragmatic hernia with the small intestine. We therefore diagnosed him with an incarcerated Bochdalek hernia associated with increased intra-abdominal pressure during use of blow gun. Laparoscopic repair was performed. The omentum, transverse colon, and small intestine were located in the left thoracic cavity, without ischemic change. After placing the herniated organs into the abdominal cavity, we performed a primary closure of the diaphragmatic defect with interrupted non-absorbable sutures.

DISCUSSION

It is generally recommended that all adult Bochdalek hernia patients undergo surgical repair to prevent life-threatening complications due to incarceration. Recently, laparoscopic techniques for repair the hernia have gained popularity, especially in elective cases. In our case, we could successfully perform emergency laparoscopic repair, as it is associated with a shorter inpatient hospitalization period.

CONCLUSION

An incarcerated Bochdalek hernias associated with increased intra-abdominal pressure is an uncommon clinical finding in an adult, and laparoscopic repair of an incarcerated Bochdalek hernia is safe, feasible, and an excellent option as it is minimally invasive.

In vivo evaluation of a modified linear stapling device designed to facilitate accurate pathologic examination of the surgical margin

BACKGROUND

Microscopic involvement of the resection margin could influence the long-term outcome of patients undergoing curative surgery for gastric cancer. Linear staplers, commonly used for gastrectomies, are often equipped with three lines of staples on either side of the resection line. Although multiple lines of staples reinforce closure of the gastric or intestinal stump, they could hinder accurate histopathologic evaluation of the surgical margin of the resected specimen.

METHODS

We modified a linear stapling device by removing one line (stapler E2) or two lines (stapler E1) of staples on the specimen side, and attempted to dissect a silicon film and then the stomach from a porcine model using the stapling device and examined the distances between the cutting edge and the nearest staple line.

RESULTS

The distance between the cutting edge and the staple line for stapler E1 was significantly greater than the distance between the cutting edge and the nearest staple line for stapler E2 or the control device. Consequently, specimens of exemplary quality were available for pathologic examination of the surgical margin. Moreover, the lack of multiple layers of staples did not result in contamination of the abdominal cavity with gastric juice during laparoscopic procedures in the porcine model.

CONCLUSIONS

Stapler E1 is safe and could be useful for the pathologic evaluation of the true surgical margin.

Efficacy of totally laparoscopic distal gastrectomy for gastric cancer in elderly patients

Elderly patients are often considered as high-risk for major abdominal surgery due to reduced functional reserve and increased comorbidities. We herein evaluated the efficacy of totally laparoscopic distal gastrectomy (TLDG) in elderly patients with gastric cancer by measuring the postoperative systemic responses and postoperative analgesic consumption. A total of 102 patients with gastric cancer [57 who underwent TLDG and 45 who underwent laparoscopy-assisted distal gastrectomy (LADG)] were enrolled in this study. The patients were classified as elderly (aged ≥75 years) and non-elderly (aged <75 years) groups. The surgical outcome and postoperative analgesic consumption were evaluated. The elderly group exhibited a higher incidence of comorbidities and a longer postoperative hospital stay compared with those of younger patients, although there was no difference in the incidence of postoperative complications. In addition, the total consumption of additional analgesics until postoperative day 5 in patients who underwent TLDG was significantly lower compared with that in patients who underwent LADG in the elderly group; there was no such difference in the non-elderly group. The results suggested that TLDG was better for the management of postoperative pain in elderly patients with gastric cancer, who exhibit the highest mortality rates in the adult surgical population.

Synchronous neuroendocrine tumors in both the pancreas and ileum: A case report

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This is the first case of synchronous pancreatic and ileal NET in a non-MEN 1 patient.

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Both morphologic and immunophenotypic findings were different.

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The synchronous occurrence of these tumors may be considered as a chance occurrence.

Introduction

Although it is well-known that in multiple endocrine neoplasia type 1 (MEN 1) disease, multiple endocrine lesions frequently occur, synchronous or metachronous neuroendocrine tumors (NETs) in non-MEN 1 patients are extremely rare.

Presentation of case

An asymptomatic 72-year-old woman with an ileal NET was referred to our hospital. Abdominal computed tomography revealed another circular tumor within the pancreatic head. She was classified as a non-MEN 1 patient. An operative procedure was performed with a preoperative diagnosis of synchronous NET, which was confirmed by pathological examination.

Discussion

Both morphologic and immunophenotypic findings were different between in the ileum and pancreas. Therefore, it was reasonable to consider that both tumors were primary tumors. The synchronous occurrence of these tumors is unusual, and it may be considered as a chance occurrence.

Conclusion

We here report the first case of synchronous pancreatic NET and ileal NET in a non-MEN 1 patient.

Long great saphenous vein grafting as temporary coronary bypass for extended left hepatectomy: report of a case

The right gastroepiploic artery (RGEA) has been used in coronary artery bypass grafting (CABG) as an alternative graft. In particular abdominal surgeries, surgery is required to rescue the graft flow into the coronary artery. A 77-year-old male with a history of CABG using RGEA was admitted with a diagnosis of a large hepatocellular carcinoma (HCC) occupying the whole caudate lobe. Preoperative coronary angiography indicated that the graft from the right internal mammary artery to the proximal left circumflex artery was obliterated among three branch bypasses. Following laparotomy, a great saphenous vein was harvested and delivered from the right axial artery to the RGEA graft over the thoracic wall, and the RGEA graft was ligated and divided. Subsequently, extended left hepatectomy was safely performed. Following hepatectomy, the RGEA graft was restored to the former condition, and the temporary graft was removed. After overcoming hyperbilirubinemia, the patient was discharged on postoperative day 28. This experience indicates that temporary bypass using the long great saphenous vein is effective and safe during long and invasive surgeries.

Total Pancreatectomy with Celiac Axis Resection and Hepatic Artery Restoration Using Splenic Artery Autograft Interposition

Although the indication of locally advanced pancreatic cancer with arterial involvement is controversial, the outcome of the patients with such disease treated by combined resection and reconstruction of the invaded artery has improved recently. For pancreatic body carcinoma invading the celiac axis, distal pancreatectomy with celiac axis resection has been safely performed. However, in case of pancreatic body carcinoma with involvement of the celiac axis, the common hepatic artery and the gastroduodenal artery, margin-negative resection requires total pancreatectomy with celiac axis resection and restoration of hepatic arterial flow. Here, we describe an interposition grafting technique using the splenic artery harvested from the resected specimen. This technique is effective and may widen the resectability of pancreatic cancer in selected patients.

Pneumatosis intestinalis with obstructing intussusception: A case report and literature review

Pneumatosis intestinalis (PI) often represents a benign condition that should not be considered as an argument for surgery. We report a patient with PI and obstructing intussusception who underwent urgent colectomy and review the literatures regarding PI with intussusception. A 20-year-old man presented at our hospital with a 3-d intermittent lower abdominal pain history. He underwent steroid therapy for membranoproliferative glomerulonephritis for 4 years. Computed tomography revealed ascending colon intussusception with air within the wall. Intraoperative colonoscopy revealed numerous soft polypoid masses with normal overlying mucosa and right hemicolectomy was performed. Histological examination of colonic wall sections revealed large cysts in the submucosal layer. The pathological diagnosis was PI. Nine cases of intussusception associated with primary PI have been reported. Although primary PI often represents a benign condition that should not be considered as an argument for surgery, if the case involves intussusception and obstruction, emergent laparotomy should be considered.

Inframesocolic Superior Mesenteric Artery First Approach as an Introductory Procedure of Radical Antegrade Modular Pancreatosplenectomy for Carcinoma of the Pancreatic Body and Tail

Superior mesenteric artery (SMA)-first approaches are operative tactics used to determine tumor resectability early during pancreatoduodenectomy. With locally advanced carcinoma of the pancreatic body and tail, early determination of SMA involvement also helps establish whether curative resection is feasible. During either radical antegrade modular pancreatosplenectomy (RAMPS) or classic left-to-right distal pancreatectomy, dissection of the SMA is performed after transection of the pancreas or wide detachment of the distal pancreas and spleen. Herein, we describe an inframesocolic SMA-first approach as an introductory procedure when treating carcinoma of the pancreatic body and tail. This first approach procedure provides a reliable and safe introduction to RAMPS.

Preoperative chemoradiation therapy for esophageal cancer is a risk factor for the elevation of high mobility group box-1, leading to an increase in postoperative severe pulmonary complications

We herein clarified the time course of changes in the serum high mobility group box chromosomal protein-1 (HMGB-1) concentrations in esophageal cancer patients after esophagectomy, and investigated whether the perioperative serum HMGB-1 levels correlate with the administration of neoadjuvant chemoradiation therapy (NACRT) and the postoperative clinical course, especially the occurrence of pulmonary complications, in such patients. Sixty patients who underwent right transthoracic esophagectomy for esophageal cancer were enrolled in this study. The relationship between the perioperative serum HMGB-1 levels and NACRT, and the postoperative severe pulmonary complications were evaluated. Patients with severe pulmonary complications (n = 44) tended to have undergone NACRT more often than those without severe pulmonary complications (n = 16). The preoperative and postoperative day 7 serum HMGB-1 concentrations were significantly higher in patients with severe pulmonary complications than those in patients without severe pulmonary complications. In the univariate and multivariate analyses, the use of NACRT and the preoperative elevations in the serum HMGB-1 levels (>4.2 ng/mL) were found to be significantly associated with pulmonary dysfunction. Furthermore, the response to NACRT was found to be significantly associated with the preoperative serum HMGB-1 levels. The use of NACRT contributes to preoperative serum HMGB-1 elevation, and these were risk factors for the occurrence of severe postoperative pulmonary complications in patients with esophageal cancer after thoracic esophagectomy.

The impact of postoperative adjuvant chemotherapy on the development of nonalcoholic fatty liver disease after pancreatoduodenectomy

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) after pancreatoduodenectomy (PD) is increasingly being recognized as a late postoperative complication, but the main causes have not been fully investigated. This study aimed to clarify the relationship between NAFLD after PD and postoperative adjuvant chemotherapy, focusing particularly on the adjuvant chemotherapy regimens administered.

MATERIALS AND METHODS

We retrospectively reviewed the medical records of 154 patients who underwent PD from April 2007 to December 2013, to identify the clinicopathologic factors most strongly influencing NAFLD development after PD. Moreover, the postoperative adjuvant chemotherapeutic regimen and the course after the cessation of adjuvant chemotherapy were examined in detail.

RESULTS

The incidence of postoperative NAFLD was 26.6% (41/154). The incidence of NAFLD was significantly higher in the patients with than in those without adjuvant chemotherapy: 38% versus 19% (P = 0.016). Multivariate analysis identified postoperative adjuvant chemotherapy (P = 0.021) and remnant pancreatic volume (P < 0.0001) as independent risk factors. The prevalence of NAFLD after PD was higher in patients treated with the S-1 regimen than in those given either regimens such as those containing gemcitabine or no adjuvant chemotherapy. Recovery from NAFLD 1 y after the cessation of adjuvant chemotherapy was observed in 54.5% (12/22) of patients receiving this treatment. In those treated with the S-1 regimen, improvement was more frequent than in those not receiving adjuvant chemotherapy (57.1% versus 11.8%, P = 0.018).

CONCLUSIONS

Considering the development of NAFLD, adjuvant chemotherapy after PD should be cared for the patients with small remnant pancreas.

Laparoscopic jejunostomy for obstructing upper gastrointestinal malignancies

The aim of this study was to describe a minimally invasive laparoscopic jejunostomy (Lap-J) technique for obstruction due to upper gastrointestinal malignancies and evaluate the nutritional benefit of Lap-J during neoadjuvant chemotherapy (NAC) in cases with obstructing esophageal cancer. Under general anesthesia, the jejunum 20-30 cm distant from the Treitz ligament was pulled out through an extended umbilical laparoscopic incision and a jejunal tube was inserted to 30 cm. The loop of bowel was gently returned to the abdomen and the feeding tube was drawn through the abdominal wall via the left lower incision. The jejunum was then laparoscopically sutured to the anterior abdominal wall. Lap-J was performed in 26 cases. The median operative time was 82 min. The postoperative course was uneventful. Lap-J prior to NAC was not associated with a decrease in body weight or serum total protein during NAC, compared with patients who received NAC without Lap-J. This minimally invasive jejunostomy technique may be particularly useful in patients in whom endoscopic therapy is not feasible due to obstruction from upper gastrointestinal malignancies.

Evaluation of light scattering and absorption properties of in vivo rat liver using a single-reflectance fiber probe during preischemia, ischemia-reperfusion, and postmortem

Diffuse reflectance spectroscopy (DRS) has been extensively used for characterization of biological tissues as a noninvasive optical technique to evaluate the optical properties of tissue. We investigated a method for evaluating the reduced scattering coefficient μ(s)', the absorption coefficient μ(a), the tissue oxygen saturation StO₂, and the reduction of heme aa3 in cytochrome c oxidase CcO of in vivo liver tissue using a single-reflectance fiber probe with two source-collector geometries. We performed in vivo recordings of diffuse reflectance spectra for exposed rat liver during the ischemia-reperfusion induced by the hepatic portal (hepatic artery, portal vein, and bile duct) occlusion. The time courses of μ a at 500, 530, 570, and 584 nm indicated the hemodynamic change in liver tissue as well as StO₂. Significant increase in μ(a)(605)/μ(a)(620) during ischemia and after euthanasia induced by nitrogen breathing was observed, which indicates the reduction of heme aa3, representing a sign of mitochondrial energy failure. The time courses of μ(s)' at 500, 530, 570, and 584 nm were well correlated with those of μ(a), which also reflect the scattering by red blood cells. On the other hand, at 700 and 800 nm, a temporary increase in μ(s)' and an irreversible decrease in μ(s)' were observed during ischemia-reperfusion and after euthanasia induced by nitrogen breathing, respectively. The change in μ(s)' in the near-infrared wavelength region during ischemia is indicative of the morphological changes in the cellular and subcellular structures induced by the ischemia, whereas that after euthanasia implies the hepatocyte vacuolation. The results of the present study indicate the potential application of the current DRS system for evaluating the pathophysiological conditions of in vivo liver tissue.

Laparoscopic resection of a huge retroperitoneal cystic lymphangioma after successful reduction of tumor size with a double balloon catheter

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We present a rare case of huge retroperitoneal cystic lymphangioma, diagnosed radiologically.

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The lymphangioma was successfully resected laparoscopically after aspiration using a SAND balloon catheter.

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Our case demonstrates the feasibility of minimally invasive laparoscopic resection of such lesions.

Introduction

Retroperitoneal cystic lymphangiomas are rare. We report a case of retroperitoneal huge cystic lymphangioma that was successfully aspirated the cyst’s contents with double balloon catheter and excised laparoscopically.

Presentation of case

A 34-year-old man was admitted to our hospital with low-grade fever and abdominal pain that had lasted for 1 week. Abdominal computed tomography and magnetic resonance imaging showed a fluid-filled multilocular mass measuring 13.5 cm in diameter around the tail of the pancreas, which was diagnosed as a retroperitoneal cystic lymphangioma. We successfully excised the tumor by laparoscopic distal pancreatosplenectomy. We punctured and aspirated the tumor with a double-balloon catheter to decrease the tumor’s size without spilling the tumor content. Cytology showed no malignant cells, and histopathological examination confirmed cystic lymphangioma. No recurrence was noted on radiographic imaging 10 months postoperatively.

Discussion and conclusion

Laparoscopic treatment for retroperitoneal huge cystic lymphangioma is feasible, and the double balloon catheter is useful for reducing the tumor volume.

Prognostic value of poorly differentiated clusters in the primary tumor in patients undergoing hepatectomy for colorectal liver metastasis

BACKGROUND

This study aimed to determine the prognostic value of a novel grading system based on the histologic assessment of poorly differentiated clusters (PDCs) in the primary lesions in patients with hepatectomy for colorectal liver metastasis (CRLM). Preoperative survival predictors for CRLM are required to determine candidates for perioperative chemotherapy who would otherwise have a poor prognosis.

METHODS

In total, 411 consecutive patients undergoing curative resection of primary colorectal cancers and metastatic liver lesions at 2 institutions were enrolled. Cancer clusters comprising ≥ 5 cancer cells, lacking a gland-like structure, were defined as PDCs and quantifiably graded.

RESULTS

According to PDCs, 65, 127, and 219 patients were classified as being grades (G)1, G2, and G3, respectively. PDCs were associated with T and N stages and tumor budding in primary tumor, extrahepatic disease, and serum CEA levels (P ≤ .0001-.045), but not with the number and size of liver metastasis. PDC grade significantly influenced recurrence rate in extrahepatic sites, including the lung and peritoneum (P < .0001). The 2-year disease-free survival after hepatectomy was 64.6%, 38.8%, and 22.4% in G1, G2, and G3, respectively. Based on multivariate analysis, PDC grade was selected as an independent prognostic factor together with other conventional factors such as extrahepatic disease and the number of liver metastasis.

CONCLUSION

PDC grade in primary lesions is a novel potent prognostic indicator in CRLM independent of the anatomic extent of disease. Notably, PDC grade can bias survival rates in clinical studies targeting perioperative chemotherapy in CRLM.

[Risk factors and prevention of surgical site infection for colorectal surgery]

Surgical site infection (SSI), the most frequent adverse event after colorectal surgery, leads to longer hospital days and increased healthcare costs. The development of SSI depends on a complex interplay between patient-related and procedure-related factors. This review refers to the several risk factors for the development of SSI and the risk factor index which were indicated by National Nosocomial Infections Surveillance. Furthermore, this review will focus on the prevention of SSI and refer to colon preparation and preventive antibiotics for colorectal surgery.

Importance of maintaining left gastric arterial flow at Appleby operation preserving whole stomach for central pancreatic cancer

The safety of whole stomach-preserving Appleby operation with resection of the left gastric artery (LGA) for pancreatic cancer cannot be assured. The anatomy of the celiac axis (CA) with special regard to the position of the origin of the LGA was examined. Using 3D images of the vascular architecture reconstructed from volume data of helical CT, the length of the CA and the position of the origin of the LGA from the CA were measured in 53 patients. Among 53 patients, 47 patients (89%) had classical anatomy of the CA branches. The mean length(2 standard deviation) of the CA and the distance from the root of the LGA to the bifurcation of the CA were 25.2mm (-4.9) (range 14.6-36.5) and 10.3mm (+4.5)(range 2.4-21.9), respectively. In 23 (45%) cases, the LGA arose farther than 10mm away from the bifurcation of the CA. Among six patients with anatomical variation of the arteries, two (4%) had the LGA directly arising from the aorta. Conservation of the LGA at modified Appleby operation would give complete cancer removal by en bloc resection of the nerve plexus, without risk of ischemic complications of the stomach and liver.

Predictive value of pleural and serum interleukin-6 levels for pneumonia and hypo-oxygenations after esophagectomy

OBJECTIVE

Pulmonary complications after esophagectomy continue to be a significant cause of morbidity and mortality. Although several factors have been implicated to be associated with pulmonary complications after esophagectomy, the prediction of pulmonary complications remains a challenge. The purpose of this study was to evaluate the predictive value of cytokine levels in sera and pleural drainage fluid for pneumonia and hypo-oxygenations following esophagectomy.

METHODS

A total of 66 patients who underwent esophagectomy for esophageal cancer were retrospectively evaluated for preoperative status, surgical procedures, and postoperative systemic response and laboratory data up to postoperative day (POD) 7. Interleukin-6 (IL-6) and IL-8 levels were also examined in patient sera and pleural drainage fluid until POD 5.

RESULTS

Eighteen patients (27.3%) had pneumonia following esophagectomy. Patients with pneumonia had significantly more frequent intraoperative blood transfusions, more frequent re-intubation, longer hospital stays, and higher hospital mortality than those without pulmonary complications. Patients with pneumonia had significantly higher levels of serum and pleural IL-6 immediately after surgery and on POD 1 than those without pneumonia. Univariate and multivariate analyses revealed higher pleural IL-6 levels were associated with postoperative minimum PaO2/FiO2 ratio.

CONCLUSIONS

The elevation of pleural IL-6 levels immediately after surgery and on POD 1 may predict the incidence of pneumonia and the levels of postoperative impaired oxygenation following esophagectomy.

Laparoscopic gastrectomy after incomplete endoscopic resection for early gastric cancer

Endoscopic submucosal dissection (ESD) utilizes electrical coagulation, which can cause burns, fibrosis and adhesion of the stomach and surrounding tissue; these complications might increase the surgical difficulties for subsequent laparoscopy-assisted gastrectomy (LAG) and the risk of complications. However, scarce data are available on the influence of previous ESD on LAG. The purpose of this study was to evaluate the feasibility and safety of LAG following incomplete ESD in patients with early gastric cancer. Ninety-seven patients who underwent LAG were analyzed retrospectively; 17 patients had undergone ESD previously and the remaining 80 patients had no history of ESD. Clinicopathological data and surgical outcomes were compared between the two groups. No differences were observed in surgical outcomes of LAG after ESD in terms of operation time, intraoperative blood loss, total number of harvested lymph nodes, time until start of flatus, and postoperative hospital stay. These results were not influenced by tumor location and operative procedures. In conclusion, in terms of surgical outcomes, LAG is a safe and feasible procedure for the treatment of early gastric cancer regardless of previous endoscopic treatment. LAG may be the first-choice radical treatment after incomplete ESD for early gastric cancer.

Outcome of overlap anastomosis using a linear stapler after laparoscopic total and proximal gastrectomy

BACKGROUND

Recently, novel intracorporeal esophagojejunostomy using a linear stapler after laparoscopic total gastrectomy (LTG) was reported and termed as the overlap method. In this study, we evaluated the feasibility and safety of the overlap method for esophagojejunostomy or esophagogastrostomy after LTG or laparoscopic proximal gastrectomy (LPG), respectively.

METHODS

Twenty-five patients underwent anastomosis using a linear stapler during esophagojejunostomy and esophagogastrostomy after LTG and LPG, respectively. Clinicopathological data and surgical outcomes were evaluated.

RESULTS

The average surgical duration for LTG was 236.8 min compared with 224.1 min for LPG. Postoperative complications were observed in four patients (16.0%); these included a wound infection, an intestinal obstruction, an afferent loop syndrome, and a reflux symptom. The average postoperative hospital stay of the patients was 12.5 days. There was no case of conversion to open surgery, anastomotic leakage or stenosis, or mortality.

CONCLUSIONS

The overlap method for esophagojejunostomy or esophagogastrostomy after LTG or LPG is safe and feasible and does not require an additional minilaparotomy, which may result in less pain and favorable cosmetic outcomes.

Influence of glutamine-supplemented Caco-2 cells on cytokine production of mononuclear cells

BACKGROUND

Caco-2 cells, cultured with mononuclear cells, were used as an in vitro model of human intestinal cell function. This study shows the effect of glutamine (Gln) supplementation on the production of tumor necrosis factor alpha, interleukin-10 (IL-10), and interleukin-6 (IL-6).

METHODS

Confluent Caco-2 cells were cultured in media with Gln at 0 mmol/L, 4 mmol/L, or 10 mmol/L +/- 1 microg/mL lipopolysaccharide (LPS), treated with fluorescein isothiocyanate- (FITC-) conjugated intercellular adhesion molecule-1 (ICAM-1) mononuclear antibody, and assessed for ICAM-1 expression levels via flow cytometry. Confluent Caco-2 cells alone in apical inserts, or mononuclear cells (MNCs) alone in basal chambers of transwells, were cultured in media with 0 mmol/L, 4 mmol/L, or 10 mmol/L Gln. Supernatants were taken to assess cytokine and endotoxin levels. Confluent Caco-2 cells in apical inserts of transwells were cultured in media containing Gln at 0 mmol/L, 4 mmol/L, or 10 mmol/L, whereas MNCs were cultured in the basal chamber in media containing Gln at 4 mmol/L +/- LPS. Supernatants were collected to determine cytokine levels in each chamber.

RESULTS

With Gln supplementation of the media at 10 mmol/L, enterocytes displayed a decrease in ICAM-1 expression. MNCs showed a decrease in tumor necrosis factor alpha and IL-6 production and an increase in IL-10 production when incubated with Caco-2 cells in media supplemented with Gln at 10 mmol/L.

CONCLUSIONS

Although cytokine production by Caco-2 or mononuclear cells incubated alone was not influenced by the Gln concentration of the media, cultured together, Gln levels affected cytokine production by mononuclear cells, which suggests that Caco-2 cells produce mediators in Gln-rich conditions that can influence mononuclear cell cytokine production.

Role of macrophage inflammatory protein 2 in acute lung injury in murine peritonitis

BACKGROUND

Acute lung injury is a frequent extraabdominal complication of bacterial peritonitis, and neutrophil plays an important role in this lung damage. Macrophage inflammatory protein 2 (MIP-2) serves the same chemotactic function as IL-8 which is a potent neutrophil chemotactic factor in humans, and we investigated the role of MIP-2 associated with neutrophil recruitment in the lung of murine peritonitis.

METHODS

Cecal ligation and puncture (CLP) were performed on mice. MIP-2 levels in blood and lung tissue, MIP-2 mRNA expression in lung tissue and bronchoalveolar lavage fluid (BALF), and CD11b expression on peripheral blood neutrophil and BALF cells were determined after CLP. In addition, we investigated the effect of anti-MIP-2 antibody on the lung injury associated with peritonitis.

RESULTS

MIP-2 mRNA expression was observed in lung tissue after CLP and numerous neutrophils were accumulated in the lung under those conditions. Anti-MIP-2 antibody contributed to the inhibition of the CD11b expression and chemotaxis of pulmonary neutrophils, lung edema, and thus the reduction in peritonitis-related mortality.

CONCLUSIONS

MIP-2 plays a pivotal role in neutrophil recruitment in the lung following peritonitis, and control of neutrophil accumulation in the lung by neutralizing MIP-2 is recommended as a new therapeutic approach to the lung damage associated with peritonitis.

Severe sepsis induces deficient interferon-gamma and interleukin-12 production, but interleukin-12 therapy improves survival in peritonitis

BACKGROUND

After severe sepsis, there is an increase of Th2 cytokine and a decrease in Th1 cytokine that may account for impaired cellular immunity. The aim of this study is to evaluate the Th1, Th2 cytokine balance in the serum, peritoneal lavage fluid (PLF) and liver mononuclear cells (MNC) of experimental peritonitis mice, and determine the effect of interleukin-12 (IL-12), a cytokine stimulating Th1 cytokine production, when administered to septic mice.

METHODS

Experimental bacterial peritonitis mice was induced by cecal ligation and puncture (21-gauge needle, mild peritonitis) or cut (5 mm, severe peritonitis). Serum and PLF levels and liver MNC production of interferon (IFN)-gamma, IL-10, and IL-12 were measured after the procedure. Mild and severe peritonitis mice were treated intraperitoneally with recombinant IL-12 (r-IL-12) either 6 hours before or 6 and 24 hours after the procedure. The survival rates were then compared with nontreated mice.

RESULTS

Serum and PLF IFN-gamma, IL-12 levels in severe peritonitis mice were significantly lower than those in mild peritonitis mice at 6 and 12 hours after the procedure. On the other hand, serum and PLF IL-10 levels in severe peritonitis mice were significantly higher than those in mild peritonitis mice at 6 hours after the procedure. Furthermore, liver MNC IFN-gamma production in severe peritonitis mice was significantly higher than that in mild peritonitis mice at 6 hours after the procedure, but liver MNC IL-12 production in severe peritonitis mice was significantly lower than that in mild peritonitis mice at 12 hours after the procedure. Severe peritonitis mice treated with r-IL-12 at 6 hours before the procedure improved survival rate, and mild peritonitis mice treated with r-IL-12 at 24 hours after the procedure showed significantly improved survival rates.

CONCLUSIONS

Change in the Th1, Th2 cytokine balance in peritonitis mice might induce a shift toward a Th2 dominant phenotype according to the severity of peritonitis, and the capacity to produce IFN-gamma and IL-12 by liver MNC is reduced. Therapies designed to augment the production of Th1 cytokines, such as IL-12, may thus prove to be beneficial in the treatment of severe sepsis after peritonitis.