Impact of shear stress on sacral pressure injury from table rotation during laparoscopic colorectal surgery performed in the lithotomy position

This study aimed to evaluate the impact of shear stress on surgery-related sacral pressure injury (PI) after laparoscopic colorectal surgery performed in the lithotomy position. We included 37 patients who underwent this procedure between November 2021 and October 2022. The primary outcome was average horizontal shear stress caused by the rotation of the operating table during the operation, and the secondary outcome was interface pressure over time. Sensors were used to measure shear stress and interface pressure in the sacral region. Patients were divided into two groups according to the presence or absence of PI. PI had an incidence of 32.4%, and the primary outcome, average horizontal shear stress, was significantly higher in the PI group than in the no-PI group. The interface pressure increased over time in both groups. At 120 min, the interface pressure was two times higher in the PI group than in the no-PI group (PI group, 221.5 mmHg; no-PI group, 86.0 mmHg; p < 0.01). This study suggested that shear stress resulting from rotation of the operating table in the sacral region by laparoscopic colorectal surgery performed in the lithotomy position is the cause of PI. These results should contribute to the prevention of PI.

A silicone disc for liver retraction in laparoscopic gastrectomy reduces the postoperative increase in the liver enzyme level

PURPOSE

To compare changes in liver enzyme levels on postoperative day 1 between patients with and without silicone disc (SD) use during liver retraction in laparoscopic gastrectomy for gastric cancer and laparoscopic gastric mobilization for esophageal cancer.

METHODS

This prospective randomized controlled phase II trial was conducted between June 30, 2020, and November 30, 2022, to investigate the benefits of using an SD with a Nathanson liver retractor (NLR) compared with those using an NLR in laparoscopic gastrectomy and gastric mobilization. The primary endpoint was the change in transaminase level on postoperative day 1.

RESULTS

A total of 86 patients received randomized assignments and were included in the analysis, with 44 assigned to the SD (-) group and 42 to the SD (+) group. On postoperative day 1, the SD (+) group showed a significantly lower increase in the aspartate aminotransferase levels than the SD (-) group (SD [+], 94.4% vs. SD [-], 179.8%; p = 0.012). Similarly, the SD (+) group showed a significantly lower increase in alanine aminotransferase levels than the SD (-) group (SD [+], 71.6% vs. SD [-], 201.5%; p = 0.014).

CONCLUSION

In laparoscopic gastrectomy, the use of an SD combined with an NLR appears to mitigate postoperative liver dysfunction.

Laparoscopic median arcuate ligament section for median arcuate ligament compression syndrome initially detected as splenic infarction: a case report

BACKGROUND

Median arcuate ligament compression syndrome (MALS) causes upper abdominal pain and at times hemodynamic abnormalities in the pancreaticoduodenal region. Herein, we present a case of a 70 year-old man, initially diagnosed with splenic infarction and was successfully treated laparoscopically.

CASE PRESENTATION

A 70-year-old man with abdominal pain admitted to our hospital. Abdominal-enhanced computed tomography revealed a poorly contrasted area in the spleen and stenosis at the root of the celiac artery. Arterial dilatation was observed around the pancreaticoduodenal arcade, however, no obvious aneurysm formation or arterial dissection was observed. Abdominal-enhanced magnetic resonance imaging indicated the disappearance of the flow void at the root of the celiac artery. The patient had no history of atrial fibrillation and was diagnosed with splenic infarction due to median arcuate ligament compression syndrome. We performed a laparoscopic median arcuate ligament section with five ports. Intraoperative ultrasonography showed a retrograde blood flow in the common hepatic artery and the celiac artery. After releasing the compression, the antegrade blood flow from the celiac artery to the splenic artery, and the common hepatic artery were visualized using intraoperative ultrasonography. The postoperative course of the patient was uneventful, and he was discharged on postoperative day 9. Postoperative computed tomography a month after surgery revealed no residual stenosis of the celiac artery or dilation of the pancreaticoduodenal arcade. Furthermore, the poorly contrasted area of the spleen improved.

CONCLUSIONS

Reports indicate that hemodynamic changes in the abdominal visceral arteries due to median arcuate ligament compression are related to the formation of pancreaticoduodenal aneurysms. In this case, median arcuate ligament compression syndrome caused splenic infarction by reducing blood flow to the splenic artery.

Clinical impact of diarrhea during enteral feeding after esophagectomy

BACKGROUND

Enteral feeding (EF) is recommended to enhance nutritional status after esophagectomy; however, diarrhea is a common complication of EF. We investigated the clinical and prognostic impact of diarrhea during EF after esophagectomy.

METHODS

One hundred and fifty-two patients who underwent transthoracic esophagectomy were enrolled. The King's stool chart was used for stool characterization. The short- and long-term outcomes were compared between a non-diarrhea (Group N) and diarrhea group (Group D).

RESULTS

A higher dysphagia score (≥ 1) was observed more frequently in Group D than in Group N (45.7% vs. 19.8%, p = 0.002). Deterioration of serum total protein, serum albumin, serum cholinesterase, and the prognostic nutritional index after esophagectomy was greater in Group D than in Group N (p = 0.003, 0.004, 0.014, and 0.001, respectively). Patients in Group D had significantly worse overall survival (OS) and recurrence-free survival (RFS) than those in Group N (median survival time (MST): OS, 21.9 vs. 30.6 months, p = 0.001; RFS, 12.4 vs. 27.7 months, p < 0.001). In stratified analysis due to age, although there was no difference in OS with or without diarrhea in young patients (MST: 24.1 months in a diarrhea group vs. 33.6 months in a non-diarrhea group, p = 0.218), patients in a diarrhea group had significantly worse OS than those in a non-diarrhea group in elderly patients (MST: 17.8 months vs. 27.9 months, p < 0.001).

CONCLUSIONS

Diarrhea during EF can put elderly patients at risk of postoperative malnutrition and a poor prognosis after esophagectomy.

Tenascin C in pancreatic cancer-associated fibroblasts enhances epithelial mesenchymal transition and is associated with resistance to immune checkpoint inhibitor

Tenascin C (TNC) is an extracellular matrix glycoprotein that is highly expressed in cancer stroma and is associated with tumor progression in pancreatic adenocarcinoma (PAAD). In this study, we aimed to investigate the potential involvement of TNC in the response to immune checkpoint inhibitors (ICI) among PAAD patients. Transcriptomic profiles were obtained from public databases and analyzed to compare TNC mRNA levels between tumor and normal tissues. Bioinformatic programs were used to predict paracrine communications between cancer cells and cancer-associated fibroblasts (CAFs), and the Tumor Immune Dysfunction and Exclusion (TIDE) score was calculated to predict response to ICI treatment in PAAD patients. An independent immunotherapeutic cohort was used to validate the clinical impact of the signatures. Results showed that TNC mRNA levels were significantly upregulated in tumors compared to normal tissues in PAAD, and patients with high TNC expression had significantly shorter overall survival than those with low TNC expression (P = 0.0125). TNC was predominantly expressed in CAFs of PAAD patients and was found to potentially enhance the epithelial-mesenchymal transition (EMT) of cancer cells via integrin receptors, contributing to resistance to ICI treatment. Patients with high TNC expression and high ITGαV or ITGB3 expression were associated with poor response to ICI therapy. In conclusion, these findings suggest that TNC-high CAFs play a crucial role in tumor progression and resistance to ICI therapy in PAAD patients, and targeting TNC and its interactions with cancer cells may provide a potential strategy for improving the efficacy of ICI therapy in PAAD.

Prediction of postoperative complications after hepatectomy with dynamic monitoring of central venous oxygen saturation

BACKGROUND

The usefulness of static monitoring using central venous pressure has been reported for anesthetic management in hepatectomy. It is unclear whether intra-hepatectomy dynamic monitoring can predict the postoperative course. We aimed to investigate the association between intraoperative dynamic monitoring and post-hepatectomy complications. Furthermore, we propose a novel anesthetic management strategy to reduce postoperative complication.

METHODS

From 2018 to 2021, 93 patients underwent hepatectomy at our hospital. Fifty-three patients who underwent dynamic monitoring during hepatectomy were enrolled. Flo Trac system was used for dynamic monitoring. The baseline central venous oxygen saturation (ScvO2) was defined as the average ScvO2 for 30 min after anesthesia induction. ScvO2 fluctuation (ΔScvO2) was defined as the difference between the baseline and minimum ScvO2. Postoperative complications were evaluated using the comprehensive complication index (CCI).

RESULTS

Patients with ΔScvO2 ≥ 10% had significantly higher CCI scores (0 vs. 20.9: p = 0.043). In univariate analysis, patients with higher CCI scores demonstrated significantly higher preoperative C-reactive protein-to-lymphocyte ratio (7.51 vs. 24.49: p = 0.039), intraoperative bleeding (105 vs. 581 ml: p = 0.008), number of patients with major hepatectomy (4/45 vs. 3/8: p = 0.028), and number of patients with ΔScvO2 ≥ 10% (11/45 vs. 6/8; p = 0.010). Multivariate logistic regression analysis revealed that ΔScvO2 ≥ 10% (odds ratio: 9.53, p = 0.016) was the only independent predictor of elevated CCI.

CONCLUSIONS

Central venous oxygen saturation fluctuation during hepatectomy is a predictor of postoperative complications. Anesthetic management based on intraoperative dynamic monitoring and minimizing the change in ScvO2 is a potential strategy for decreasing the risk of post-hepatectomy complications.

The cholinesterase and C-reactive protein score is a potential predictor of pseudoaneurysm formation after pancreaticoduodenectomy in patients with soft pancreas

BACKGROUND

Pseudoaneurysm (PA) rupture after pancreaticoduodenectomy (PD) is a life-threatening complication. Most PA cases originate from postoperative pancreatic fistulas (POPFs). Although several risk factors for POPF have been identified, specific risk factors for PA formation remain unclear. Therefore, we retrospectively analyzed PD cases with soft pancreas and proposed a novel strategy for early detection of PA formation.

METHODS

Overall, 120 patients underwent PD between 2010 and 2020 at our institution; of these, 65 patients with soft pancreas were enrolled. We evaluated the clinicopathological factors influencing PA formation and developed a risk score to predict PA formation.

RESULTS

In total, 11 of the 65 patients developed PAs (PA formation group: PAG), and 8 of these 11 PAs ruptured. The median time to PA formation was 15 days, with a minimum of 5 days. The PAG was significantly older than the non-PA formation group, were predominantly men, and had comorbid diabetes mellitus. Pre- and intra-operative findings were similar between the two groups. Importantly, no significant differences were found in postoperative drain amylase levels and total drain amylase content. Cholinesterase and C-reactive protein (CRP) levels on postoperative day (POD) 3 were significantly different between the two groups. Multivariate analysis showed that cholinesterase ≤ 112 U/L and CRP ≥ 16.0 mg/dl on POD 3 were independent predictors of PA formation.

CONCLUSIONS

Decreased cholinesterase and elevated CRP on POD 3 (Cho-C score) are useful predictors of PA formation in cases with soft pancreas. In such cases, periodic computed tomography evaluations and strict drain management are necessary to prevent life-threatening hemorrhage.

Prognostic impact of perioperative change in serum p53 antibody titers in esophageal squamous cell carcinoma

BACKGROUND

The clinical effectiveness of tumor markers for estimating prognosis in esophageal squamous cell carcinoma (ESCC) remains unclear. We assessed the clinical impact of changes in perioperative serum p53 antibodies (s-p53-Abs) titers in ESCC.

METHODS

From January 2011 to March 2021, 249 patients were enrolled in this study. Titers of s-p53-Abs were measured before the initial treatment and 3 months after esophagectomy. Patients were divided into a s-p53-Abs decreased or unchanged group (Group D, n = 217) and an increased group (Group I, n = 32). Short- and long-term outcomes were compared between the groups.

RESULTS

There was no correlation between the changes in squamous cell carcinoma antigen and carcinoembryonic antigen titers and recurrence site, number of recurrent lesions, and prognosis. However, the recurrence rate was significantly higher in Group I than in Group D (53.1% vs. 28.6%, p = 0.008), especially for distant organ recurrence (37.5% vs. 18.4%, p = 0.019). Furthermore, the rate of polyrecurrence was higher in Group I than in Group D (34.4% vs. 14.3%, p = 0.009). Recurrence-free survival (RFS) was significantly worse in Group I than in Group D (median survival time, 21.2 months vs. 36.7 months, p = 0.015). Multivariate analysis revealed that lymphatic vessel infiltration (hazard ratio [HR], 1.721; 95% CI 1.069-2.772; p = 0.026), blood vessel infiltration (HR, 2.348; 95% CI 1.385-3.982; p = 0.002), advanced pathological stage (≥ III) (HR, 3.937; 95% CI 2.295-6.754; p < 0.001), and increased s-p53-Abs titers (HR, 2.635; 95% CI 1.488-4.667; p = 0.001) were independent predictors of poor RFS.

CONCLUSIONS

Elevation of s-p53-Abs titers after esophagectomy can predict polyrecurrence in distant organs and poor prognosis.

Using a multistep approach with multidisciplinary team to increase the diagnosis rate of Lynch syndrome-associated colorectal cancer after universal screening: a single-center study in Japan

BACKGROUNDS

This study aimed to evaluate the changes in the rates of genetic counseling and genetic testing as well as the diagnosis rate of Lynch syndrome (LS)-associated colorectal cancer before and after multistep approach with multidisciplinary team in Japanese.

METHODS

In September 2016, we started universal screening for LS by mismatch repair protein immunohistochemistry and prospectively collected the records. Following patient interviews, we started multistep approach with multidisciplinary team (MA) in January 2020. MA consists of six surgeons, one genetic counselor, one medical geneticist, and six pathologists. MA is set up to compensate for patients' lack of knowledge about genetic diseases and make case selection for elderly colorectal cancer patients with deficient mismatch repair (dMMR). MA is designed as a system that could be performed by a small number of medical genetic specialists. A total of 522 patients were included during the study duration, 323 and 199 patients in the pre-MA (P-MA) and MA groups, respectively.

RESULTS

The frequency of dMMR in all patients was 10.0%. The patient interview results indicated a significant lack of patient education regarding genetic diseases. The rates of genetic counseling and genetic testing was significantly higher in MA group than in P-MA group (genetic counseling: MA 34.6% vs. P-MA 7.7%, p = 0.04; genetic testing: MA 30.8% vs. P-MA 3.8%, p = 0.02). Moreover, the diagnosis rate of LS-associated colorectal cancer was significantly higher in MA group (2.5%) than in P-MA group (0.3%) (P = 0.03). In addition, MA could be performed without problems despite the small number of medical and human genetics specialists.

CONCLUSIONS

MA has achieved appropriate pickup of suspected hereditary colorectal cancer patients and complemented the lack of knowledge about genetic diseases. The introduction of MA increased LS-associated colorectal cancer after universal screening. MA is an appropriate LS screening protocol for Japanese patients who lag behind in medical and human genetics education.

What is the best reconstruction procedure after esophagectomy? A meta-analysis comparing posterior mediastinal and retrosternal approaches

Thoracic esophagectomy is a particularly invasive and complicated surgical procedure, with a reconstruction of the gastrointestinal tract, such as the stomach, jejunum, or colon. The posterior mediastinal, retrosternal, and subcutaneous routes are the three possible esophageal reconstruction routes. Each route has advantages and disadvantages, and the optimal reconstruction route after esophagectomy remains controversial. Additionally, the best anastomotic techniques after esophagectomy in terms of location (Ivor Lewis or McKeown) and suturing (manual or mechanical) are debatable. Our meta-analysis investigating postoperative complications after esophagectomy between the posterior mediastinal and retrosternal routes revealed that the posterior mediastinal route was associated with a significantly lower anastomotic leakage rate than the retrosternal route (odds ratio = 0.78, 95% confidence interval: 0.70-0.87, p < 0.0001). Conversely, pulmonary complications (odds ratio = 0.80, 95% confidence interval: 0.58-1.11, p = 0.19) and mortality between the posterior mediastinal and retrosternal routes (odds ratio = 0.79, 95% confidence interval: 0.56-1.12, p = 0.19) were not significantly different. However, the incidence of pneumonia may be lower when using the retrosternal route rather than the posterior mediastinal route for performing minimally invasive esophagectomy. The McKeown procedure is oncologically necessary for tumors located above the carina to dissect upper mediastinal and cervical lymph nodes; however, the Ivor Lewis procedure offers perioperative and oncological safety for tumors located under the carina. An individualized treatment strategy for selecting the optimal reconstruction procedure can be proposed in future studies based on oncological and patient risk factors considering mid- to long-term quality of life.

Episodic transient deformation revealed by the analysis of multiple GNSS networks in the Noto Peninsula, central Japan

Since November 30, 2020, an intense seismic swarm and transient deformation have been continuously observed in the Noto Peninsula, central Japan, which is a non-volcanic/geothermal area far from major plate boundaries. We modeled transient deformation based on a combined analysis of multiple Global Navigation Satellite System (GNSS) observation networks, including one operated by a private sector company (SoftBank Corp.), relocated earthquake hypocenters, and tectonic settings. Our analysis showed a total displacement pattern over 2 years shows horizontal inflation and uplift of up to ~ 70 mm around the source of the earthquake swarm. In the first 3 months, the opening of the shallow-dipping tensile crack had an estimated volumetric increase of ~ 1.4 × 10⁷ m³ at a depth of ~ 16 km. Over the next 15 months, the observed deformation was well reproduced by shear-tensile sources, which represent an aseismic reverse-type slip and the opening of a southeast-dipping fault zone at a depth of 14-16 km. We suggest that the upwelling fluid spread at a depth of ~ 16 km through an existing shallow-dipping permeable fault zone and then diffused into the fault zone, triggering a long-lasting sub-meter aseismic slip below the seismogenic depth. The aseismic slip further triggered intense earthquake swarms at the updip.

Phosphatidylcholine in bile-derived small extracellular vesicles as a novel biomarker of cholangiocarcinoma

BACKGROUND

Owing to the lack of definite diagnostic modalities, it is challenging to distinguish malignant cases of cholangiocarcinoma (CCA), which often causes biliary tract obstruction, from benign ones. Here, we investigated a novel lipid biomarker of CCA in bile-derived small extracellular vesicles (sEVs) and developed a simple detection method for clinical application.

METHODS

Bile samples from seven patients with malignant diseases (hilar CCA = 4, distal CCA = 3) and eight patients with benign diseases (gallstones = 6, primary sclerosing cholangitis = 1, autoimmune pancreatitis = 1) were collected through a nasal biliary drainage tube. sEVs were isolated via serial ultracentrifugation and characterized using nanoparticle tracking analysis, transmission electron microscopy, and immunoblotting (with CD9, CD63, CD81, and TSG101). Comprehensive lipidomic analysis was performed using liquid chromatography-tandem mass spectrometry. Using a measurement kit, we further confirmed whether lipid concentrations could be used as a potential CCA marker.

RESULTS

Lipidomic analysis of bile sEVs in the two groups identified 209 significantly increased lipid species in the malignant group. When focusing on lipid class, phosphatidylcholine (PC) level was 4.98-fold higher in the malignant group than in the benign group (P = 0.037). The receiver operating characteristic (ROC) curve showed a sensitivity of 71.4%, a specificity of 100%, and an area under the curve (AUC) of 0.857 (95% confidence interval [CI]:0.643-1.000). Using a PC assay kit, the ROC curve showed a cutoff value of 16.1 μg/mL, a sensitivity of 71.4%, a specificity of 100%, and an AUC of 0.839 (95% CI: 0.620-1.000).

CONCLUSION

PC level in sEVs from human bile is a potential diagnostic marker for CCA and can be assessed by a commercially available assay kit.

Long-term Prognostic Impact of Metachronous Rectal Cancer in Patients With Familial Adenomatous Polyposis: A Single-center Retrospective Study

AIM

To evaluate the risk factors and long-term prognosis of metachronous rectal cancer in the remnant rectum of patients with familial adenomatous polyposis (FAP).

PATIENTS AND METHODS

Sixty-five patients (49 families) who underwent prophylactic surgery, including bowel resection, for FAP between January 1976 and August 2022 at Hamamatsu University Hospital were included and divided into two groups based on the presence of metachronous rectal cancer. Risk factors for metachronous rectal cancer development were analysed in cases treated with total colectomy with ileorectal anastomosis (IRA) and stapled total proctocolectomy with ileal pouch anal anastomosis (IPAA) (IRA, n=22; stapled IPAA n=20; total, n=42).

RESULTS

The median surveillance period was 169 months. Twelve patients developed metachronous rectal cancer (IRA, n=5; stapled IPAA, n=7), of which six with advanced cancer died. Patients who temporarily dropped out of surveillance were significantly more likely to have metachronous rectal cancer (metachronous vs. non-metachronous rectal cancer: 33.3% vs. 1.9%, p<0.01). The mean duration of surveillance suspension was 87.8 months. Cox regression analysis revealed that temporary surveillance drop-out independently affected the risk (p=0.04). The overall survival associated with metachronous rectal cancer was 83.3% at 1 year and 41.7% at 5 years. Overall survival was significantly worse in advanced cancer than in early cancer cases (p<0.01).

CONCLUSION

Temporary drop-out from surveillance was a risk factor for metachronous rectal cancer development, and advanced cancer had a poor prognosis. Continuous surveillance of patients with FAP, without temporary drop-out, is strongly recommended.

Analysis of external pressure on the left calf in the Lloyd-Davies position during colorectal surgery

PURPOSE

Well-leg compartment syndrome (WLCS) is a potentially life-threatening postoperative complication related to the Lloyd-Davies surgical position, which can place increased external pressure on the calf region. We conducted this study to analyze external pressure changes, by applying a leg holder system to the left calf region of patients placed in the Lloyd-Davies position during laparoscopic surgery.

METHODS

The study participants were 50 patients who underwent laparoscopic surgery for colorectal cancer in the Lloyd-Davies position. We assessed the maximum external pressure (MEP) on the left calf region using a pressure-distribution measurement system. Intraoperative measurements were taken continuously, and the MEP was evaluated with the patient horizontal and every 30 min during surgery in the head and right-down tilt position.

RESULTS

The intraoperative MEP increased gradually when the patient was in the head and right-down tilt position and decreased when the patient was returned to the horizontal position. The MEP was higher in patients aged < 60 years, those who were obese, and those with a thick calf circumference. Both body mass index (BMI) and the maximum left calf circumference (MLCC) were found to correlate with the MEP.

CONCLUSIONS

In addition to a high BMI, which is a well-known risk factor for WLCS, a high MLCC should be considered another risk factor, especially for patients under 60 years.

Refractory postoperative Staphylococcus hominis bacteremia in a patient with an ACTH-producing pancreatic neuroendocrine neoplasm: a case report

Background

Staphylococcus hominis (S. hominis) is an opportunistic pathogen that is often highly resistant to antibiotics and is difficult to treat. In patients diagnosed with an adrenocorticotropic hormone (ACTH)-producing tumor that compromises the immune system due to hypercortisolemia, cancer treatment and infection control should be considered simultaneously. This report presents a case of refractory postoperative S. hominis bacteremia requiring the prolonged administration of several antibiotics in a patient with an ACTH-producing pancreatic neuroendocrine neoplasm (pNEN).

Case presentation

A 35-year-old man visited a neighboring hospital for a thorough examination after experiencing weight gain and lower limb weakness for several months. Enhanced computed tomography revealed a pancreatic tail tumor and bilateral adrenal enlargement. Elevated plasma ACTH and serum cortisol were noted. Biopsy under endoscopic ultrasonography revealed the tumor as an ACTH-producing pNEN. The patient was transferred to our hospital for further treatment. Pneumocystis pneumonia was noted and treated with sulfamethoxazole and adjunctive glucocorticoids. Hypercortisolism was controlled with metyrapone and trilostane. Somatostatin receptor scintigraphy and ethoxybenzyl magnetic resonance imaging detected other lesions in the pancreatic head. A total pancreatectomy was performed given that the lesions were found in both the pancreatic head and tail. Plasma ACTH and serum cortisol levels decreased immediately after the resection. Pathological examination revealed that the pancreatic tail tumor was NEN G2 and T3N1aM0 Stage IIB and the pancreatic head lesions were SSTR-positive hyperplasia of the islet of Langerhans cells. On postoperative day 11, catheter-associated bacteremia occurred. Initially, meropenem hydrate and vancomycin hydrochloride were administered empirically. S. hominis was identified and appeared sensitive to these antibiotics according to susceptibility testing. However, S. hominis was repeatedly positive in blood cultures for more than one month, despite treatment with several antibiotics. Eventually, with the combined use of three antibiotics (meropenem hydrate, vancomycin hydrochloride, and clindamycin phosphate) for more than 3 weeks, the S. hominis-associated bacteremia improved. He was discharged 79 days after surgery.

Conclusions

Our patient with an ACTH-producing pNEN was immunocompromised and needed meticulous attention for infectious complications even after successful tumor removal. Specifically, S. hominis bacteremia in such patients demands intensive treatments, such as with combinational antibiotics.

Anterior superior pancreaticoduodenal artery pseudoaneurysm after distal pancreatectomy with en bloc celiac axis resection successfully treated with balloon-assisted coil embolization

Bleeding is a fatal complication after pancreatectomy. Although coil embolization is a widely accepted treatment option, ischemia of the remaining organs should be prevented. This study reports the successful treatment of intra-abdominal hemorrhage following distal pancreatectomy with en bloc celiac axis resection (DP-CAR) using balloon-assisted coil embolization (BACE). A 59-year-old man was diagnosed with locally advanced pancreatic cancer. The tumor involves the common hepatic artery, splenic artery, and celiac artery. After four cycles of treatment with gemcitabine/nab-paclitaxel, the soft-density masses, surrounding the artery, shrunk. DP-CAR and R0 resections were performed. A minor postoperative pancreatic fistula occurred. Six months postoperatively, the computed tomography showed delayed asymptomatic bleeding from an anterior superior pancreaticoduodenal artery (ASPDA) pseudoaneurysm located near the gastroduodenal artery confluence. BACE was performed by placing a microballoon catheter in the region of confluence of the ASPDA and posterior superior pancreaticoduodenal artery (PSPDA) to prevent coil migration. After inserting the microballoon catheter, coil embolization was performed in the ASPDA. Hepatic blood flow was maintained from the PSPDA. BACE is a useful technique to preserve blood flow to the remnant organs when performing coil embolization for bleeding following a distal pancreatectomy, especially following a DP-CAR.

Artificial intelligence-based classification of peripheral blood nucleated cells using label-free imaging flow cytometry

Label-free image identification of circulating rare cells, such as circulating tumor cells within peripheral blood nucleated cells (PBNCs), the vast majority of which are white blood cells (WBCs), remains challenging. We previously described developing label-free image cytometry for classifying live cells using computer vision technology for pattern recognition, based on the subcellular structure of the quantitative phase microscopy images. We applied our image recognition methods to cells flowing in a flow cytometer microfluidic channel, and differentiated WBCs from cancer cell lines (area under receiver operating characteristic curve = 0.957). We then applied this method to healthy volunteers' and advanced cancer patients' blood samples and found that the non-WBC fraction rates (NWBC-FRs), defined as the percentage of cells classified as non-WBCs of the total PBNCs, were significantly higher in cancer patients than in healthy volunteers. Furthermore, we monitored NWBC-FRs over the therapeutic courses in cancer patients, which revealed the potential ability in monitoring the clinical status during therapy. Our image recognition system has the potential to provide a morphological diagnostic tool for circulating rare cells as non-WBC fractions.

Saturated Fatty Acids in Cell Membrane Lipids Induce Resistance to 5-Fluorouracil in Colorectal Cancer Cells

BACKGROUND/AIM

Resistance to chemotherapy is a major obstacle for patients with unresectable colorectal cancer (CRC); however, the factors that induce chemoresistance have not been elucidated. Lipid composition influences neoplastic behaviour. Therefore, this study examined whether lipid composition affects sensitivity to chemotherapeutic agents in CRC.

MATERIALS AND METHODS

We performed a lipidomic analysis of a CRC xenograft-derived spheroid model to identify potential relationships between the lipid profile and chemoresistance to 5-fluorouracil (5-FU). Genetic and pharmacological modulation of lipid synthesis were also used in the HCT-116 and DLD-1 CRC cell lines to further characterize resistance to 5-FU.

RESULTS

Our lipidomic profiling revealed that phospholipids with saturated fatty acids (SFAs) were more abundant in 5-FU-resistant spheroids. The importance of phospholipids containing SFA in chemoresistance was confirmed by showing that in HCT-116 and DLD-1 cells, genetic or pharmacological inactivation of stearoyl-CoA desaturase-1, a key enzyme that converts SFAs to monounsaturated fatty acids, increased the proportion of SFAs in membranous phospholipids and reduced cell membrane fluidity, and this ultimately resulted in resistance to 5-FU.

CONCLUSION

These data suggest that the saturated to monounsaturated fatty acid ratio in cellular membranous phospholipids affects sensitivity to chemotherapeutic agents.

Usefulness of Procalcitonin as a Predictor of Long-Term Prognosis in the Early Postoperative Period after Esophagectomy for Esophageal Cancer

The aim of this study was to investigate the relationship between serum procalcitonin (PCT) levels after esophagectomy and infectious complications and long-term prognosis. A total of 105 patients who underwent esophagectomy between 2012 and 2019 were stratified into two groups: PCT-High group of ≥1 ng/mL and PCT-Low group of <1 ng/mL. The clinical outcomes and prognostic factors were compared between the two groups 2 postoperative days (POD), 4 POD, and 7 POD after esophagectomy. As the postoperative days passed, the association between PCT and infectious complications became stronger, and the positive predictive value was 100% at 7 POD. At 2 POD, there was no significant association between PCT elevation and infectious complications. Patients in the PCT-Low group had significantly worse overall survival (OS) and recurrence-free survival (RFS) than those in the PCT-High group at 2 POD (p = 0.026 and p = 0.011, respectively). In multivariate analysis, advanced pathological stage (hazard ratio (HR), 5.348; 95% confidence interval (CI), 2.299−12.500; p < 0.001) and PCT-Low group at 2 POD (HR, 3.673; 95% CI, 1.116−12.092; p = 0.032) were also independent predictors of worse OS. PCT in the early postoperative period after esophagectomy could be a good predictor of prognosis.

Neutrophil-to-Lymphocyte Ratio to Predict the Efficacy of Immune Checkpoint Inhibitor in Upper Gastrointestinal Cancer

BACKGROUND/AIM

Although the effectiveness of immune checkpoint inhibitors (ICIs) in upper gastrointestinal (UGI) cancer including esophageal squamous cell carcinoma (ESCC) and gastric/gastroesophageal adenocarcinoma (GEA) has been proven, prediction of their efficacy remains unknown. This study aimed to develop optimal serum nutritional indicators or a combination of blood cell components to predict the efficacy of ICI before beginning UGI cancer treatment.

PATIENTS AND METHODS

We retrospectively reviewed the data of 61 UGI cancers (31 ESCC and 30 GEA) patients treated with nivolumab or pembrolizumab. We investigated the impact of serum albumin level, total lymphocyte count (TLC), prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and lymphocyte-to-monocyte ratio (LMR) on the efficacy of ICIs and long-term survival. The median cutoff value was adopted separately in ESCC and GEA.

RESULTS

NLR-Low was significantly correlated with better overall survival (p=0.014), and PLR-Low was significantly correlated with improved disease control rate and better progression-free survival in UGI cancer patients. Both results indicate that a better prognosis is correlated to a greater number of lymphocytes. Multivariate analysis revealed that NLR-High [hazard ratio (HR)=2.865; 95% confidence interval (CI)=1.030-7.937; p=0.044] was the only independent poor prognostic factor.

CONCLUSION

NLR-Low has the potential to predict the good efficacy of ICIs and survival outcomes in patients with UGI cancer. NLR could be useful in determining the optimal treatment strategies for these patients.

Comparison of operative outcomes between monopolar and bipolar coagulation in hepatectomy: a propensity score-matched analysis in a single center

Background

Various hemostatic devices have been utilized to reduce blood loss during hepatectomy. Nonetheless, a comparison between monopolar and bipolar coagulation, particularly their usefulness or inferiority, has been poorly documented. The aim of this study is to reveal the characteristics of these hemostatic devices.

Methods

A total of 264 patients who underwent open hepatectomy at our institution from January 2009 to December 2018 were included. Monopolar and bipolar hemostatic devices were used in 160 (monopolar group) and 104 (bipolar group) cases, respectively. Operative outcomes and thermal damage to the resected specimens were compared between these groups using propensity score matching according to background factors. Multivariate logistic regression analysis was performed to identify predictive factors for postoperative complications.

Results

After propensity score matching, 73 patients per group were enrolled. The monopolar group had significantly lower total operative time (239 vs. 275 min; P = 0.013) and intraoperative blood loss (487 vs. 790 mL; P < 0.001). However, the incidence rates of ascites (27.4% vs. 8.2%; P = 0.002) and grade ≥ 3 intra-abdominal infection (12.3% vs. 2.7%; P = 0.028) were significantly higher in the monopolar group. Thermal damage to the resected specimens was significantly longer in the monopolar group (4.6 vs. 1.2 mm; P < 0.001). Use of monopolar hemostatic device was an independent risk factor for ascites (odds ratio, 5.626, 95% confidence interval 1.881–16.827; P = 0.002) and severe intra-abdominal infection (odds ratio, 5.905, 95% confidence interval 1.096–31.825; P = 0.039).

Conclusions

Although monopolar devices have an excellent hemostatic ability, they might damage the remnant liver. The use of monopolar devices can be one of the factors that increase the frequency of complications.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02231-y.

Development and Validation of the Optimal Circumferential Resection Margin in Pathological T3 Esophageal Cancer: A Multicenter, Retrospective Study

BACKGROUND

The clinical significance of circumferential resection margin (CRM) in esophageal squamous cell carcinoma (ESCC) remains unclear. Optimal CRM for predicting the recurrence of pathological T3 ESCC was investigated.

METHODS

Seventy-three patients were retrospectively investigated in the development cohort. Patients were divided into CRM-negative and CRM-positive groups, and clinicopathological factors and survival outcomes were compared between the groups. The cutoff value was validated in another validation cohort (n = 99).

RESULTS

Receiver operating characteristic analysis in the development cohort showed the cutoff value of CRM was 600 μm. In the validation cohort, patients in the CRM-positive group showed a significantly higher rate of locoregional recurrence (p = 0.006) and worse recurrence-free survival (RFS) (p < 0.001) than those in the CRM-negative group. Multivariate analysis identified positive CRM as an independent predictive factor for poor RFS (hazard ratio, 2.695; 95% confidence interval, 1.492-4.867; p = 0.001). The predictive value of our criteria of positive CRM for RFS was higher than that of the Royal College of Pathologists (RCP) and the College of American Pathologists (CAP) criteria. Stratified analysis in the neoadjuvant chemotherapy groups also revealed that the rate of locoregional recurrence was higher in the CRM-positive group than in the CRM-negative group both in the pathological N0 and N1-3 subgroups.

CONCLUSIONS

CRM of 600 μm can be the optimal cutoff value rather than the RCP and CAP criteria for predicting locoregional recurrence after esophagectomy. These results may support the impact of perioperative locoregional control of locally advanced ESCC.

Survival impact of perioperative changes in prognostic nutritional index levels after esophagectomy

BACKGROUND

The correlation between perioperative changes in nutritional status during esophagectomy and prognosis remains unclear. This study aimed to evaluate the impact of changes in prognostic nutritional index levels during the perioperative period on esophageal cancer patient survivals.

METHODS

From January 2009 to May 2019, 158 patients with esophageal squamous cell carcinoma were enrolled. From the time-dependent ROC analysis, the cutoff values of preoperative and postoperative prognostic nutritional index levels were 46.9 and 40.9. Patients were divided into preoperative-high group (Group H) and preoperative-low group (Group L). Then, patients in Group L were divided into preoperative-low and postoperative-high group (Group L-H) and preoperative-low and postoperative-low group (Group L-L). Long-term outcomes and prognostic factors were evaluated.

RESULTS

Patients in Group L had significantly worse overall survival than those in Group H (p = 0.001). Patients in Group L-L had significantly worse overall survival than those in Group L-H (p = 0.023). However, there was no significant difference in overall survival between Groups H and L-H (p = 0.224). In multivariable analysis, advanced pathological stage (hazard ratio 10.947, 95% confidence interval 2.590-46.268, p = 0.001) and Group L-L (hazard ratio 2.171, 95% confidence interval 1.249-3.775, p = 0.006) were independent predictors of poor overall survival.

CONCLUSIONS

Patients in Group L-H had a good prognosis, similar to those in Group H. This result indicated that increasing the postoperative prognostic nutritional index level sufficiently using various intensive perioperative support methods could improve prognosis after esophagectomy in patients with poor preoperative nutritional status.

Usefulness of wearable fitness tracking devices in patients undergoing esophagectomy

BACKGROUND

Esophageal cancer surgery requires maintenance and enhancement of perioperative nutritional status and physical function to prevent postoperative complications. Therefore, awareness of the importance of preoperative patient support is increasing. This study examined the usefulness of using a diary in combination with a wearable fitness tracking device (WFT) in patients undergoing surgery for esophageal cancer.

METHODS

Ninety-four patients who underwent esophagectomy between February 2019 and April 2021 were included. Physicians, nurses, dietitians, and physical therapists provided diary-based education for the patients. In addition, a WFT was used by some patients. The perioperative outcomes of patients who used both the diary and WFT (WFT group) and those who used the diary alone (non-WFT group) were compared. In addition, propensity score matching was performed to improve comparability between the two groups.

RESULTS

After the propensity score matching, the rate of postoperative pneumonia was significantly lower in the WFT group (0% vs. 22.6%, P = 0.005). The postoperative hospital stay was shorter in the WFT group (P = 0.012). Nutritional status indices, such as the prognostic nutritional index, also improved significantly in the WFT group at 1 month after surgery (P = 0.034). The rate of diary entries was significantly higher in the WFT group (72.3% vs. 28.3%, P < 0.001).

CONCLUSION

The use of a WFT reduced the incidence of postoperative pneumonia and improved postoperative nutritional status and rates of diary entries after esophagectomy, suggesting that its use may be useful for promoting recovery after esophagectomy.

Function-Preserving Gastrectomy for Early Gastric Cancer

Simple Summary

For patients with early gastric cancer (EGC), a good prognosis is achieved by conventional standard gastrectomy with radical lymphadenectomy. However, postgastrectomy syndrome is often inevitable and results in decreased quality of life (QOL). To improve patients’ QOL, proximal gastrectomy instead of total gastrectomy and pylorus-preserving gastrectomy instead of distal gastrectomy have been widely accepted as function-preserving gastrectomies. Recently, personalized, minimized gastrectomy with sentinel node navigation surgery has been developed and is expected to be an ideal treatment option for patients with EGC. Herein, we review the indications, surgical techniques, and postoperative outcomes of function-preserving gastrectomy.

Abstract

Recently, minimally invasive (endoscopic or laparoscopic) treatment for early gastric cancer (EGC) has been widely accepted. However, a standard gastrectomy with radical lymphadenectomy is generally performed in patients with EGC who have no indications for endoscopic resection, and postgastrectomy dysfunction is one of the problems of standard gastrectomy. Function-preserving gastrectomy, such as proximal gastrectomy and pylorus-preserving gastrectomy, can be considered when attempting to preserve the patient’s quality of life (QOL) postoperatively. In addition, sentinel node navigation surgery for EGC has been applied in clinical practice in several prospective studies on function-preserving personalized minimized gastrectomy. In the near future, the sentinel lymph node concept is expected to form the basis for establishing an ideal, personalized, minimally invasive function-preserving treatment for patients with EGC, which will improve their postoperative QOL without compromising their long-term survival. In this review article, we summarize the current status, surgical techniques, and postoperative outcomes of function-preserving gastrectomy for EGC.

The Impact of Infectious Complications after Esophagectomy for Esophageal Cancer on Cancer Prognosis and Treatment Strategy

Despite advances in the perioperative management of esophagectomy, it is still a highly invasive procedure for esophageal cancer and is associated with severe postoperative complications. The two major postoperative infectious complications after esophagectomy are pulmonary complications and anastomotic leakage. We previously reported that postoperative infectious complications after esophagectomy adversely affect long-term survival significantly in a single institution and meta-analysis. Additionally, we reviewed the mechanisms of proinflammatory cytokines, such as C-X-C motif ligand 8 (CXCL8) and its cognate receptor, C-X-C chemokine receptor 2 (CXCR2), in contributing to tumorigenesis and tumor progression. Moreover, we previously reported that introducing minimally invasive esophagectomy, including robot assistance, laparoscopic gastric mobilization, and multidisciplinary team management, significantly reduced postoperative infectious complications after esophagectomy. Further, this review also suggests future treatment strategies for esophageal cancer, considering the adverse effect of postoperative infectious complications after esophagectomy.

Favorable clinical response and drug retention of anti-IL-6 receptor inhibitor in rheumatoid arthritis with high CRP levels: the ANSWER cohort study

OBJECTIVE

Currently, biological disease-modifying anti-rheumatic drugs (bDMARDs) with different modes of action [tumour necrosis factor inhibitor (TNFi), interleukin-6 receptor inhibitor (IL-6Ri), or cytotoxic T-lymphocyte antigen 4-immunoglobulin (CTLA4-Ig)] are used in clinical practice to treat rheumatoid arthritis (RA). However, it is unclear which type of bDMARD is the most efficacious for a specific clinical situation. C-reactive protein (CRP) is an acute-phase reactant driven by IL-6 signalling. Here, we aimed to establish whether therapeutic efficacy differs between IL-6Ri and other bDMARDs with alternative modes of action in RA patients according to their CRP level.

METHOD

RA patients treated with bDMARDs were enrolled from an observational multicentre registry in Japan. Patients were classified into three groups according to baseline CRP tertiles. The overall 3 year retention rates of each bDMARD category were assessed. The Clinical Disease Activity Index (CDAI) was also assessed before and 3, 6, and 12 months after bDMARD initiation.

RESULTS

A total of 1438 RA patients were included and classified into three groups according to tertiles of baseline CRP levels (CRP¹, 0-0.3; CRP², 0.3-1.8; CRP³, 1.8-18.4 mg/dL). In CRP³, the overall 3 year drug retention rates were significantly higher for IL-6Ri than for TNFi and CTLA4-Ig (77.5 vs 48.2 vs 67.3, respectively). No significant difference was evident in terms of CDAI 12 months after bDMARD initiation in CRP¹-CRP³.

CONCLUSION

IL-6Ri may be a favourable therapeutic option over TNFi and CTLA4-Ig in RA patients with high CRP levels.

Short-term Outcomes of Robot-assisted Minimally Invasive Esophagectomy Compared With Thoracoscopic or Transthoracic Esophagectomy

BACKGROUND/AIM

There is no study comparing open esophagectomy (OE), video-assisted thoracic surgery (VATS), and robot-assisted minimally invasive esophagectomy (RAMIE) in a single institution.

PATIENTS AND METHODS

This study included 272 patients who underwent subtotal esophagectomy divided into three groups: OE (n=110), VATS (n=127), and RAMIE (n=35) groups. Moreover, short-term outcomes were compared.

RESULTS

Overall complications (CD≥II) were significantly less in the RAMIE than the OE and VATS groups. Recurrent laryngeal nerve paralysis (CD≥II) was significantly lower in the RAMIE than the OE group (p=0.026) and tended to be lower than that in the VATS group (p=0.059). The RAMIE group had significantly less atelectasis (CD≥I and II), pleural effusion (CD≥I and II), arrhythmia (CD≥II), and dysphagia (CD≥II), than both the OE and VATS groups.

CONCLUSION

RAMIE reduced overall postoperative complications after esophagectomy compared with both OE and VATS.

Significance of the Glasgow prognostic score for short-term surgical outcomes: A nationwide survey using the Japanese National Clinical Database

AIM

Preoperative inflammation-based Glasgow prognostic score (GPS) is a useful tool for predicting long-term prognosis in cancer patients. However, its association with postoperative short-term outcomes remains unknown. The aim of this study is to investigate the association between GPS and postoperative morbidity and mortality among patients undergoing surgery for various gastrointestinal malignancies.

METHODS

Using the Japanese National Clinical Database, we analyzed the records of 312 357 patients with gastrointestinal malignancy who underwent six typical elective surgeries, including esophagectomy, distal gastrectomy, total gastrectomy, right hemicolectomy, low anterior resection, and pancreaticoduodenectomy, between January 2015 and December 2018. We assigned GPS of 0, 1, or 2 to patients with no, one, or both decreased albumin and elevated C-reactive protein levels, respectively. We investigated the relationship of GPS with operative morbidity and mortality for each procedure with adjustments for patients' demographics, preoperative status, comorbidities, and cancer stages.

RESULTS

Crude operative morbidity was significantly higher for GPS 1 and 2 than GPS 0 patients in all procedures except pancreaticoduodenectomy. The postoperative length of hospital stay was significantly longer for GPS 1 and 2 patients in all procedures (P < .001). Operative mortality was also higher for GPS 1 and 2 patients in all procedures. The associations remained significant after adjustments for potential confounders of age, sex, physical status, tumor classification, use of preoperative therapy, and comorbidities.

CONCLUSION

This nationwide study provides solid evidence on the strong association between GPS and postoperative outcomes.

Impact of Immune-related Adverse Events on Nivolumab Efficacy in Patients With Upper Gastrointestinal Cancer

BACKGROUND

The development of immune-related adverse events (irAEs) has been found to be associated with survival benefits in some cancers. However, data on the relation between irAEs and gastroesophageal adenocarcinoma (GEA) or esophageal squamous cell carcinoma (ESCC) are scarce.

PATIENTS AND METHODS

We retrospectively reviewed the data of 29 GEA and 21 ESCC patients treated with nivolumab. We investigated the impact of the development of irAEs in GEA and ESCC patients on best overall response and survival.

RESULTS

Patients with irAEs had significantly better best overall response, overall survival and progression-free survival than those without irAEs (p=0.007, p<0.001 and p=0.005, respectively). Multivariate analyses identified an Eastern Cooperative Oncology Group performance status ≥2 and the absence of an irAE as independent poor prognostic factors (p<0.001 and 0.016, respectively).

CONCLUSION

The development of irAEs has the potential to predict survival outcomes in patients with GEA and ESCC treated with nivolumab.

Usefulness of a finger-mounted tissue oximeter with near-infrared spectroscopy for evaluating the intestinal oxygenation and viability in rats

PURPOSE

To investigate the utility of the device for evaluating intestinal oxygenation and viability using an animal model.

METHODS

Sprague-Dawley rats underwent laparotomy under general anesthesia, and the blood vessels in the terminal ileum were clamped to create ischemia. We measured the regional tissue oxygenation saturation (rSO2) using an oximeter after 1, 3, and 6 h of vessel clamping. Ischemic tissue damage was assessed using a histological score. The intestine was reperfused after each clamping period, and intestinal rSO2 and survival rate were evaluated.

RESULTS

When reperfusion was performed at 1 and 3 h after ischemia, rSO2 increased after 10 min, and it improved to the same level as for normal intestine after 1 h; all rats survived for 1 week. In contrast, after 6 h of ischemia, rSO2 did not increase after reperfusion, and all animals died within 2 days. The histological scores increased after 1 h of reperfusion, with longer clamping periods.

CONCLUSION

A finger-mounted tissue oximeter could evaluate intestinal ischemia and the viability, which is thus considered to be a promising result for future clinical application.

Comprehensive strategy for perioperative care of pancreaticoduodenectomy according to the risk stratification by pancreatic fistula and delayed gastric emptying

BACKGROUND/OBJECTIVE

Pancreaticoduodenectomy (PD) is highly invasive with unsatisfactory postoperative complication rates. Nutritional and fluid management after major surgery attracts much attention with regard to the reduction in severe postoperative complications. We retrospectively analyzed PD cases and proposed a novel strategy for perioperative fluid and nutritional therapy according to the risk stratification by pancreatic fistula (PF) and delayed gastric emptying (DGE).

METHODS

Between 2003 and 2018, 140 patients underwent PD at our institute of which 134 patients were enrolled. We evaluated the clinicopathological factors affecting severe (≥10%) body weight loss (BWL), factors affecting the incidence of PF and intraabdominal complications (IAC), and factors related to DGE.

RESULTS

Multivariate analysis indicated that male sex, severe PF, and DGE are significant risk factors for BWL ≥10%. PF and IAC were predominantly observed in male patients and those with non-pancreatic cancer. A fluid balance ≥6000 ml on postoperative day 2 was the sole risk factor for primary DGE. Secondary DGE significantly correlated with stomach preserving PD. Importantly, the average BWL was around 15% in grade B or C secondary DGE.

CONCLUSION

Severe postoperative complications resulted in significant BWL. Enteral feeding is unnecessary in cases with a hard pancreas and dilated pancreatic duct if appropriate perioperative fluid management is performed. Secondary DGE followed by PF or IAC is unavoidable to some extent, especially in the case of soft pancreas with a fine pancreatic duct. In such cases, enteral feeding with tube ileostomy should be considered, and stomach preserving PD is likely to be harmful.

Risk Factors for Totally Implantable Central Venous Access Port-related Infection in Patients With Malignancy

BACKGROUND

We sought to identify the risk factors of totally implantable central venous access port (TICVAP)-related infections in patients with malignant disease.

PATIENTS AND METHODS

Overall, 324 consecutive patients who received a TICVAP at our institution were retrospectively analysed. We further analysed cases of TICVAP-related complications. The risk factors for TICVAP-related infection were investigated using Cox regression hazard models.

RESULTS

With a median TICVAP duration of 268 days (range=1-1,859 days), TICVAP-related complications were observed in 36 cases and infectious complications in late phase were the most common, seen in 19 cases (9.26%). A multivariate analysis showed that patients with head and neck malignancy (p<0.001) and patients who received TICVAP insertion in the upper arm (p<0.001) were independently at a higher risk for TICVAP-related infections.

CONCLUSION

Patients with head and neck malignancy or TICVAP insertion in the upper arm have potentially increased risk for late-phase TICVAP-related infections.

Ephrin Receptor A4 Expression Enhances Migration, Invasion and Neurotropism in Pancreatic Ductal Adenocarcinoma Cells

BACKGROUND/AIM

We sought to identify the mechanisms of perineural invasion in pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

We utilized in vitro cancer cell-nerve co-culture models comprising human PDAC cell lines (MIA Paca2 and PANC-1) and a dorsal root ganglion (DRG) isolated from neonatal mice. We compared gene expression profiles between cell lines with/without DRG conditioned medium (DRG-CM) using RNA-sequencing (RNA-seq).

RESULTS

Migration, invasion, and neurotropism were significantly enhanced in MIA Paca2 but not in PANC-1 cells co-cultured with DRGs. Among 285 genes which showed significant differences in expression levels between cell lines in RNA-seq, we focused on Ephrin receptor A4 (EPHA4), which was upregulated in MIA Paca2 cells treated with DRG-CM. The abilities of migration, invasion, and neurotropism enhanced by DRG co-culture were abolished when EPHA4 was knocked down by siRNA in MIA Paca2 cells.

CONCLUSION

EPHA4 can be a potential target gene to regulate perineural invasion in PDAC cells.

Evaluation of Definitive Chemoradiotherapy Versus Radical Esophagectomy in Clinical T1bN0M0 Esophageal Squamous Cell Carcinoma

BACKGROUND

The standard treatment for patients with clinical T1bN0M0 esophageal squamous cell carcinoma is radical esophagectomy. Definitive chemoradiotherapy is regarded as a treatment option, and recently, good clinical outcomes of this treatment have been reported. This study compared prognosis after definitive chemoradiotherapy with radical esophagectomy.

METHODS

From January 2011 to December 2019, 68 consecutive patients who were diagnosed clinical T1bN0M0 squamous cell carcinoma were enrolled and investigated retrospectively. Patients were classified into two groups whether treated by surgery or definitive chemoradiotherapy. Survival outcomes were compared, and subsequent therapies after recurrence were also investigated.

RESULTS

Among 68 patients, 39 patients underwent surgery and 29 patients received definitive chemoradiotherapy. No significant difference was noted in overall survival between the two groups. However, the rate of 5-year recurrence-free survival was significantly lower in definitive chemoradiotherapy group than that of surgery group (91.1 vs. 62.7%, hazard ratio 3.976, 95% confidence interval 1.076-14.696, p = 0.039). Patients who had local recurrence after definitive chemoradiotherapy received endoscopic submucosal dissection or photodynamic therapy as salvage therapies, which resulted in no disease progression and a good prognosis.

CONCLUSIONS

Definitive chemoradiotherapy may become a promising alternative therapy comparable with radical esophagectomy in patients with clinical T1bN0M0 esophageal squamous cell carcinoma. Early detection of recurrence by frequent follow-up after definitive chemoradiotherapy is important to control disease within local recurrence, and salvage therapy for local lesions could contribute to long-term survival.

Daikenchuto increases blood flow in the superior mesenteric artery in humans: A comparison study between four-dimensional phase-contrast vastly undersampled isotropic projection reconstruction magnetic resonance imaging and Doppler ultrasound

Respiratory-gated four-dimensional phase-contrast vastly undersampled isotropic projection reconstruction (4D PC-VIPR) is magnetic resonance (MR) imaging technique that enables analysis of vascular morphology and hemodynamics in a single examination using cardiac phase resolved 3D phase-contrast magnetic resonance imaging. The present study aimed to assess the usefulness of 4D PC-VIPR for the superior mesenteric artery (SMA) flowmetry before and after flow increase was induced by the herbal medicine Daikenchuto (TJ-100) by comparing it with Doppler ultrasound (DUS) as a current standard. Twenty healthy volunteers were enrolled in this prospective single-arm study. The peak cross-sectionally averaged velocity was measured by 4D PC-VIPR, peak velocity was measured by DUS, and flow volume (FV) of SMA and aorta were measured by 4D PC-VIPR and DUS 25 min before and after the peroral administration of TJ-100. The peak cross-sectionally averaged velocity, peak velocity, and FV of SMA measured by 4D PC-VIPR and DUS significantly increased after administration of TJ-100 (4D PC-VIPR: the peak cross-sectionally averaged velocity; p = 0.004, FV; p = 0.035, DUS: the peak velocity; p = 0.003, FV; p = 0.010). Furthermore, 4D PC-VIPR can analyze multiple blood vessels simultaneously. The ratio of the SMA FV to the aorta, before and after oral administration on the 4D PC-VIPR test also increased (p = 0.015). The rate of change assessed by 4D PC-VIPR and DUS were significantly correlated (the peak cross-sectionally averaged velocity and peak velocity: r = 0.650; p = 0.005, FV: r = 0.659; p = 0.004). Retrospective 4D PC-VIPR was a useful modality for morphological and hemodynamic analysis of SMA.

Successful laparoscopic approach for idiopathic adult colo-colonic intussusception: a case report

Background

Adult intussusception is recognized as an abdominal emergency. More than 90% of adult patients with intussusception have distinct causes that are related to benign or malignant tumors. In contrast, idiopathic intussusceptions, which are observed in children, are rare conditions in adult. Especially, colo-colonic idiopathic intussusceptions are rare among them. Surgery is traditionally considered the primary treatment option. Recently, laparoscopic surgery has been reported to be safe and feasible. However, laparoscopic surgical reduction, which is a common procedure in pediatric surgery, is not common in adult intussusception.

Case presentation

We report a 34-year-old man who presented with sudden abdominal pain. Computed tomography revealed the target sign in the transverse colon. There was no evidence of bowel obstruction, bowel wall edema, or tumor. We diagnosed idiopathic intussusception and selected laparoscopic procedure because of the strong abdominal pain experienced by the patient. There were no signs of perforation, bowel wall ischemia, or tumor in abdominal cavity. We confirmed idiopathic colo-colonic anterograde intussusception. Laparoscopic surgical reduction was achieved by a combination of delicate direct pressure on the anal side of the transverse colon and gentle pulling on the oral side. The patient’s postoperative course was uneventful.

Conclusions

We achieved successful surgical reduction laparoscopically because of an accurate preoperative diagnosis based on characteristic computed tomography features and appropriate surgical technique. Laparoscopic procedure and surgical reduction is considered to be an effective treatment strategy for adult idiopathic intussusceptions with severe symptoms.

Multimodal therapy with surgery and adjuvant nivolumab for late-onset multiple liver metastases of choroidal malignant melanoma: a case report

BACKGROUND

Choroidal malignant melanoma is the most common primary malignant tumor of the eye in adults. Prognosis after recurrence of this disease has been dismal because of the absence of an effective therapy. However, resection of recurrent foci and a subsequent treatment with immune-checkpoint inhibitor may improve the prognosis after recurrence of this disease. This study presents a case of late-onset liver metastases of choroidal malignant melanoma, successfully treated with hepatectomy and postoperative adjuvant nivolumab.

CASE PRESENTATION

A 53-year-old woman had undergone left ocular enucleation because of choroidal malignant melanoma 13 years prior to admission. She visited a nearby clinic with complaints of epigastric pain. She was referred to our hospital because a giant liver tumor was observed on abdominal ultrasonography. Enhanced computed tomography revealed multiple liver tumors in the right lobe, 49 mm in diameter with ring enhancement in subsegment (S) 5/6, and 14 and 8 mm without any enhancement in S7 and S5, respectively. On magnetic resonance imaging, the main tumor showed high intensity on T1-weighted with fat suppression, suggesting melanin deposition. Based on the diagnosis of multiple liver metastases of choroidal malignant melanoma, right hepatectomy and regional lymphadenectomy were performed. She was discharged without postoperative complications. Histological examination revealed that all tumors were metastatic malignant melanoma. She was treated with nivolumab postoperatively, and no recurrences were observed during 22 months of follow-up.

CONCLUSIONS

Aggressive surgery plus adjuvant nivolumab appears to be a promising treatment for choroidal malignant melanoma with late-onset liver metastases.

Aggressive Recurrent Pancreatic Cancer Producing Granulocyte Colony-Stimulating Factor

Granulocyte colony-stimulating factor (G-CSF) is a glycoprotein which stimulates the proliferation, differentiation, and functional activation of myeloid hematopoietic cells. G-CSF-producing pancreatic cancer is rare and its prognosis is strikingly poor. A 69-year-old woman with well-to-moderately differentiated ductal adenocarcinoma (pT3N0M0, stage IIA) underwent distal pancreatectomy and splenectomy. Postoperative adjuvant chemotherapy with S-1 was administered for 6 months. Eleven months after surgery, periodic blood examination revealed remarkable leukocytosis (19,120/µL) without fever, which worsened 3 weeks later (36,160/µL). Furthermore, laboratory data showed elevation of the fibrin degradation product-D dimer and that the G-CSF level was high (406 pg/mL), as well as thrombopenia. Multiple liver and lung metastases were detected by contrast-enhanced computed tomography (CT). The patient was treated with gemcitabine plus nab-paclitaxel, and heparin, thrombomodulin alfa, and platelet transfusion were administered concurrently. Leukocytosis and thrombopenia were alleviated after 1 course of chemotherapy. However, remarkable leukocytosis (53,480/µL) recurred on day 1 of the third course of chemotherapy. Contrast-enhanced CT showed a significantly increased number of liver metastases and lung metastases. The patient chose not to receive second-line chemotherapy and died 1 month later at the affiliated hospital. Pancreatic cancer producing G-CSF shows very aggressive behavior. Leukocytosis without infection during routine observation should be considered as a warning of a rapidly growing recurrence.

Postoperative chylothorax with a duplicated left-sided thoracic duct: a case report and review of the literature

Postoperative chylothorax is a potentially lethal complication after esophagectomy. A 53-year-old woman underwent subtotal esophagectomy. The thoracic duct was resected due to swollen lymph nodes. Postoperative chylothorax was diagnosed but conservative treatment was ineffective. Lipiodol lymphangiography revealed leakage from a duplicated left-sided thoracic duct. Left-sided video-assisted thoracoscopic ligation of the left-sided thoracic duct was performed. Because anatomical variations in the thoracic duct contribute to refractory chylothorax, lymphangiography is useful in detecting the position of thoracic duct injury as well as any duct anomalies. Based on lymphangiography, left-sided video-assisted thoracoscopic surgery could be considered in case of left-sided thoracic duct injury.

Usefulness of laparoscopic narrow-band imaging for the evaluation of therapeutic effects on peritoneal metastasis in gastric cancer

287

Background: As recent advances in chemotherapy improved prognosis of gastric cancer (GC) patients with peritoneal metastasis (PM), accurate diagnosis of PM has become more important. However, the sensitivity of conventional imaging modalities such as CT or PET is not satisfactory. Staging laparoscopy (SL) is often used to diagnose PM in advanced GC patients, but accurate detection of PM can be difficult. In this study, we evaluate the usefulness of laparoscopic narrow-band imaging (NBI) versus conventional laparoscopic white-light imaging (WLI) for the diagnosis of PM and for the evaluation of therapeutic effect of chemotherapy. Methods: We excised 54 white nodules from the parietal peritoneum of 40 GC patients. Among them, 9 patients received chemotherapy for advanced or recurrent GC before SL, and 31 did not receive chemotherapy except for adjuvant chemotherapy with S-1. The WLI and NBI findings were compared with the pathological findings. Results: Intranodular vessels were evaluated by WLI and NBI for dilatation, tortuousness, heterogeneity, and brown spots. Detection of any one abnormal finding on NBI plus clear demarcation of the peritoneal nodules on WLI more properly diagnosed 42 peritoneal nodules of 31 patients who did not receive chemotherapy (sensitivity, 100%; specificity, 88.9%; accuracy, 95.2%). In contrast, diagnosis ability was poor for 12 peritoneal nodules of 9 patients who received chemotherapy before SL (sensitivity, 66.7%; specificity, 33.3%; accuracy, 58.3%). Conclusions: Laparoscopic NBI is a useful tool for the diagnosis of PM in advanced GC before chemotherapy, and disappearance of dilated vessels on laparoscopic NBI could be useful to evaluate the therapeutic effect.

Multidisciplinary team management for prevention of pneumonia and long-term weight loss after esophagectomy: a single-center retrospective study

BACKGROUND

In April 2017, we launched the multidisciplinary Hamamatsu Perioperative Care Team (HOPE) for all surgical patients. We developed a reinforced intervention strategy, particularly for esophagectomy. We herein report the outcomes of the HOPE at 2 years after commencement.

METHODS

A total 125 patients underwent esophagectomy and gastric conduit reconstruction for esophageal or esophagogastric junction cancer between January 2014 and December 2018 at the Department of Surgery in Hamamatsu University School of Medicine. The patients were divided into the pre-HOPE group including 62 patients who underwent esophagectomy before the introduction of the HOPE and the HOPE group including 63 patients who underwent esophagectomy after the introduction of the HOPE. The outcomes of surgery were compared between the two groups.

RESULTS

There were no significant differences in the clinicopathological characteristics between the two groups. The incidence rates of atrial fibrillation and pneumonia were significantly lower in the HOPE group than in the pre-HOPE group (6% vs. 19%, p = 0.027 and 14% vs. 29%, p = 0.037, respectively). The estimated calorie doses at the time of discharge were approximately 750 and 1500 kcal/day in the pre-HOPE group and the HOPE group, respectively. The body weight loss was significantly less in the HOPE group than the pre-HOPE group at 1, 3, 6, and 12 months postoperatively than that before the surgery (p < 0.001).

CONCLUSIONS

The introduction of the multidisciplinary HOPE was associated with a significant reduction in the incidence of postoperative pneumonia and significantly less weight loss.

Abstract 4028: Tenascin C in gastric cancer stroma is a predictive marker for postoperative prognosis

Background: Tenascin C, a glycoprotein in the extracellular matrix is reportedly associated with poor clinical outcome in several malignancies. We have previously reported that tenascin C in colorectal cancer stroma is a predictive marker for liver metastasis (Br J Cancer 117:1360-70, 2017). In this study, we evaluated the clinicopathological and prognostic significance of tenascin C expression in gastric cancer stroma.

Materials and methods: Expression levels of tenascin C protein were immunohistochemically analyzed in 176 primary gastric cancer samples. Tenascin C staining intensity and relativity were classified into four scores and two groups, respectively. The correlation of the tenascin C staining intensity and relativity with clinicopathological factors, postoperative overall survival (OS) and disease-free survival (DFS) were analyzed.

Results: There were positive correlations between the tenascin C staining intensity or relativity and tumor depth, lymphatic invasion, venous invasion, lymph node metastasis, pathological stage, high preoperative carcinoembryonic antigen (CEA)&gt;5ng/ml, and high preoperative carbohydrate antigen (CA19-9) &gt;37U/ml. Multivariate analysis revealed that high tenascin C staining intensity significantly correlated with tumor invasion into the muscularis propria (p=0.015) and venous invasion (p=0.042), and that high tenascin C staining relativity correlated with venous invasion (p=0.013). Gastric cancer patients with high tenascin C staining intensity had significantly shorter postoperative OS (p&lt;0.001), whereas tenascin C staining relativity did not correlate with postoperative OS (p=0.05). High tenascin C staining intensity and relativity significantly correlated with shorter postoperative DFS (p&lt;0.001 and 0.005, respectively). Cox proportional hazard model identified high tenascin C staining intensity as an independent prognostic factor for poor postoperative OS (hazard ratio (HR): 13.16, 95% confidence interval (CI): 1.362-125.000, p=0.026) and DFS (HR: 6.02, 95%CI: 1.538-23.810, p=0.010).

Conclusions: Tenascin C protein expression in primary tumor stroma was identified as a predictive marker for postoperative prognosis in patients with gastric cancer.

Citation Format: Hirotoshi Kikuchi, Tomohiro Murakami, Sanshiro Kawata, Amane Hirotsu, Tomohiro Matsumoto, Yusuke Ozaki, Yoshihiro Hiramatsu, Kinji Kamiya, Yoshifumi Morita, Takanori Sakaguchi, Hiroyuki Konno, Hiroya Takeuchi. Tenascin C in gastric cancer stroma is a predictive marker for postoperative prognosis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4028.

Rapid recurrence of primary gastric choriocarcinoma after complete resection

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A 78-year-old man was diagnosed with stage cIB primary gastric choriocarcinoma.

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Total gastrectomy with spleen-preserving D2 lymphadenectomy was performed.

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Early recurrence was diagnosed 3 months postoperatively.

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The patient underwent a standard nongestational choriocarcinoma chemotherapy.

Introduction

Primary gastric choriocarcinoma (PGC) is a rare and rapidly invasive tumor. We report a case of PGC diagnosed by endoscopic biopsy and treated with gastrectomy and chemotherapy.

Presentation of case

A 78-year-old man was referred to our hospital because esophagogastroduodenoscopy showed a tumor at the fornix of the stomach. Pathologic examination of biopsy specimens revealed choriocarcinoma. Abdominal computed tomography (CT) revealed no enlarged abdominal lymph nodes or distant metastases. Robot-assisted total gastrectomy with spleen-preserving D2 lymphadenectomy was performed on the basis of a diagnosis of cT2N0M0, stage cIB PGC. The pathologic diagnosis was pT2, ly0, v1, pN0, PM0, DM0, stage pIB PGC. The postoperative course was uneventful, and the patient was followed carefully without adjuvant chemotherapy. Three months after gastrectomy, blood tests indicated that serum β-human chorionic gonadotropin (β-hCG) levels had increased, and CT revealed multiple liver metastases. The patient underwent a standard nongestational choriocarcinoma chemotherapy regimen with etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine. Although β-hCG levels temporarily decreased with chemotherapy, the patient experienced tumor recurrence with ascites and his serological test demonstrated an elevated level of β-hCG (120 ng/mL). The patient died 10 months postoperatively.

Conclusion

We report a case of stage pIB PGC with poor prognosis, recurring at only 3 months postoperatively despite curative surgery and chemotherapy.

Label-free classification of cells based on supervised machine learning of subcellular structures

It is demonstrated that cells can be classified by pattern recognition of the subcellular structure of non-stained live cells, and the pattern recognition was performed by machine learning. Human white blood cells and five types of cancer cell lines were imaged by quantitative phase microscopy, which provides morphological information without staining quantitatively in terms of optical thickness of cells. Subcellular features were then extracted from the obtained images as training data sets for the machine learning. The built classifier successfully classified WBCs from cell lines (area under ROC curve = 0.996). This label-free, non-cytotoxic cell classification based on the subcellular structure of QPM images has the potential to serve as an automated diagnosis of single cells.