Effect of Risk Factor Score on Early Recurrence After Pancreatectomy for Invasive Pancreatic Ductal Adenocarcinoma.

BACKGROUND/AIM: This study aimed to identify the risk factors for early recurrence (ER) after pancreatic ductal adenocarcinoma (PDAC) resection to create a novel scoring system for ER and analyze their effect on the recurrence pattern. PATIENTS AND METHODS: Sixty patients with PDAC who underwent pancreatectomy were included. The predicted risk factors for ER were analyzed. A new score defining ER was created and analyzed for recurrence pattern and prognosis. RESULTS: Independent predictors included high CA 19-9 (≥147 U/ml), high lymph node ratio (LNR of ≥0.1277), and no adjuvant chemotherapy (AC). The 5-year overall survival rates with a score of 0, 1, and 2 were 55.8%, 11.0%, and 0%, respectively. In the moderate- risk score group, prognosis was improved by induction of AC within 58 days. CONCLUSION: Preoperative high CA19-9, high LNR, and no AC could be ER predictors. Induction of postoperative chemotherapy within 58 days may improve prognosis.

Osteosarcopenia impacts treatment outcomes for Barcelona Cancer Liver Classification stage A hepatocellular carcinoma.

AIM: To study the effect of preoperative osteosarcopenia (OSP) on the prognosis of treatment (surgery or radiofrequency ablation (RFA)) in patients with Barcelona Cancer Liver Classification stage A hepatocellular carcinoma (BCLC A HCC). METHODS: This study enrolled 102 patients with BCLC A HCC who underwent surgical resection (n = 45) and RFA (n = 57); the patients were divided into two groups: OSP (n = 33) and non-OSP (n = 69). Overall survival (OS) and disease-free survival (DFS) curves for both the groups and treatment methods (surgery and RFA) were generated using the Kaplan-Meier method and compared using the log-rank test. Univariate analyses for OS and DFS were performed using log-rank test. Multivariate analyses were performed for factors that were significant at univariate analysis by Cox proportional hazard model. RESULTS: Multivariate analysis showed that OSP (HR 2.44; 95 % CI 1.30-4.55; p < 0.01) and treatment (HR 0.57; 95 % CI 0.31-0.99; p = 0.05) were significant independent predictors of DFS; and treatment (HR, 0.30; 95 % CI 0.10-0.85; p = 0.03) was a significant independent predictor of OS in the non-OSP group, in which the OS rate was significantly lower in patients treated with RFA than in those treated by resection (p = 0.01). CONCLUSIONS: OSP is a prognostic factor for BCLC A HCC treatment. Surgical approach was associated with a significantly better prognosis in patients without OSP compared to those who underwent RFA.

Long-term outcomes of choledochoduodenostomy for choledocholithiasis: increased incidence of postoperative cholangitis after total or distal gastrectomy.

PURPOSE: Choledochoduodenostomy (CDD) is performed to treat choledocholithiasis (CDL) cases where endoscopic stone removal is difficult. Recognizing CDD characteristics is important for CDL treatment planning. METHODS: A total of 116 patients, including 33 patients ≥ 80 years old (29 with previous total gastrectomy, 19 with previous distal gastrectomy, 20 with built-up stones, 19 with periampullary diverticulum, 10 with confluence stones, 8 with repetitive recurrent stones, 4 with hard stones, 3 with endoscopic retrograde cholangiography [ERC] not available due to lack of cooperation, 2 with a history of pancreatitis post-ERC, and 2 in whom ERC could not be performed due to a disturbed anatomy) underwent CDD for CDL. Postoperative complications and long-term outcomes were evaluated. RESULTS: The in-hospital mortality rate was 0%. The morbidity (grade ≥ IIIA according to the Clavien-Dindo classification) rates in the elderly (≥ 80 years old) and non-elderly (51-79 years old) patients were 3.0% (1/33) and 2.4% (2/83), respectively (p = 0.85). Long-term complications included cholangitis in eight (7%) patients, of which three cases were repetitive and seven had an operative history of total or distal gastrectomy. The incidence of postoperative cholangitis after total or distal gastrectomy was 15% (7/48), which was significantly higher than that involving other causes (1.5%, 1/68; p < 0.01). Two patients with cholangitis after total gastrectomy experienced early recurrence of lithiasis at 2 and 9 months after surgery. CONCLUSIONS: CDD is safe, even in elderly patients. However, a history of total gastrectomy or distal gastrectomy may increase the incidence of postoperative cholangitis.

Transperineal Repair of Secondary Perineal Hernia Using a Mesh with a Memory-recoil Ring.

Objectives: The aim of this study was to evaluate the effectiveness of transperineal repair of secondary perineal hernia (SPH) using a mesh with a memory-recoil ring. Methods: Seven patients with SPH who underwent transperineal repair (TPR) between July 2010 and May 2022 were retrospectively analyzed. TPR was performed using a mesh with a memory-recoil ring. Results: All SPHs developed after abdominoperineal resections in patients with anorectal malignancies. The median longitudinal and transverse diameters of the hernia orifice were 8 (7-10) cm and 6 (5-7) cm, respectively. In all cases, the mesh was fixed to the ischial tuberosity, residual levator muscle, coccygeus muscle, and coccyx after thorough dissection of the sac. The median operation time was 154 (142-280) min. Perioperative complications occurred in 2 cases (29%). One was enterotomy, which caused postoperative mesh infection requiring extraction of the mesh. The other was vaginal injury, which resulted in vaginal fistula but closed spontaneously. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed during a median follow-up of 35 (9-151) months. Conclusions: TPR using a mesh with a memory-recoil ring is safe, feasible and promising technique for SPH repairs.

A Novel Observational Strategy for Nonfunctional Pancreatic Neuroendocrine Neoplasms With Texture Analysis: A Multicenter Retrospective Study.

Background/Aim: Surgical resection is recommended for nonfunctional pancreatic neuroendocrine neoplasms (NF-pNENs). However, metastasis is rare in patients with small lesions with histological grade 1 (G1); thus, observation is an optional treatment approach for small NF-pNENs. Texture analysis (TA) is an imaging analysis mode for quantification of heterogeneity by extracting quantitative parameters from images. We retrospectively evaluated the utility of TA in predicting histological grade of resected NF-pNENs in a multicenter retrospective study. Patients and Methods: The utility of TA in preoperative prediction of grade were evaluated with 29 patients treated by pancreatectomy for NF-pNEN who underwent preoperative dynamic computed tomography scan between January 1, 2013 and December 31, 2020 at three hospitals affiliated with the Jikei University School of Medicine. TA was performed with dedicated software for medical imaging processing for determining histological tumor grade using dynamic computed tomography images. Results: Histological tumor grades based on the 2017 World Health Organization Classification for Pancreatic Neuroendocrine Neoplasms were grade 1, 2 and 3 in 18, 10 and one patient, respectively. Preoperative grades by TA were 1 and 2/3 in 15 and 14 patients, respectively. The sensitivity, specificity and area under the curve for TA-oriented grade 1 lesions were 1.00, 0.889 and 0.965 (95% confidence interval=0.901-1.000), respectively. Conclusion: TA is useful for predicting grade 2/3 NF-pNEN and can provide a safe option for observation for patients with small grade 1 lesions.

The impact of C-reactive protein-albumin-lymphocyte (CALLY) index on the prognosis of patients with distal cholangiocarcinoma following pancreaticoduodenectomy.

Aim: The C-reactive protein (CRP)-albumin-lymphocyte (CALLY) index is a novel inflammation-based biomarker, which has been associated with long-term outcomes in patients with hepatocellular carcinoma. We aimed to investigate whether the CALLY index can predict the prognosis for distal cholangiocarcinoma after pancreaticoduodenectomy. Methods: The study comprised 143 patients who had undergone primary pancreaticoduodenectomy for distal cholangiocarcinoma between 2002 to 2019. The CALLY index was defined as (albumin × lymphocyte)/ (CRP × 104). We investigated the association of CALLY index with disease-free survival and overall survival by univariate and multivariate analyses. Results: Eighty-seven (61%) patients had a preoperative CALLY index <3.5. In multivariate analysis, obstructive jaundice drainage (P < .01), poorly differentiated tumor (P < .01), and CALLY index<3.5 (P = .02) were independent predictors of disease-free survival, while obstructive jaundice drainage (P < .01), poorly differentiated tumor (P < .01), and CALLY index <3.5 (P = .02) were independent predictors of overall survival. Conclusion: The CALLY index may be an independent and significant indicator of poor long-term outcomes in patients with distal cholangiocarcinoma after pancreaticoduodenectomy, suggesting the importance of comprehensive assessment for inflammatory status.

Efficacy and Cost-effectiveness of Pegfilgrastim for Preventing Febrile Neutropenia During Docetaxel, Cisplatin, and 5-Fluorouracil Therapy for Esophageal Cancer.

BACKGROUND/AIM: The docetaxel, 5-fluorouracil, and cisplatin (DCF) regimen is an effective form of chemotherapy for advanced esophageal cancer. However, the incidence of adverse events, such as febrile neutropenia (FN), is high. This study retrospectively examined whether pegfilgrastim treatment reduces FN development during DCF therapy. PATIENTS AND METHODS: This study evaluated 52 patients who were diagnosed with esophageal cancer and underwent DCF therapy at Jikei Daisan Hospital, Tokyo, Japan, between 2016 and 2020. They were divided into non-pegfilgrastim and pegfilgrastim-treated groups, and side-effects of chemotherapy and cost-effectiveness of pegfilgrastim were examined. RESULTS: Eighty-six cycles of DCF therapy were conducted (33 and 53 cycles, respectively). FN was observed in 20 (60.6%) and seven (13.2%) cases, respectively (p<0.001). The lowest absolute neutrophil count during chemotherapy was significantly lower in the non-pegfilgrastim group (p<0.001), and the number of days until improvement from nadir was significantly shorter in the pegfilgrastim group (9 vs. 11 days; p<0.001). No significant difference was found in the onset of grade 2 or more adverse events by Common Terminology Criteria for Adverse Events. However, renal dysfunction was significantly lower in the pegfilgrastim group (30.7% vs. 60.6%, p=0.038). Hospitalization costs were also significantly lower in this group (692,839 vs. 879,431 Japanese yen, p=0.028). CONCLUSION: This study revealed the usefulness and cost-effectiveness of pegfilgrastim in prevention of FN in patients treated with DCF.

A Multidisciplinary Treatment Strategy With Conversion Surgery for Hepatocellular Carcinoma.

BACKGROUND/AIM: Sorafenib was previously the only targeted therapy for hepatocellular carcinoma (HCC). However, pharmaceutical therapy for HCC has undergone remarkable advances in recent years. Herein, we report cases of unresectable advanced HCC responding to pharmaceutical therapy resulting in improved prognosis through surgical intervention. PATIENTS AND METHODS: Five patients with intermediate and advanced stage HCC treated with lenvatinib followed by hepatectomy between October 2019 and September 2022 were retrospectively reviewed. Patient characteristics, tumor factors, and treatment factors were compared. RESULTS: The median patient age was 66 (60-79) years, and all patients (100%) were male. The median follow-up period was 10.4 months. All five patients received lenvatinib treatment for more than 2 months before surgery. Three patients achieved partial responses and 2 patients had stable disease with modified RESIST in response to lenvatinib. Three patients had a partial pathological response (50% or more tumor necrosis). Four patients underwent R0 resection and 3 cases had no recurrence. CONCLUSION: Lenvatinib might be useful for intermediate and advanced HCC and long-term survival may be obtained by combining lenvatinib therapy with surgery.

Primary upper lumbar hernia repaired by transabdominal preperitoneal approach technique using a self-expanding mesh with a memory-recoil ring, report of a case.

BACKGROUND: Upper lumber hernia is a rare entity which can cause obstruction and strangulation. Laparoscopic technique has been considered effective for such hernia repairs; however, there is no report of use of the self-expanding mesh. CASE PRESENTATION: A 77-year-old woman visited to our hospital complaining of a bulge of about 5 cm in the left lumbar dorsal region while standing. Abdominal CT and MRI scans showed a fascial defect in the left lumbar abdominal wall and confirmed the presence of a hernia, in which retroperitoneal fatty tissue and the descending colon protruded. Transabdominal preperitoneal repair (TAPP) was performed and the operative findings revealed the hernia orifice, 3 × 2.5 cm in diameter, between two intercostal nerves. To avoid nerve injury or entrapment, the number of mesh fixation was desirable minimum; therefore, a self-expanding mesh with a memory-recoil ring was used. The mesh, 9.5 × 13 cm in diameter, was placed and tacked to the abdominal wall at two points, 1 cm ventral and dorsal to the hernia orifice. The postoperative course was uneventful and no pain or recurrence was observed with follow-up of 6 months. CONCLUSION: We herein present a case of upper lumber hernia successfully repaired by TAPP with a self-expanding mesh.

D1 Distal Pancreatectomy for Left-sided Pancreatic Ductal Adenocarcinoma Is Justifiable: A Propensity-score Matched Multicenter Study.

BACKGROUND/AIM: Evidence on the optimal extent of lymph node dissection for left-sided pancreatic ductal adenocarcinoma (PDAC) is scarce. The aim of the current study was to compare the long-term outcomes of patients who underwent D1 distal pancreatectomy (DP) with D2 DP for left-sided PDAC. PATIENTS AND METHODS: Patients undergoing DP for left-sided PDAC at the four institutions affiliated to The Jikei University were enrolled in this study. Patients were divided into D1 and D2 groups. Patients' clinical characteristics, overall survival (OS), and relapse-free survival (RFS) were compared between the two groups before and after propensity-score matched (PSM) analysis. RESULTS: Of 145 patients with left-sided PDAC, 55 patients underwent D1 DP and 90 underwent D2 DP, of whom 38 matched pairs were included in the PSM analytic cohort. In the unmatched cohort, no significant difference was found between the D1 and D2 groups for both OS (median 2.51 vs. 3.07 years; p=0.709) and RFS (median 1.47 vs. 1.27 years; p=0.565). After PSM, OS (median 2.37 vs. 3.56 years; p=0.407) and RFS (median 1.35 vs. 1.11 years; p=0.542) were not significantly different between the two groups. In a comparison of regional and systemic recurrence sites, no significant difference was observed between the two groups (p=0.500). CONCLUSION: The long-term survival of D1 DP for left-sided PDAC was not inferior to D2 DP. In an era in which the importance of multidisciplinary treatment for PDAC has been documented, unnecessary extended surgery should be avoided.

The effectiveness of adjuvant chemotherapy for Stage I pancreatic cancer based on the UICC 8th edition.

BACKGROUND: Adjuvant chemotherapy is recommended for patients with pancreatic cancer after curative resection. However, there is limited evidence regarding the efficacy and prognostic factors for adjuvant chemotherapy in patients with stage I pancreatic cancer. This study aimed to identify patients in whom chemotherapy was effective and to detect prognostic factors for stage I pancreatic cancer based on guidelines of the 8th edition of the Union for International Cancer Control (UICC). METHODS: Between 2009 and 2017, 108 patients diagnosed with stage I pancreatic cancer were enrolled in this study. They were distributed into invasion (n = 68) and non-invasion (n = 40) groups. The relationship between clinicopathological variables, including various prognostic factors, disease-free survival (DFS), and overall survival (OS), were investigated by univariate and multivariate analyses. RESULTS: Five-year survival in all patients with stage I pancreatic cancer was 38.9%. Adjuvant chemotherapy failed to improve DFS or OS in patients with stage I cancer (DFS, p = 0.26; OS, p = 0.30). In subgroup analysis, adjuvant chemotherapy significantly improved DFS (multivariate-adjusted hazard ratio (HR), 0.40; 95% confidence interval [CI], 0.21-0.78; p = 0.007) and OS (multivariate-adjusted HR, 0.32; 95% CI, 0.15-0.68; p = 0.003) in the invasion group than in non-invasion group. In contrast, in the non-invasion group, adjuvant chemotherapy failed to improve DFS and OS in univariate analysis (DFS, p = 0.992; OS, p = 0.808). CONCLUSION: For stage I pancreatic cancer, based on guidelines of the UICC 8th edition, adjuvant chemotherapy may benefit patients with extrapancreatic invasion.

Emergency transanal total mesorectal excision for perforated rectal cancer: a two-case series.

BACKGROUND: Surgery for perforated rectal cancer is technically difficult because of paralytic dilatation due to generalized fecal peritonitis, the presence of a bulky tumor, and fecal retention due to obstruction. Transanal total mesorectal excision (TaTME) is the latest minimally invasive transanal technique pioneered to facilitate difficult pelvic dissections. It can provide a good surgical field linearly from the perineal side and reduce manipulations from the intraabdominal side. Here, we present two cases of emergency TaTME performed for perforated rectal cancer. CASE PRESENTATION: The patients were a 38-year-old female and a 75-year-old male. They were diagnosed with perforated rectal cancer and were in a state of septic shock. Emergency Hartmann's procedure was performed in both cases. Intraoperative findings showed fecal contamination of the entire abdomen and dilated intestines and bulky tumors with perforation. The female patient had multiple uterine fibroids, and the male patient had an enlarged prostate. For both patients, dissection of the mesorectum to the anal side of the tumor and transection of the rectum on the anal side of the tumor via a linear stapler were considered difficult because of the insufficient surgical field of view into the pelvis. Therefore, a two-team approach with TaTME was adopted. En bloc resection of the rectum was completed by collaboration of the abdominal team and the transanal team, and the autonomic nerves were successfully preserved. Finally, the specimens were resected, and the anal edge of the rectum was closed with a purse-string suture by the transanal team. Although these two cases were emergency surgeries in difficult situations, the cancer lesions were successfully and safely removed without involvement of the resection margin. CONCLUSIONS: This is the first report of emergency TaTME. Although these cases were emergency operations in a situation where it was difficult to pursue radical resection-and often times in these situations, the operation may end with only stoma creation-the specimens were safely resected. Emergency TaTME is a useful procedure for treatment of perforated rectal cancer.

A rare case of pseudoaneurysmal hemorrhage, necrotizing fasciitis, and costochondritis after pancreaticoduodenectomy.

BACKGROUND: Necrotizing fasciitis after pancreaticoduodenectomy (PD) has never been reported. We experienced a case of necrotizing fasciitis caused by pseudoaneurysmal hemorrhage after PD. CASE PRESENTATION: A 72-year-old male was diagnosed with cholangiocarcinoma and underwent PD. Bile leakage was detected postoperatively, conservatively resolved, and the patient was discharged on the 36th day after surgery. On the 42nd day after surgery, a pseudoaneurysm of the gastroduodenal artery ruptured. Transcatheter arterial embolization was performed for hemostasis: however, a large intra-abdominal abscess caused by an infected hematoma was recognized. On the 57th day after surgery, the patient developed necrotizing fasciitis. He underwent debridement with skin reconstruction using a latissimus dorsi flap and skin transplantation. Costochondritis and liver metastasis were detected on the 267th day after surgery. Infection was controlled by rib cartilage resection, debridement, and negative pressure wound therapy. Chemotherapy involving gemcitabine and cisplatin was initiated on the 460th day after the initial surgery with a partial response (PR) and was continued for more than one year. CONCLUSIONS: We herein reported a rare case of necrotizing fasciitis following hematoma infection after PD that was treated using multidisciplinary therapy with PR following chemotherapy.

The impact of S-1 for the patient with lymph nodal metastasis biliary tract cancer as adjuvant chemotherapy: a multicenter database analysis.

INTRODUCTION: Although adjuvant chemotherapy is expected to improve the prognosis for patients with biliary tract cancer after curative resection, there is limited evidence regarding the efficacy and prognostic factors of adjuvant chemotherapy. We investigated the effective subgroups for whom adjuvant chemotherapy with S-1 in biliary tract cancer patients. METHODS: 413 patients who underwent curative resection for biliary tract cancer at our four affiliated hospitals between 2009 and 2019 were included in this study. The association of adjuvant chemotherapy with long-term outcomes in overall and patient subgroups were investigated by univariate and multivariate analyses. RESULTS: Among overall patients, adjuvant chemotherapy with S-1 did not improve disease free survival (p = 0.29) and overall survival (p = 0.83). In the subgroup analysis, adjuvant chemotherapy with S-1 improved both disease-free and overall survival in patients with lymph node metastasis, advanced Stage (III and IV), and microscopic residual tumor. In 135 patients with lymph node metastasis, adjuvant chemotherapy with S-1 was given in 67 patients (50%). In the patients with lymph node metastasis, preoperative bile duct drainage (p = 0.01) and adjuvant chemotherapy (p = 0.04) were independent and significant predictors of disease-free survival, while preoperative bile duct drainage (p = 0.03), tumor differentiation (p = 0.03), and adjuvant chemotherapy (p = 0.03) were independent and significant predictors of overall survival. CONCLUSION: After resection of biliary tract cancer, adjuvant chemotherapy with S-1 appears to benefit those who had lymph node metastasis.

New Scoring System for Prediction of Surgical Difficulty During Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage.

Background: The surgical difficulty of laparoscopic cholecystectomy (LC) after percutaneous transhepatic gallbladder drainage (PTGBD) remains unknown. This study aimed to establish a scoring system (SS) to predict the necessity of a bailout procedure during LC after PTGBD and to evaluate the relationship between SS and perioperative complications. Methods: We retrospectively studied 70 patients who underwent LC after PTGBD. Preoperative factors potentially predictive of the need for the bailout procedure were analyzed. The SS included significantly predictive factors, with their cutoff values determined by receiver operating characteristic curves. Patients were assigned a score of 1 when exhibiting only one of these abnormalities. We compared the perioperative factors between three groups with scores of 0, 1, or 2. The SS was applied to another series of 65 patients for validation. We compared the score-2 patient perioperative factors between LC with the bailout procedure and open cholecystectomy from the beginning (OC). Results: Independent predictors were time until PTGBD after symptom onset and the maximal wall gallbladder thickness (cutoff values: 3 days and 10 mm, respectively). The high-score group was significantly associated with bile duct injury (BDI). The sensitivity and specificity of our SS were 75.0% and 98.1% in validation, respectively. The score-2 OC and laparoscopic subtotal cholecystectomy (LSC) groups had no BDI. Conclusions: The SS using time until PTGBD after symptom onset and gallbladder wall thickness for predicting the need for the bailout procedure correctly predicted the need. The scores might be associated with the risk of BDI, and LSC or OC might be a better choice for score-2 patients.

Clinical Features and Treatment Outcomes of Pseudoaneurysm Following Pancreatic Resection.

BACKGROUND/AIM: Management strategies for pseudoaneurysm rupture after pancreatic resection have not yet been firmly established due to its low incidence and effects of environmental variability among centers. This study aimed to provide a basis for treatment strategy improvement. PATIENTS AND METHODS: Clinical features and outcomes of 29 patients who experienced pseudoaneurysm formation or rupture following pancreatic resection were retrospectively reviewed. RESULTS: The incidence of pseudoaneurysm formation was 2.8%. In 28 of 29 patients, pseudoaneurysm was identified via emergent dynamic computed tomography (CT). The rates of complete cessation of bleeding by interventional radiology (IVR) and surgical intervention were 88% and 100%, respectively. Mortality rate was 13.8%. Four patients treated by IVR died, including three of massive bleeding and one of liver failure. CONCLUSION: Patients with suspected pseudoaneurysm rupture after pancreatic resection should undergo immediate CT. Open surgery is preferable for patients with incomplete hemostasis by IVR or those who cannot immediately undergo IVR, however, IVR is an effective alternative.

Feasibility of using a tailored mesh in laparoscopic Sugarbaker parastomal hernia repair.

BACKGROUND: In parastomal hernia (PH) repair, laparoscopic Sugarbaker technique (LS) is considered the best practice; however, meshes specific for LS repairs ceased to be available. PURPOSE: The aim of the study was to evaluate feasibility of using a physician-modified mesh (tailored mesh: TM) in LS. METHODS: Thirty-three patients who underwent LS for PH between June 2012 and September 2021 were examined to compare surgical outcomes between LS with TM (n = 11) and with a ready-made specific mesh (SM, n = 22). All meshes were coated plastic meshes. Statistical analysis was performed with the Mann-Whitney U test and Fisher's exact test. P < .05 was considered to be statistically significant. RESULTS: We compared the outcomes of TM with SM in LS for similar hernia types during median follow-up periods of 23 (range, 2-29) and 74 (range, 36-110) months (P < .0001), respectively. The median operation times were 146 (range, 45-423) for TM and 193 (range, 65-386) minutes for SM (P = .2301). Perioperative complications were observed in one TM patient (9%) and two SM patients (9%) (P = 1.0000). The lengths of postoperative stay were similar. Recurrence was observed in two cases in the SM group (9%) within 1 year after the operation. CONCLUSION: In LS, TM seems to be a feasible mesh comparable to SM within short- and mid-term follow-up.

Development of recognised position-guided navigation system.

BACKGROUND: Previously, we developed an image-guided navigation system (IG-NS) incorporating augmented reality technology. Nevertheless, the system could still only aid the operator by presenting imagery and was short of achieving the goal of developing a real navigation system. Therefore, we developed a recognised position-guided navigation system (RP-NS) and herein reported the functionality and usefulness of this system in a phantom model for clinical applications. METHODS: We developed RP-NS which was reconstructed by adding the positional recognition and instruction functions with the cautions by displaying the images on the monitor with a voice to the IG-NS. We evaluated accuracy of positional recognition and instruction functions using phantom model. By utilising the chronological recording of the tip position of the surgical apparatus, the surgical precision of the operators was assessed. Finally, the feasibility of improvements in surgical precision using this system was evaluated. RESULTS: The RP-NS indicated an accuracy of the position recognition functions with an error of 2.7 mm. The surgeons could perform partial hepatectomies within mean value of 7.5% error as compared with calculated volume according to the instruction. Improvements in surgical precision using this system were obtained on the surgeons with different levels. CONCLUSIONS: The RP-NS was highly effective as a navigation system owing to precise positional recognition and adequate instruction functions. Therefore, these results indicate that the use of this system may complement differences in proficiency, and numerically evaluate surgical skills and analyse tendencies of surgeons.

Retroperitoneal lymphangioma mimicking malignant tumor treated by pancreaticoduodenectomy.

Lymphangiomas are classified as lymphatic malformations, which are more common in children and rare in adults. It frequently occurs in the cervical and axillary regions and uncommonly in the retroperitoneum. A 39-year-old woman presented to our department for the investigation for a 55 mm asymptomatic mass in the right anterior adrenal cavity. Abdominal ultrasound showed a tumor containing cysts in the right anterior adrenal cavity. Contrast-enhanced computed tomography showed that the tumor was poorly contrasted and ill-defined. Magnetic resonance imaging suggested that the tumor contained a small amount of fat. The tumor tended to grow, and the possibility of malignant diseases such as liposarcoma could not be excluded. Therefore, surgical resection was performed. Since intraoperative findings showed that the tumor tightly invaded to the duodenum and pancreatic head, a pancreaticoduodenectomy was selected. The entire tumor was removed without exposing the tumor. Macroscopic findings indicated that the specimen was 55 mm in size, indistinctly demarcated, yellow-white in color, and polycystic. Histologically, lymphovascular proliferation was observed with infiltration of the pancreatic head and the duodenal muscle layer. The diagnosis of lymphangioma was finally made. There was no recurrence 2 years after surgery.

Impact of osteopenia on surgical and oncological outcomes in patients with pancreatic cancer.

INTRODUCTION: Osteopenia, which is defined as a decrease in bone mineral density, has been recently recognized as a metabolic and an oncological biomarker for surgery in patients with malignancy. We aimed to study the prognostic impact of osteopenia in patients with pancreatic cancer (PC) after resection. METHODS: A total of 56 patients who underwent curative resection of PC were retrospectively investigated. The skeletal muscle index at the third lumbar spine and bone mineral density at the 11th thoracic vertebra were measured using computed tomography. RESULTS: Sarcopenia and osteopenia were identified in 24 (43%) and 27 (48%) patients, respectively. The overall and disease-free survival rates were significantly lower in the sarcopenia group than in the non-sarcopenia group (p < 0.01 and p < 0.01, respectively) and in the osteopenia group than in the non-osteopenia group (p < 0.01 and p < 0.01, respectively). In multivariate analysis, sarcopenia (odds ratio [OR] 4.05; 95% confidence interval [CI] 1.23-13.38; p = 0.02) was a significant independent predictor of 1-year disease-free survival. Further, sarcopenia (OR 6.00; 95% CI 1.46-24.6; p = 0.01) and osteopenia (OR 4.66; 95% CI 1.15-18.82; p = 0.03) were significant independent predictors of 2-year overall survival. CONCLUSION: Osteopenia is a significant negative factor for 2-year overall survival after curative resection of PC.