Right lateral approach to the superior mesenteric artery in robotic pancreaticoduodenectomy.

Ninomiya and colleagues introduced a novel approach to the superior mesenteric artery in robotic pancreaticoduodenectomy. The right lateral approach allows repositioning of the superior mesenteric artery to the right-most surface, facilitating safer artery division and simplifying detachment around the superior mesenteric vein, potentially reducing operative time and minimizing blood loss.

Predicting conversion surgery in patients with locally advanced pancreatic cancer after modified FOLFIRINOX treatment.

BACKGROUND: /Objective: FOLFIRINOX therapy (FFX) for locally advanced pancreatic cancer (LAPC) is increasingly recognized as a potent neoadjuvant therapy that enables transition to conversion surgery (CS). However, predictors of CS achievement after chemotherapy are controversial. This study aimed to demonstrate the efficacy of CS after modified FFX (mFFX) in patients with LAPC and to identify and score predictors of CS. METHODS: From January 2014 to December 2018, patients with LAPC who received mFFX as a first-line treatment were screened. Patients' overall survival was compared with and without CS. Moreover, the predictors for CS were analyzed to create scores for the CS factors. RESULTS: Forty-three patients received mFFX, including 20 patients who underwent CS (CS group, 46.5%). R0 resection was achieved in 16 patients (80%). The median survival time was 39.2 months (95% confidence interval [CI] 17.3-53.8) for the CS group and 16 months (95% CI 10.5-22.6) for the non-CS group (P < 0.001; hazard ratio 0.25, 95% CI 0.12-0.54). Since an average relative dose intensity of ≥90%, tumor reduction of ≥35%, and carbohydrate antigen 19-9 reduction of ≥70% or normalization were associated with successful transition to CS in the multivariate analysis, these factors were scored (CS score, range 0-3). All of the patients in the CS group fell into the 2-3 category, compared with 2 of 23 patients in the non-CS group (P < 0.001). CONCLUSION: CS after FFX contributes to the long-term survival of patients with LAPC. The CS score could be an indicator for transition to CS.

Refractory Acute Antibody Mediated Rejection in Liver Transplant After Desensitization of Preformed Donor Specific Antibody-Validity of Bortezomib and Everolimus: A Case Report.

Here, we report a case of living donor liver transplantation (LDLT) complicated with severe acute antibody-mediated rejection (aAMR), although desensitization was performed for preformed donor-specific anti-human leukocyte antigen antibody (DSA). LDLT was performed in a 59-year-old woman with alcoholic cirrhosis with a graft from her 60-year-old husband as a living donor. She had reproductive history of 4 gravidity and parity with her husband. Preoperative serologic studies showed positive complement-dependent cytotoxic crossmatch and anti-human leukocyte antigen-A26 antibody was identified as DSA. Desensitization for preformed DSA with rituximab and plasma exchange was performed before LDLT. We decided to perform LDLT using her husband right liver as living donor graft since the DSA mean fluoro-intensity was down to negative range. The immunosuppressive regimen was comprised with steroid and tacrolimus. However, the recipient developed acute cellular rejection on day 5 after LDLT, followed by severe aAMR. Re-administration of rituximab followed by 4 courses of plasma exchange failed to treat aAMR. The DSA mean fluoro-intensity was successfully suppressed after bortezomib was administered however impaired serologic liver function test and cholestasis were remained. The liver function test and cholestasis in the graft were improved after Everolimus was administered. The recipient was discharged on postoperative day 196. In conclusion, we report a case of LDLT who developed aAMR after desensitization of preformed DSA and was successfully treated with intensive therapy with bortezomib and everolimus.

A Stereoselective Synthesis of Fused Carbocycles with a cis-1,2-Diol Moiety by Desymmetrization: SmI2-Mediated Pinacol Coupling of meso-Cyclic 1,3-Diones.

Samarium diiodide (SmI2)-mediated desymmetrization of a meso-cyclic 1,3-dione pinacol coupling is described. The reaction proceeds with high stereoselectivity to provide fused carbocyclic compounds with three contiguous stereogenic centers featuring an all-carbon quaternary center and a cis-1,2-diol moiety.

The Efficacy of S-1 as Adjuvant Chemotherapy for Resected Biliary Tract Carcinoma: A Propensity Score-Matching Analysis.

Even though S-1 is a widely used chemotherapeutic agent, there is no evidence for its use in an adjuvant setting for biliary tract carcinoma (BTC). Patients who underwent surgical treatment for BTC between August 2007 and December 2018 were selected. Propensity score matching was performed between patients who received S-1 as adjuvant chemotherapy (S-1 group) and those who underwent surgical treatment alone (observation group). Of 170 eligible patients, 38 patients were selected in each group after propensity score matching. Among those in the matched cohort, both the median recurrence-free survival (RFS) and overall survival (OS) in the S-1 group were significantly longer than those in the observation group (RFS, 61.2 vs. 13.1 months, p = 0.033; OS, not available vs. 28.2 months, p = 0.003). A multivariate analysis of the OS revealed that perineural invasion and adjuvant S-1 chemotherapy were independent prognostic factors. According to a subgroup analysis of the OS, the S-1 group showed significantly better prognoses than the observation group among patients with perineural invasion (p < 0.001). S-1 adjuvant chemotherapy might improve the prognosis of BTC, especially in patients with perineural invasion.

[A Case of Locally Advanced, Pancreatic Mixed Acinar-Endocrine Carcinoma(MAEC) Resected using Superficial Femoral Vein Grafts for Portal Reconstruction].

A 46-year-old woman with epigastric pain was found to have a tumor of the pancreatic head. Computed tomography(CT) revealed a plethoric and poorly-marginated, 7 cm tumor in the pancreatic head. The superior mesenteric vein(SMV)was infiltrated from the duodenal inferior margin and a 6 cm occlusion extended to the merger with the splenic vein. Diagnostic criteria identified locally advanced pancreatic cancer(UR-P)with a limitation in portal reconstruction. Endoscopic ultrasoundguided fine needle aspiration(EUS-FNA)diagnosed mixed acinar-endocrine carcinoma(MAEC). Due to rarity, a chemotherapy protocol has not been established. Thus, the first option for treatment was resection. CT showed that the required graft was 7 cm in length, with SMV 0.5 cm in diameter at the intestinal side and 1.4 cm in diameter at the hepatic side; accordingly, the superficial femoral vein (SFV)was selected for use. Compared to the external iliac vein, the graft is slightly thinner and about 10 cm can be harvested. This graft is useful for cases that require reconstruction of the distal SMV.

[Portal Stent for Gastrointestinal Bleeding Caused by Portal Stenosis after Hepato-Biliary-Pancreatic Surgery].

It is known that gastrointestinalbl eeding occurs due to portalstenosis as a complication in the hepato-biliary-pancreatic region at later postoperative stages. Our department has treated 5 portal stent cases since 2015. The pressure difference between the hepatic side and intestinalside at the portalstenosis site decreased from 9-14(median: 10)cmH2O to 0-6 (median: 2)cmH2O in all cases before and after placement of the stent, resulting in hemostasis(observation period 4-18 months, median: 12 months). In surgery of the hepato-biliary-pancreatic regions, veins flowing into the portal vein are also incised by dissection of the hepatoduodenal ligament. Accordingly, it has been inferred that when the portal vein becomes stenotic, the collateralroutes flow into the portalvein at the hepatic portalsite in a hepatopetalmanner through the cholangiojejunal anastomosis site from the mesenteric veins of the elevated jejunum, and the submucosal weak collateral routes collapse, causing gastrointestinal bleeding. Rebleeding is highly likely in cases with only endoscopic treatment and embolization of collateralroutes. On the other hand, it is thought that portalstenting is a radicaltreatment and is thus the first option for management.

[A Case of Splenic Lymph Node Metastasis from the Distal Bile Duct Carcinoma Seven Years after a Curative Resection].

We report a case of splenic lymph node recurrence 7 years after a distal bile duct carcinoma. A 70s man underwent pylorus ring-preserving pancreaticoduodenectomy for distal bile duct carcinoma in 20XX. The pathological diagnosis was T2N0M0, Stage Ⅱ(Japanese Classification of the Biliary Tract Cancers 5th edition). Then, S-1 was administered as an adjuvant chemo- therapy 1month later and continued for 3 years. At 7 years postoperatively, the serum CEA level was elevated(CEA 77.0 ng/ mL), and FDG-PET showed high-grade accumulation in the splenic hilum lymph node, which was diagnosed as lymph node recurrence. Because it was a solitary metastasis and had a long recurrence-free period, tumor resection was not performed, and the patient opted for a nonsurgicaltreatment. No recurrence occurred to date. Recurrent resection is rarely performed for splenic lymph node metastasis.

[Conversion Surgery after Etoposide/Cisplatin(EP)Therapy for Huge Pancreatic Neuroendocrine Carcinoma - A Case Report].

Neuroendocrine carcinoma(NEC)is known as rapid tumor growth, high grade malignancy and poor prognosis. We report a case of huge pancreatic NEC successfully performed conversion surgery after EP therapy. A 70-year-old female, was presented to our hospital with appetite loss. CT scan revealed huge tumor, 15 cm in diameter, locating at the pancreas with possible involvement to liver, stomach, common hepatic artery, left gastric artery and gastroduodenal artery. Peritoneal dissemination and para-aortic lymph node metastasis were also suspected. EUS-FNA showed neuroendocrine carcinoma with almost 100%positive staining rate of Ki-67. We immediately started etoposide/cisplatin(EP)therapy. After 6 courses of EP, the tumor shrank remarkably and peritoneal disseminations were disappeared. Common hepatic artery and gastroduodenal artery became free from the tumor. However, after 7 courses of EP, CT and PET-CT revealed tumor re-growth. Also renal impairment could not afford to continue EP therapy. Therefore we decided to perform conversion surgery. In the guideline in Japan, there is no content specialized for surgical treatment for NEC. Moreover, second-line of chemotherapy for NEC has not been established. In the future, accumulation of NEC cases will contribute to develop effective multidisciplinary treatment.

[Resection for the Recurrence of Hepatocellular Carcinoma in the Inferior Vena Cava and Right Atrium under Deep Hypothermic Circulatory Arrest].

A 77-year-old man underwent extended right lobectomy of the liver for rupture of hepatocellular carcinoma. Recurrence in the inferior vena cava andright atrium was noted 30 months after surgery. We performedextirpation of this tumor thrombosis under retrograde cerebral perfusion during deep hypothermic circulatory arrest. The pericardium was cut through sternotomy, and cooling was initiated. After cardiac arrest at 20.4°C, the inferior vena cava was separated. An incision was made in the right atrium andthe tumor thrombus was extirpated. In the meantime, brain protection was maintainedby retrograde cerebral perfusion. The patient was discharged on day 12 without postoperative complications. He remains alive 6 months after surgery without recurrence. This procedure prevented pulmonary embolism due to tumor thrombosis release. It was also possible to perform the procedure with retrograde cerebral perfusion.

[A Case of Pancreatic Metastasis from Pulmonary Pleomorphic Carcinoma].

We report a case of pancreatic metastasis of pulmonary pleomorphic carcinoma with duodenal invasion after left lower lobectomy. A 65-year-old male underwent left lower lobectomy for left lung cancer in 2016. The final pathological finding was a diagnosis is of pleomorphic carcinoma, pT2bN0M0, stageⅡA. The patient rejected postoperative chemotherapy for 10 months after lung surgery, and he was admitted to our hospital with poor oral intake. CT revealed that the tumor was located in the 2nd part of the duodenum, was about 7 cm in diameter, and was suspected to invade the superior mesenteric vein (SMV). Gastroendoscopy revealed whole-circumference stenosis at the 2nd part of the duodenum. The biopsy was suspicious of duodenal metastasis from pulmonary pleomorphic carcinoma. We scheduled pancreaticoduodenectomy with reconstruction of the portal vein. Regarding the intraoperative findings, the tumor was palpated at the 2nd part of the duodenum, and the tumor invaded the transverse colon and right urinary duct. The SMV had been invaded from the gastro-colic trunk to the root of the ileocolic vein. Therefore, pancreaticoduodenectomy, reconstruction of the portal vein with replacement of the graft of the left external iliac vein, right hemicolectomy, and right ureteral resection were performed. Regarding the pathological findings, the tumor existed in the pancreatic parenchyma and invaded the duodenal mucosa. The tumor cells were similar to those in a previous pulmonary pleomorphic carcinoma. The final pathological diagnosis was pancreatic metastases from pulmonary pleomorphic carcinoma. Surgical reports of metastatic pancreatic tumor have been observed sporadically; however, those reports were of pancreatic metastasis of renal cancer, and there are few reports of resection of pancreatic metastasis. This is a very valuable case of pancreatic metastasis from pulmonary pleomorphic carcinoma that could be resected.

[A Case of Pancreatic Head Neuroendocrine Tumor with Multiple Liver Metastases Successfully Treated with Multimodality Therapy IncludingRepeat Hepatectomy].

A 68-year-old man who had a history of bone marrow transplantation for acute myeloid leukemia was referred to our hospital due to an abnormal liver function test. Based on the clinical diagnosis of P-NET G2 with multiple livermetastases, pylorus-preserving pancreaticoduodenectomy with combined resection of the portal vein and liver sampling were performed (R2 resection). The resected specimen revealed NET-G2 tumorof the pancreatic head(Ki-67 proliferation index 5.0%)and hepatic metastasis(Ki-67 index 2.2%). Although CDDP/ETP(PE)and everolimus(AfinitorTM)regimen were started postoperatively, PE was discontinued due to bone marrow suppression. As the liver metastasis stayed SD for 4 months by everolimus single therapy, 6 hepatic metastases were resected for curative intent 5 months postoperatively. Thereafter, multiple liver metastases appeared 10 months after the metastasectomy. Everolimus single therapy was restarted. As the metastases were maintained SD for 4 months, repeat hepatectomy was performed for curative intent after right portal vein embolization. Multimodality therapy including repeat metastasectomy should be considered for selected patients with P-NET G2 with liver metastases for prolonged survival, if the operation can be performed with low perioperative morbidity.

[Pancreaticoduodenectomy in a Patient with Severe Hyperbilirubinemia - A Case Report].

Although the safety of pancreaticoduodenectomy(PD)with hyperbilirubinemia has been reported, the permissible value of preoperative serum bilirubin is unknown. A 58-year-old man developed obstructive jaundice due to duodenal adenocarcino- ma. The initial serum bilirubin value was 26.8mg/dL, and preoperative biliary drainage was performed. However, the serum bilirubin value only decreased to 17.7mg/dL. The other liver function tests were normal. Therefore, we decided to perform PD despite persistent severe hyperbilirubinemia. The postoperative course was uneventful and the bilirubin value improved. He was discharged 17 days after the operation. In the present case, we safely performed PD despite severe jaundice after adequate preoperative liver function evaluation. The attempt to reduce the bilirubin value before surgery did not appear to affect the postoperative course.

[Conversion Therapy Using Etoposide and Cisplatin Chemotherapy for Liver Metastases from Advanced Gastric Mixed Adenoneuroendocrine Carcinoma - A Case Report].

Gastric mixed adenoneuroendocrine carcinoma(MANEC)with multiple liver metastases is a rare condition with most data being derived from case reports. We present a case with liver metastases from gastric MANEC that respond remarkably to chemotherapy. Sixty-one-year-old male with severe anemia referred to surgical consultation due to advanced gastric cancer with multiple liver metastases. To relieve uncontrollable tumor bleeding, simple distal gastrectomy for symptom palliation was performed. Based on the tentative diagnosis with gastric poorly differentiated adenocarcinoma, a course of TS-1 and oxaliplatin therapy was administrated. Thereafter final diagnosis with neuroendocrine carcinoma with tubular adenocarcinoma was made, and the chemotherapy was switched to etoposide and cisplatin. Follow up abdominal CT scan after the third course of the therapy showed remarkable tumor shrinkages(PR). In anticipation of the chemotherapy effects in the adjuvant setting, we performed liver metastasectomy for curative intent. Two of 6 resected liver specimens showed no viable cancer cells at all (pCR). However, immediately after the surgery, multiple liver metastases developed, and the recurrent masses had kept growing up rapidly. The third line carboplatin and etoposide chemotherapy was given once but was withdrawn because of bone marrow suppression. At the present, the patient is alive with recurrent diseases for 18 months after initial diagnosis.

The Coexistence of Somatostatinoma and Gastrointestinal Stromal Tumor in the Duodenum of a Patient with Von Recklinghausen's Disease.

We herein describe a case of somatostatinoma coexisting with a gastrointestinal stromal tumor (GIST) in the duodenum of an 81-year-old woman with Von Recklinghausen's disease (VRD) and common bile duct stone who presented with diarrhea of three months in duration. Gastroduodenoscopy revealed an ulcer on the second part of the duodenum. A 2.1-cm enhancing tumor was observed to extend from the ulcer on an abdominal computed tomography scan. Subtotal stomach-preserving pancreaticoduodenectomy revealed a somatostatinoma on the papilla of the vater and duodenal GIST. There have been only eight reports on VRD associated with ampullary somatostatinoma and GIST. An awareness of this possibility in patients with gastrointestinal lesions is necessary for proper treatment and patient management.

[Strategy for Unresectable Pancreatic Cancer with Stenosis of the Duodenum - A Case Report].

Unresectable(UR)pancreatic cancer often causes duodenal obstruction. Case 1: A 58-year-old man was diagnosed with UR pancreatic cancer with obstruction of the 3rd duodenal portion. A duodenum 2nd portion jejunum bypass was performed, and FOLFIRINOX was introduced and continued over 6 months. Case 2: A 74-year-old man was diagnosed with UR pancreatic cancer with obstruction of the duodenum near the Treitz ligament. A duodenum 3rd portion jejunum bypass was performed, and gemcitabine plus nab-paclitaxel was introduced. After 8 courses of GN, adjuvant surgery was performed. Both patients resumed oral intake within a few days after bypass, their performance statuses(PS)were improved, and their body weights increased. Because a duodenal jejunum bypass is more physiological than a gastro-jejunum bypass and duodenal stent, stable ingestion is enabled, and they are stable enough for early initiation of chemotherapy.

[Primary Prophylactic Administration of Pegfilgrastim in FOLFIRINOX Therapy for Locally Advanced Pancreatic Carcinoma].

FOLFIRINOX therapy has a high response rate for pancreatic carcinoma, but has serious adverse effects. FOLFIRINOX therapy was administered to 11 patients with locally advanced pancreatic carcinoma at our hospital. We investigated the usefulness of primary prophylactic administration of pegfilgrastim(PegG). In the group receiving PegG, as well as with onset of neutropenia and thrombocytopenia, febrile neutropenia was reduced. Rates of anorexia and fatigue were also lower than in those who did not receive PegG. The PegG group maintained a high average relative dose intensity, as well as a high response rate. Primary prophylactic administration of PegG in FOLFIRINOX therapy is valid for pancreatic carcinoma.

Hemodynamic changes in the hepatic circulation after the modulation of the splenic circulation in an in vivo human experimental model.

Recent advances in liver surgery have highlighted the effects of the splenic circulation on the hepatic circulation with respect to the hepatic arterial buffer response (HABR). The aim of the present study was to investigate the actual hemodynamic effects of splenic artery embolization/ligation and splenectomy on the hepatic circulation in patients who underwent pancreaticoduodenectomy through in vivo experimental models. In vivo models of splenic artery embolization/ligation (only splenic artery clamping) and splenectomy (simultaneous clamping of both the splenic artery and the splenic vein) were created in 40 patients who underwent pancreaticoduodenectomy for various reasons. The portal venous flow velocity, the portal venous flow volume, the hepatic arterial flow velocity, and the hepatic arterial resistance index were measured with color Doppler ultrasonography. Clamping of the splenic artery induced an immediate and significant increase (16%) in the hepatic artery velocity (P < 0.001), and the portal venous flow also decreased significantly (10%, P = 0.03). Fifteen minutes after the clamping of the splenic artery, the hepatic artery velocity remained significantly increased at the level of the initial clamping, and the portal venous flow significantly decreased (16%, P < 0.001). Clamping of the splenic vein, which was performed after the clamping of the splenic artery, resulted in an immediate and significant decrease (30%) in the portal venous flow (P < 0.001), but the hepatic arterial flow was not affected. Fifteen minutes after the clamping of the splenic vein, there was no change in the portal flow, which remained significantly lower (28%) than the flow in controls, whereas the hepatic arterial flow further significantly increased (31%, P < 0.001). In conclusion, our findings indicate that both splenic artery embolization/ligation and splenectomy are effective for increasing hepatic arterial flow and decreasing portal flow, with splenectomy providing a greater advantage. The HABR underlies these hemodynamic changes.

[A case of inflammatory myofibroblastic tumor with repeated recurrence and metastasis].

A 37-year-old woman presented with an asymptomatic pulmonary nodule. A pulmonary S8 segmentectomy was performed. Recurrence and metastasis were noted every 6 months after surgery; repeat surgeries were performed at 18, 24, and 36 months. On histopathological examination, the tumor showed spindle cell proliferation with infiltration of various inflammatory cells, and was diagnosed as inflammatory myofibroblastic tumor (IMT). An IMT is defined as a tumor of intermediate biological potential, which may sometimes metastasize. It is necessary to note the potential for metastasis in the future, especially in cases with anaplastic lymphoma kinase (ALK)-negative immunohistological staining, where the tumor grade can be high.