Impact of Preoperative Tumor Size on Prognosis of Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinomas.

BACKGROUND: Tumor size (TS) is a well-established prognostic factor of pancreatic ductal adenocarcinoma (PDAC). However, whether a uniform treatment strategy can be applied for all resectable PDACs (R-PDACs) and borderline resectable PDACs (BR-PDACs), regardless of TS, remains unclear. This study aimed to investigate the impact of preoperative TS on surgical outcomes of patients with R-PDACs and BR-PDACs. METHODS: Chart data from three institutions were reviewed to select patients who underwent pancreatectomy for R-PDACs and BR-PDACs between January 2006 and December 2020. The patients were divided into TSsmall and TSlarge groups according to a TS cutoff value determined for each of R- and BR-PDAC using the minimum P value approach for the risk of R1 resection. RESULTS: TS of 35 mm and 24 mm was the best cutoff value in R-PDAC and BR-PDAC, respectively. The R1 rate was higher in the TSlarge than TSsmall group, in both R- (n = 35, 37% versus n = 294, 19%; P = 0.011) and BR-PDAC (n = 89, 37% versus n = 27, 15%; P = 0.030). Overall survival was significantly better in the TSsmall than TSlarge group in R-PDAC (38.2 versus 12.1 months; P < 0.001), but comparable between the two groups in BR-DPAC (21.2 versus 22.7 months; P = 0.363). Multivariate analysis revealed TS > 35 mm as an independent predictor of worse survival in patients with R-PDAC. CONCLUSION: Larger TS was associated with a higher R1 rate and is a worse prognostic factor in patients with R-PDAC.

Impact of Lymph Node Metastases Around the Superior Mesenteric Artery on Postoperative Outcomes of Pancreatic Head Cancer.

BACKGROUND: The neural plexus and lymph nodes around the superior mesenteric artery (LN#14), are the most frequent sites involved by pancreatic head cancer. However the influence of metastases to LN#14 on patients' prognosis has rarely been evaluated. METHODS: The patients who underwent pancreatectomy for pancreatic head cancer between January 2010 and December 2018 were selected. The patients with nodal metastases were classified into an LN#14 + or LN#14-group according to LN#14 metastasis. Clinical and pathological characteristics and prognosis were compared between the two groups. RESULTS: In total, 99 patients underwent pancreatectomy. Ninety-four patients were positive for lymph node metastases and 14 and 80 were classified as LN#14 + and LN#14 - , respectively. Postoperative median overall survival (OS) of the LN#14 + and LN#14 - groups was 10.2 and 31.1 months, respectively (P < 0.001). Median OS of the LN#14 + group was worse than that of patients with ≥ 4 metastatic nodes in the LN#14 - group (n = 35, 24.7 months, P = 0.002). In multivariate analysis, LN#14 + (hazard ratio [HR] = 3.89, 95% confidence interval [CI], 1.64-8.86) was one of the independent predictors of worse OS. CONCLUSION: It might be feasible to recognize LN#14 metastases as an important prognostic factor independently from other regional lymph node metastases.

Intracholecystic papillary neoplasm arising in a patient with pancreaticobiliary maljunction: a case report.

BACKGROUND: Pancreaticobiliary maljunction (PBM) is a congenital abnormality in which the pancreatic and biliary ducts join anatomically outside the duodenal wall resulting in the regurgitation of pancreatic juice into the biliary tract (pancreatobiliary reflux). Persistent pancreatobiliary reflux causes injury to the epithelium of the biliary tract and promotes the risk of biliary cancer. Intracholecyctic papillary neoplasm (ICPN) has been highlighted in the context of a cholecystic counterpart of intraductal papillary mucinous neoplasm of the pancreas and the bile duct, but the tumorigenesis of ICPNs remains unclear. CASE PRESENTATION: A 52-year-old Japanese woman was referred for the assessment of dilation of the bile duct. Computed tomography which revealed an enhanced mass in the gallbladder and endoscopic retrograde cholangiopancreatography confirmed that the confluence of the main pancreatic duct and extrahepatic bile duct (EHBD) was located outside the duodenal wall. Under the diagnosis of gallbladder cancer with PBM, cholecystectomy with full thickness dissection, EHBD resection, lymph node dissection, and hepaticojejunostomy were performed. Macroscopic examination of the resected specimen showed that the cystic duct was dilated and joined into the EHBD just above its confluence with the pancreatic duct, and the inflamed change of non-tumorous mucosa of gallbladder indicating that there was considerable mucosal injury due to pancreatobiliary reflux to the gallbladder. Histopathological examination revealed that the gallbladder tumor was a gastric-type ICPN with non-invasive component. Either KRAS gene mutation or p53 protein expression that were known to be associated with the carcinogenesis of biliary cancer under the condition of pancreatobiliary reflux was not detected in the tumor cells of ICPN. CONCLUSION: The present case might suggest that there was no association between PBM and ICPN. To reveal the tumorigenesis of ICPN and its attribution to pancreatobiliary reflux, however, further study is warranted.

Successful surgical drainage with intraoperative ultrasonography for amebic liver abscess refractory to metronidazole and percutaneous drainage: a case report.

BACKGROUND: Metronidazole (MNZ) has been clearly established as a medication for amebic liver abscess. In uncomplicated cases, surgical drainage should be avoided. We report a case of amebic liver abscess refractory to MNZ that was successfully treated using preoperative computed tomography (CT) and percutaneous and surgical drainage with intraoperative ultrasonography (IOUS). CASE PRESENTATION: A 53-year-old man with high-grade fever was diagnosed with a cystic lesion on his right hepatic lobe using CT. Percutaneous drainage was performed, and antibacterial drugs were administered. However, the infection and condition of the patient worsened. Entamoeba histolytica was detected from pus within the mediastinal cavity. Hence, the patient was diagnosed with amebic liver abscess. After the diagnosis was established, we administered MNZ for 10 days. Despite this, the patient's physical condition did not improve. Blood tests suggested impending disseminated intravascular coagulation (DIC). We performed surgical intervention to drain the amebic liver abscess refractory to conservative treatment. During surgery, imaging information from preoperative CT and IOUS enabled us to recognize the anatomical structures and determine the incision lines of the hepatic capsule and hepatic tissue. The patient's DIC immediately regressed after surgery. Unfortunately, malnutrition and disuse syndrome contributed to the patient's long recovery period. He was discharged 137 days post-surgery. CONCLUSIONS: We reported a case of amebic liver abscess refractory to conservative treatment. Surgical drainage with preoperative CT and IOUS allowed us to safely and effectively perform complex abscess decompression.

[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.

[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 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.

[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.

[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.

[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.

[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.

Advanced Adenosquamous Carcinoma of the Ampulla of Vater Treated with Adjuvant Chemotherapy after Pancreaticoduodenectomy.

Introduction: Adenosquamous carcinoma (ASC) of the ampulla of Vater (AmV) is rare. The prognosis is generally worse in patients undergoing resection of ASC of the AmV than in those undergoing resection of adenocarcinoma of the AmV because the former shows early recurrence after surgery. A treatment strategy for ASC of the AmV has not been established, and the efficacy of adjuvant chemotherapy after curative resection is unclear. Given the paucity of data, we report a case of ASC of the AmV that was curatively resected and treated with adjuvant chemotherapy. Case Presentation: A 66-year-old man presented with pruritus and anorexia. Contrast-enhanced computed tomography revealed a tumor measuring 1.6 cm in diameter located at the AmV and distal bile duct. Biopsy revealed adenocarcinoma of the AmV. The patient underwent subtotal stomach-preserving pancreaticoduodenectomy. Histopathological examination contradictorily revealed ASC of the AmV and lymph node metastases. The postoperative course of the patient was uneventful, and he was discharged on day 25. The patient underwent S-1 adjuvant chemotherapy for 6 months and did not exhibit any postoperative recurrence for a follow-up duration of 28 months. Conclusion: Although treatment strategy for ASC of the AmV has not been established, our case shows that surgery followed by S-1 adjuvant chemotherapy could improve prognosis of patients with such tumors. However, further research is required to determine the efficacy of adjuvant chemotherapy and treatment strategies for resectable ASC of the AmV.

Portal uptake function in veno-occlusive regions evaluated by real-time fluorescent imaging using indocyanine green.

BACKGROUND & AIMS: Although recent advances in preoperative imaging have enabled accurate estimation of the regional liver volume with venous occlusion, the extent of functional decrease in such regions remains unclear. In this study, the portal uptake function in postoperative veno-occlusive regions and non-veno-occlusive regions was evaluated by intraoperative fluorescent imaging after intravenous injection of indocyanine green (ICG). METHODS: In 22 liver resection patients and 23 recipients and 18 donors of liver transplantation, fluorescent intensity on the remnant liver or the liver graft was evaluated in real time following intravenous injection of ICG (0.0025 mg per 1 ml of remnant liver volume). RESULTS: Plateau ICG concentrations were significantly lower in the veno-occlusive regions (C(VO)) than in the non-veno-occlusive regions (C(Non)) in liver resection patients (median [range], 0.75 [0.29-2.0]µg/ml vs. 3.0 [0.46-6.4]µg/ml, p<0.001), donors (0.69 [0.29-1.9]µg/ml vs. 2.4 [0.46-6.4]µg/ml, p<0.001), and recipients (0.75 [0.34-1.8]µg/ml vs. 1.8 [0.54-6.4]µg/ml, p<0.001). Distributions of the C(VO)/C(Non) and the ratio of the hepatic uptake rate constant in the veno-occlusive regions to that in non-veno-occlusive regions were both around 40% (mean ± standard deviation, 0.36 ± 0.17 and 0.42 ± 0.16, respectively). When the functional remnant liver volume was calculated as a sum of non-veno-occlusive regions and veno-occlusive regions multiplied by C(VO)/C(Non), its ratio to the total liver volume was correlated with the improved postoperative/preoperative ratio of prothrombin time. CONCLUSIONS: Portal uptake function in veno-occlusive regions is approximately 40% of that in non-veno-occlusive regions. Intraoperative ICG-fluorescent imaging enables real-time evaluation of the extent of the functional decrease in veno-occlusive regions, enhancing accurate estimation of the hepatic functional reserve for determining the surgical indications and procedures.

Continuous ultrasound navigation for safe and precise anatomic resection of the liver.

BACKGROUND/AIM: Anatomic resection of the liver is one of the essential techniques in liver surgery. However, parenchymal transection precisely along intersegmental planes is still a technically demanding procedure, and an optimal navigation method is required. METHODOLOGY: Real-time ultrasound monitoring with a probe applied from behind the liver was tried as a means of locating the site where resection was proceeding in the liver and confirming the direction of hepatic parenchymal transection to facilitate anatomic resection of the liver. RESULTS: The ultrasound navigation technique was performed during 11 hepatectomies in 10 patients in whom adequate retrohepatic space could be obtained to position the ultrasound probe. Continuous monitoring of the site in the liver where the resection was being performed was feasible, and the optimal direction of parenchymal transection was easily determined on the basis of the ultrasound images without interrupting the surgical maneuvers. The mean speed of parenchymal transection was faster (2.4cm2/min vs. 1.2cm2/min, p=0.009) and the amount of blood loss per transected area was smaller (4.4mL/cm2 vs. 7.2mL/cm2, p=0.05) in patients treated with the current technique. CONCLUSIONS: Continuous ultrasound monitoring of the liver facilitates the safe and precise parenchymal transection during anatomic resections of the liver.

[Third-line therapy in a patient with recurrent colon cancer undergoing hemodialysis].

A 68-year-old man undergoing hemodialysis (HD) was diagnosed with recurrence of colon cancer and liver metastasis. He was treated with oxaliplatin, folinic acid and 5-fluorouracil (FOLFOX4), folinic acid, 5-fluorouracil and irinotecan (FOLFIRI), FOLFIRI+bevacizumab (BV), and cetuximab+irinotecan (CPT-11) as third-line therapy. Each drug was adequately reduced over time, but cetuximab was administered at the standard dose. The patient died of methicillin-resistant Staphylococcus aureus (MRSA) meningitis during the course of cetuximab+CPT-11 therapy, but there was no relation between the meningitis and the therapy. Therefore, each regimen can be safely performed, and cetuximab+CPT-11 therapy showed a significant anti-tumor effect and hence may be an effective regimen.

Surgical resection of arteriovenous malformation of the pancreatic head with acute pancreatitis: a case report.

Arteriovenous malformations (AVMs) are uncommon in the gastrointestinal tract, particularly in the pancreas. AVMs cause complications, including gastrointestinal bleeding, portal hypertension and pancreatitis. Therefore, a treatment strategy is not yet established. Surgical treatment or transcatheter arterial embolization is performed in patients with AVM, considering their conditions. A 54-year-old man presented with acute abdominal pain was diagnosed with acute pancreatitis due to AVM of the pancreatic head using dynamic computed tomography. Endoscopic ultrasonography further revealed meandering blood vessels in the pancreatic head. The patient underwent subtotal stomach-preserving pancreaticoduodenectomy. Histological examination revealed AVM of the pancreatic head with chronic pancreatitis. The patient had a good postoperative clinical course and was discharged on postoperative day 22. He remained asymptomatic. Pancreaticoduodenectomy can be considered an effective treatment method for selected cases of symptomatic AVM of the pancreatic head.

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 rare case of isolated splenic sarcoidosis: A case report and literature review.

Sarcoidosis is a multisystemic granulomatous disease. It is rarely isolated in the spleen. The present report describes a case of isolated splenic sarcoidosis that was diagnosed histologically following laparoscopic splenectomy. A 76-year-old woman, who underwent radical nephroureterectomy 7 years earlier for left renal pelvic cancer and mastectomy 6 years earlier for left breast cancer in another facility, was referred to our hospital for assessment of splenic tumors that were identified during a follow-up examination. The computed tomography scans revealed multiple nodules in the spleen, which had increased in size over 2 years. Positron emission tomography revealed accumulation of [18F]-fluorodeoxyglucose in the spleen. Laparoscopic splenectomy was performed and the diagnosis of sarcoidosis was confirmed histologically. A review of previous reports and the present case suggested that diagnosis of splenic sarcoidosis should be considered when the CT scans show multinodular splenic tumors, and sarcoidosis might be associated with malignant tumors.

Destruction of a wandering accessory right hepatic artery in a patient with pancreatic body cancer: a case report.

Aberrant right hepatic arteries are sometimes involved in pancreatic head tumors or accidentally damaged during surgical procedures, which could result in postoperative complications. The risk of such injury has been discussed in patients undergoing pancreatoduodenectomy; however, no reports describe the influence of this anomaly in distal pancreatectomy. We report a patient with pancreatic body cancer with an accessory right hepatic artery following a very unique route. A 77-year-old man was referred to our hospital for the treatment of pancreatic cancer. Computed tomography revealed an anomaly in the hepatic artery, with an accessory right hepatic artery encased in the extensive tumor, which also involved the stomach, left gastric artery, and portal vein. Curative resection was achieved by distal pancreatectomy with wedge resection of the stomach and portal vein reconstruction. Both the accessory right hepatic artery and the left gastric artery were sacrificed after confirming intrahepatic arterial flow by intraoperative Doppler ultrasonography. The route of the accessory right hepatic artery in this patient was unique in that it did not run directly into the hepatic hilum but from behind the pancreatic body, where it was incorporated into the tumor. Accurate preoperative assessment and identification of arterial variations is mandatory in any type of pancreatectomy.