Tranexamic acid and blood loss in pancreaticoduodenectomy: TAC-PD randomized clinical trial.

BACKGROUND: Tranexamic acid (TXA) may reduce intraoperative blood loss, but it has not been investigated in pancreaticoduodenectomy (PD). METHODS: A pragmatic, multicentre, randomized, blinded, placebo-controlled trial was conducted. Adult patients undergoing planned PD for biliary, duodenal, or pancreatic diseases were randomly assigned to TXA or placebo groups. Patients in the TXA group were administered 1 g TXA before incision, followed by a maintenance infusion of 125 mg/h TXA. Patients in the placebo group were administered the same volume of saline as those in the placebo group. The primary outcome was blood loss during PD. The secondary outcomes included perioperative blood transfusions, operating time, morbidity, and mortality. RESULTS: Between September 2019 and May 2021, 218 patients were randomly assigned and underwent surgery (108 in the TXA group and 110 in the placebo group). Mean intraoperative blood loss was 659 ml in the TXA group and 701 ml in the placebo group (mean difference -42 ml, 95 per cent c.i. -191 to 106). Of the 218 patients, 202 received the intervention and underwent PD, and the mean blood loss during PD was 667 ml in the TXA group and 744 ml in the placebo group (mean difference -77 ml, 95 per cent c.i. -226 to 72). The secondary outcomes were comparable between the two groups. CONCLUSION: Perioperative TXA use did not reduce blood loss during PD. REGISTRATION NUMBER: jRCTs041190062 (https://jrct.niph.go.jp).

Removing part of the pancreas is an operation with a risk of major blood loss. Tranexamic acid is a drug thought to reduce blood loss. This study asked the question, 'Does tranexamic acid reduce blood loss during surgery on the pancreas?' Half of patients received tranexamic acid during surgery. The other half received only standard care. This study showed that tranexamic acid did not decrease the blood loss during the surgery and may have little effect in patients having a pancreaticoduodenectomy.

Clinical value of fluorescent cholangiography for the infraportal type of right posterior bile duct.

BACKGROUND: The infraportal type of the right posterior bile duct (infraportal RPBD) is a well-known anatomical variation that increases the potential risk of intraoperative biliary injury. The aim of this study is to clarify the clinical value of fluorescent cholangiography during single-incision laparoscopic cholecystectomy (SILC) for patients with infraportal RPBD. MATERIAL AND METHODS: Our procedure for SILC utilized the SILS-Port, and another 5-mm forceps was inserted via an umbilical incision. A laparoscopic fluorescence imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography. Between July 2010 and March 2022, 41 patients with infraportal RPBD underwent SILC. We conducted retrospective reviews of patient data, focusing on the clinical value of fluorescent cholangiography. RESULTS: Thirty-one patients underwent fluorescent cholangiography during SILC, but the remaining ten did not. Only one patient who did not undergo fluorescent cholangiography developed an intraoperative biliary injury. The detectability of infraportal RPBD before and during the dissection of Calot's triangle was 16.1% and 45.2%, respectively. These visible infraportal RPBDs were characterized as connections to the common bile duct. The confluence pattern of infraportal RPBD significantly influenced its detectability during the dissection of Calot's triangle (p < 0.001). CONCLUSIONS: The application of fluorescent cholangiography can lead to safe SILC, even for patients with infraportal RPBD. Its benefit is emphasized when infraportal RPBD is connected to the common bile duct.

Short- and Long-Term Outcomes of Transabdominal Preperitoneal, Open Mesh Plug and Open Tissue Inguinal Hernia Repair.

BACKGROUND: There have been few comparisons of the postoperative outcomes of transabdominal preperitoneal (TAPP), open mesh plug (mesh plug) and open tissue (tissue) hernia repair. The objectives of this study were to compare these repair methods. METHODS: This was a retrospective study of 1813 inguinal hernia patients between January 2008 and December 2016. Of these patients, 474 underwent TAPP repair, 1293 underwent mesh plug repair, and 46 underwent tissue repair. The short-term and long-term outcomes determined by questionnaire were compared among the three groups. In addition, risk factors for patient dissatisfaction were assessed. RESULTS: In the TAPP group, the postoperative complications rate was the lowest at 4.6% (7.4% and 6.5% in the mesh plug and the tissue groups, respectively, P = 0.07), and recurrence rate was lower compared to the mesh plug group (0.8% vs. 3.3%, P = 0.002). As long-term outcomes, 92%, 88% and 75% of patients were satisfied in the TAPP, mesh plug and tissue groups, respectively (P = 0.03). The rate of patients with numbness was 3.1% in the TAPP group, 5.2% in the mesh plug group and 14% in the tissue group (P = 0.04). Predictive independent risk factors for patient dissatisfaction were complications (OR: 3.99, 95% CI: 1.35-11.8, P = 0.012) and infection (OR: 16.9, 95% CI: 1.25-229, P = 0.003). CONCLUSIONS: TAPP repair is superior to mesh plug and tissue repairs in terms of complications, satisfaction and numbness, as determined by questionnaire. Complications and infection were independently associated with the patient dissatisfaction.

Phase 2 Trial of Adjuvant Chemotherapy With S - 1 for Node-Positive Biliary Tract Cancer (N-SOG 09).

BACKGROUND: Nodal metastasis is a leading attributable factor of poor survival in biliary tract cancer (BTC), and adjuvant chemotherapy targeting this high-risk feature has not been attempted to date. This study aimed to test the efficacy of adjuvant S - 1 for patients with node-positive BTC. METHODS: This single-arm multicenter phase 2 trial enrolled patients who underwent resection for histologically proven node-positive BTC. In this trial, S - 1 was administered at a dose of 80-120 mg/day on 14 days of a tri-weekly cycle for 6 months. The primary end point of the trial was 3-year overall survival (OS), in which the result would be promising if the 90% confidence interval (CI) surpassed a threshold of 30% (alpha error, 0.1; beta error, 0.2). The secondary end points were relapse-free survival (RFS), feasibility, and toxicity. RESULTS: The trial included 50 patients with perihilar (n = 23) or distal (n = 20) cholangiocarcinoma, or gallbladder cancer (n = 7). The median numbers of positive lymph nodes and examined lymph nodes were respectively 2 and 15. The 3-year OS and RFS were respectively 50% (90% CI, 40.9-59.1%) and 32.0% (95% CI, 19.1-44.9%), with median survival times of 34.6 months (95% CI, 19.3-49.8 months) and 18.4 months (95% CI, 11.9-24.9 months). Although hematologic toxicity often occurred, grades 3 and 4 toxicity were rare. The completion rate of the test therapy was 64%, and the median relative dose intensity was 87.5% (interquartile range, 50-100%). CONCLUSION: Adjuvant chemotherapy with S - 1 may be promising for patients with node-positive BTC.

Lower bile duct metastasis from rectal cancer after surgery for liver metastasis and intrahepatic bile duct metastasis: a case report.

BACKGROUND: Biliary metastasis of colorectal cancer is a manifestation of metastatic liver carcinoma, and is often difficult to differentiate from cholangiocarcinoma. Further, lower bile duct metastasis of colorectal cancer is rare. We report the case of a 74-year-old woman who underwent pylorus-preserving pancreatoduodenectomy for lower bile duct metastasis of rectal cancer. CASE PRESENTATION: The patient had undergone laparoscopic low anterior resection for rectal cancer (pT3N0M0 stage IIA) 6 years ago, laparoscopic anterior liver resection for liver metastasis (Couinaud segment V) 3 years ago, and left and caudal lobectomy with extrahepatic bile duct resection for left intrahepatic bile duct metastasis 6 months ago. A follow-up examination showed a 15 mm mass in the common bile duct, for which she underwent pylorus-preserving pancreatoduodenectomy. Histological and immunohistological examination of the specimens revealed similar cytokeratin (CK) expression patterns, which were negative for CK7 and positive for CK20. Therefore, the definitive diagnosis was metastasis from rectal cancer. CONCLUSIONS: In summary, we encountered a case of lower bile duct metastasis from rectal cancer, which is often difficult to differentiate from cholangiocarcinoma. In such patients, CK7 and CK20 expression patterns are important in differentiating the two. The mechanism of metastasis in this case was considered to be through cancer cell implantation from lymphatic spread, or through distant metastasis of the primary cancer.

[Resection of an Advanced Rectal Gastrointestinal Stromal Tumor Following Neoadjuvant Chemotherapy].

A 66-year-old man was referred to our hospital after being diagnosed with a pelvic tumor. A subsequent transperineal biopsy revealed spindle cells with CD34·c-kit(+). An enhanced computed tomography scan showed a giant rectal-derived tumor in the pelvis. The tumor was pressing on the urinary bladder and the prostate, and appeared to invade the posterior wall ofthese organs. The patient was diagnosed with rectal GIST, and neoadjuvant therapy with 400mg/day imatinib was initiated. Three months later, the tumor reduction rate was at 33.6%, and surgery was performed. The operative method applied was pelvic exenteration and ileal conduit, for local R0 resection. The patient has remained recurrence free for 2.5 years since the surgery.

Low prognostic nutrition index as a prognostic biomarker in elderly patients with early gastric cancer after gastrectomy.

Purpose Non-invasive biomarkers including systemic inflammatory or nutrition-based index including neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) lymphocyte to monocyte ratio (LMR), and prognostic nutritional index (PNI) can be useful in determining treatment strategies for elderly patients with early gastric cancer (EGC). The aim of this study was to investigate the significance of these index for predicting the long-term survival of EGC patients aged 80 years over. Methods This study included 80 elderly EGC patients with pStageIA after gastrectomy. Optimal cutoff value for PNI, NLR, PLR and LMR were set by using receiver operating curve analysis. The long-term outcomes after gastrectomy were analyzed by univariate and multivariate Cox regression analyses. Results Cut-off value for PNI, NLR, PLR and LMR was set at 46.5, 2.8, 210 and 4.6, respectively. By univariate analyses, low PNI, high NLR, high PLR and low LMR were significantly associated with worse prognosis. By multivariate analysis, low PNI was confirmed as an independent prognostic factor after gastrectomy (HR 0.17 ; 95% CI 0.03-0.91 ; P = 0.04). 5-year overall survival rate of patients with low PNI (≤ 46.5) were 52.4%. Conclusion Low PNI might be useful biomarker to predict worse prognosis of elderly EGC patients after gastrectomy. J. Med. Invest. 71 : 113-120, February, 2024.

Intrathoracic anastomosis using handsewn purse-string suturing by the double-ligation method in laparo-thoracoscopic esophagectomy.

Purpose: In minimally invasive esophagectomy (MIE), it is important to reduce the rate of anastomotic leakage to ensure its safety. At our institute, the double-ligation method (DLM) has been introduced to insert and fix the anvil of the circular stapler for intracorporeal circular esophagojejunostomy in gastric surgery. We adopted this method for intrathoracic anastomosis (IA) in MIE. The aim of this study was to investigate the safety of IA with DLM in MIE. Methods: In this study, 48 patients diagnosed with primary middle or lower third segment thoracic esophageal carcinoma with clinical stage I, II, III or IV disease were retrospectively evaluated. Postoperative outcomes were assessed. Results: Among the 48 patients, 42 patients underwent laparo-thoracoscopic esophagectomy and IA using a circular stapler with the DLM. The average total operation time and thoracoscopic operation time were 433 and 229 minutes, respectively. The average purse-string suturing time was 4.7 minutes. The rates of anastomotic leakage and stenosis were 2.4% and 14.3%, respectively. The overall incidence of postoperative complications (Clavien-Dindo grade of ≥III) was 16.7%. The average postoperative stay was 16 days. Conclusion: The procedure of IA using a circular stapler with the DLM in MIE was safe and provided a low rate of anastomotic leakage.

Laparoscopic pancreaticoduodenectomy in patients with a history of right hemicolectomy : A report of three cases.

Laparoscopic pancreaticoduodenectomy (LPD) has been widely adopted in institutions with sufficiently skilled practitioners. This technique requires attentive dissection around the superior mesenteric vein (SMV) and artery. Dissection around the SMV and Henle's trunk is one of the key aspects of right hemicolectomy (RHC) ; adhesions and fibrosis around these vessels may impede LPD in patients with a history of RHC. We encountered three cases of periampullary tumors in patients with a history of RHC who were successfully treated with LPD. Cases 1, 2, and 3 were of 60-, 73-, and 74-year-old men with periampullary tumors. The operative durations in cases 1, 2, and 3 were 316, 267, and 265 min, respectively. The estimated blood loss volumes in cases 1, 2, and 3 were 20, 50, and 720 mL, respectively. The postoperative hospital stay durations in cases 1, 2, and 3 were of 13, 35, and 15 days, respectively. In conclusion, LPD following RHC may be safely completed with laparoscopy. J. Med. Invest. 70 : 285-289, February, 2023.

Neoadjuvant chemotherapy with S-1 plus cisplatin for esophageal squamous cell carcinoma.

S-1 shows good efficacy for esophageal squamous cell carcinoma (ESCC) under single use or combined with cisplatin or radiotherapy. The S-1 plus cisplatin (SP) regimen is one of the chemotherapy candidates for ESCC. However, the efficacy of the SP regimen for neoadjuvant chemotherapy (NAC) has not been verified. The aim of this study was to investigate the feasibility and efficacy of NAC with SP for advanced ESCC. In this study, patients with clinical stage II/III/IV ESCC received NAC with SP regimen from June 2016 to July 2020 in Ogaki Municipal Hospital were retrospectively evaluated. In the SP regimen, S-1 80 mg/m2 was administered on days 1-14, and cisplatin was administered 70 mg/m2 on day 1, repeated every 4 weeks, for two cycles. The completion rate, clinical and pathological response rate, adverse events, and long-term outcomes were analyzed. 43 ESCC patients were diagnosed clinical stage II/III/IV ESCC. Among the 43 patients, 31 patients underwent NAC with SP regimen. The completion rate was 93.5%. The clinical response and pathological response rates (grade 2 or 3) were 83.9% and 32.3%, respectively. Seven patients (22.6%) had a pathological complete response (grade 3). Grade 3 neutropenia was observed in 33.7% of cases. No other grade 3 cases or higher toxicity was observed. The 3-year relapse-free and overall survival rates were 52.6% and 65.6%, respectively. NAC with SP is a feasible and effective treatment strategy for advanced. ESCC. The antitumor response could be higher than that under the cisplatin plus 5-fluorouracil regimen.

Comparison of surgical outcomes of emergent laparoscopic cholecystectomy for acute cholecystitis between attending surgeons and senior residents: A propensity-matched analysis.

INTRODUCTION: Emergent laparoscopic cholecystectomy (LC) is routinely performed for acute cholecystitis (AC) at our institution. This study was conducted to investigate the feasibility and safety of emergent LC for AC performed by senior residents. MATERIALS AND METHODS: Data from 362 patients with AC who underwent emergent LC between January 2012 and June 2020 were retrospectively reviewed. Of these patients, 328 were operated on by senior residents (SR), and 34 were operated on by the attending surgeon (AS). Clinical characteristics and surgical and postoperative outcomes were compared between the SR and AS groups. Propensity score matching was used to minimize selection bias. When the operator was an SR, the LC was assisted by the AS. RESULTS: Before matching, in the SR group, more patients had a history of abdominal surgery, and C-reactive protein and white blood cell counts were significantly higher. In the image findings, the minor axis of the gallbladder (GB) was longer, and the wall of the GB was thicker in the SR group. After propensity score matching, 28 pairs were identified. There were no significant differences in operative time (83 vs 88 minutes, P = .92), the amount of blood loss (25 vs 10 mL, P = .13), conversion to open surgery (3.6% vs 3.6%, P = 1), postoperative complications (7.2% vs 0%, P = .74), and postoperative hospital stay (4 vs 4 days, P = .87). CONCLUSION: Emergent LC for AC performed by SR under supervision appears to be feasible and safe.

Preoperative risk factors for technical difficulty in emergent laparoscopic cholecystectomy for acute cholecystitis.

AIM: We have routinely performed emergent laparoscopic cholecystectomy (LC) as soon as we diagnosed acute cholecystitis (AC), if patients could tolerate surgery. This study was conducted to identify the preoperative risk factors that predict the technical difficulty of emergent LC for AC. METHODS: A retrospective review of patients with AC who underwent emergent LC between 2012 and 2019 was conducted. Technical difficulty was defined as the presence of the following conditions: open conversion, operative time ≥120 min, or blood loss ≥500 ml. RESULTS: In all, 327 patients were included and divided into difficult LC (DLC, n = 61) and nondifficult LC (non-DLC, n = 266). Multivariate logistic analysis revealed that symptom duration ≥72 h was the only independent risk factor for DLC. Comparison of late LC (beyond 72 h, LLC) and early LC (within 72 h, ELC) showed a lower rate of creation of the critical view of safety and a longer hospital stay, as well as a longer operative time, a larger amount of bleeding, and a higher open conversion rate in LLC. However, the postoperative complication rates were equivalent. CONCLUSION: LC for AC with symptom duration ≥72 h tends to be technically difficult. However, it is acceptable regarding operative outcomes.

Assessment of Perioperative Symptoms of Patients with Gastric Cancer Using The Edmonton Symptom Assessment System Revised Japanese version (ESAS-r-J).

Purpose To evaluate the perioperative symptoms of gastric cancer patients undergoing gastrectomy using the Edmonton Symptom Assessment System Revised Japanese version (ESAS-r-J), which is a nine-item visual analogue scale to rate patient symptoms. Methods Between February 2015 and March 2017, 246 patients completed the ESAS-r-J before and after gastrectomy. We evaluated the changes in the prevalence and score of each ESAS-r-J item before and after gastrectomy. In addition, we compared them after gastrectomy between patients who underwent the different approaches. Results Before gastrectomy, anxiety and well-being were the most prevalent items (80%), followed by depression (45%). After gastrectomy, well-being was the most prevalent item (87%), followed by pain (68%). The prevalence of anxiety decreased from 80% to 59% (P = 0.002). The depression and anxiety scores decreased from 1.6 to 1.1 (P < 0.001) and from 2.6 to 1.7 (P = 0.002), respectively. The total score was higher in patients who underwent open surgery than in patients who underwent laparoscopic surgery (16.9 vs 12.9 ; P = 0.031). Conclusions After gastrectomy, psychological symptoms such as depression and anxiety improved despite more physical complaints than before gastrectomy. The laparoscopy was less invasive. It is very important to take care of psychological aspects before gastrectomy. J. Med. Invest. 68 : 90-95, February, 2021.

Laparoscopic liver resection after laparoscopic pancreatoduodenectomy for liver metastases of ampulla of Vater adenocarcinoma.

BACKGROUND: Repeat laparoscopic surgery has become increasingly common. However, reports of liver resection after pancreatoduodenectomy are scarce, and we report the first successful case of a patient who underwent laparoscopic liver resection after laparoscopic pancreatoduodenectomy. CASE PRESENTATION: A 65-year-old man underwent laparoscopic pancreatoduodenectomy for ampulla of Vater adenocarcinoma. According to the American Joint Committee on Cancer (8th edition) staging guidelines, the tumour was labelled as stage IIIB (fT2N2M0). Twelve months later, a computed tomography (CT) scan revealed liver masses (in segments 3 and 5) and swollen para-aortic lymph nodes. After six chemotherapy courses of gemcitabine with cisplatin, the CT scan showed the disappearance of the para-aortic lymph nodes and progression of liver metastases. Nineteen months after the initial surgery, the patient underwent laparoscopic partial liver resection of segment 5 and left lateral sectionectomy. First, we performed the operation in the left half lateral decubitus position. In this position, the portal vein was isolated safely without hindering the hepato-jejunal anastomosis, although the adhesions around the hepato-jejunal anastomosis were dense. Therefore, we were able to perform liver transection safely with vascular inflow control. The operation duration was 235 min, and the volume of blood loss was 100 g. Macroscopically, the resected margins were negative. The patient was uneventfully discharged 12 days after the second operation. Afterwards, drainage was needed because of an intra-abdominal abscess. Currently, he has been alive for 8 months postoperatively, receives chemotherapy to suppress para-aortic lymph node metastases, and has not had another recurrence. CONCLUSIONS: Liver resection after pancreatoduodenectomy can be performed safely with an innovative body position to isolate the portal vein, which is a key point of the surgery. A laparoscopic approach for liver resection after pancreatoduodenectomy is a feasible option.