The impact of preclinical clerkship in general surgery on medical students' attitude to a surgical career.

PURPOSE: With the advent of a new program for postgraduate medical students in 2004, the number of applicants choosing surgical careers in Japan has been declining. We conducted this study to evaluate the impact of preclinical clerkship and how it affects students' attitudes toward a surgical career. METHODS: The subjects of our study were fifth-year medical students who participated in a clinical clerkship in general surgery in our department between April 2021 and March 2022. We conducted pre- and post-preclinical clerkship surveys to assess the perceived image of surgeons and the impact of clerkship on surgical career interest. RESULTS: Among 132 medical students (77 men and 55 women) who rotated through preclinical clerkship in our department, 125 participated in the survey and 66% expressed interest in a surgical career. In the post-clerkship survey, an increased interest in a surgical career was expressed by 79% of the students; notably, including those who initially expressed interest. Approximately 77% of students were satisfied with the practical skill training they received. CONCLUSION: Engaging medical students early in surgical experience through a preclinical clerkship for general surgery appears to promote their interest in a surgical career.

Regulation of MRE11A by UBQLN4 leads to cisplatin resistance in patients with esophageal squamous cell carcinoma.

Resistance to standard cisplatin-based chemotherapies leads to worse survival outcomes for patients with esophageal squamous cell carcinoma (ESCC). Therefore, there is an urgent need to understand the aberrant mechanisms driving resistance in ESCC tumors. We hypothesized that ubiquilin-4 (UBQLN4), a protein that targets ubiquitinated proteins to the proteasome, regulates the expression of Meiotic Recombination 11 Homolog A (MRE11A), a critical component of the MRN complex and DNA damage repair pathways. Initially, immunohistochemistry analysis was conducted in specimens from patients with ESCC (n = 120). In endoscopic core ESCC biopsies taken from 61 patients who underwent neoadjuvant chemotherapy (NAC) (5-fluorouracil and cisplatin), low MRE11A and high UBQLN4 protein levels were associated with reduced pathological response to NAC (P < 0.001 and P < 0.001, respectively). Multivariable analysis of surgically resected ESCC tissues from 59 patients revealed low MRE11A and high UBLQN4 expression as independent factors that can predict shorter overall survival [P = 0.01, hazard ratio (HR) = 5.11, 95% confidence interval (CI), 1.45-18.03; P = 0.02, HR = 3.74, 95% CI, 1.19-11.76, respectively]. Suppression of MRE11A expression was associated with cisplatin resistance in ESCC cell lines. Additionally, MRE11A was found to be ubiquitinated after cisplatin treatment. We observed an amplification of UBQLN4 gene copy numbers and an increase in UBQLN4 protein levels in ESCC tissues. Binding of UBQLN4 to ubiquitinated-MRE11A increased MRE11A degradation, thereby regulating MRE11A protein levels following DNA damage and promoting cisplatin resistance. In summary, MRE11A and UBQLN4 protein levels can serve as predictors for NAC response and as prognostic markers in ESCC patients.

One-stage fluoroscopy-guided laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy in patients with cholecystocholedocholithiasis who previously had undergone gastrectomy for gastric cancer.

BACKGROUND: Patients with a history of gastrectomy have a higher incidence of cholecystocholedocholithiasis (CCL) and related morbidities than the general population. However, the management of common bile duct (CBD) stones with endoscopic retrograde cholangiopancreatography is challenging in patients after Roux-en-Y or Billroth II reconstruction because of the altered gastrointestinal anatomy. The aim of the current study was to evaluate the safety and efficacy of one-stage laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy (LTPBD+LC) in patients with previous gastrectomy for gastric cancer. METHODS: This retrospective cohort study included five patients with CCL who had previously undergone gastrectomy. All five underwent LTPBD+LC between May 2015 and February 2020 at our institution. The primary end-point was complete clearance of the CBD stones. RESULTS: Of the 311 patients who had undergone gastrectomy for gastric cancer from December 2009 to December 2018 at our institution, six (1.9%) were later diagnosed with CCL. Five of the six patients did not need emergency biliary drainage and underwent conservative therapy and subsequent elective LTPBD+LC. LTPBD+LC was successfully performed in all cases. None of the patients required conversion to open surgery. The rate of complete clearance of the CBD stones was 100%. The mean operative time of the entire procedure was 126 minutes (range, 102-144 minutes), and the mean blood loss was 12.4 mL (range, 1-50 mL). There were no major perioperative complications, and the mean length of postoperative hospital stay was 4.2 days (range, 3-7 days). CONCLUSION: One-stage LTPBD+LC may be a feasible procedure for patients with CCL who have previously undergone gastrectomy for gastric cancer.

Vertical distance from navel as a risk factor for bowel obstruction associated with feeding jejunostomy after esophagectomy: a retrospective cohort study.

BACKGROUND: Placement of feeding jejunostomy (PFJ) during esophagectomy is an effective method to maintain adequate nutrition, but is associated with serious complications such as bowel obstruction and jejunal torsion. The purpose of the current study was to analyze the incidence, clinical features, and risk factors of bowel obstruction associated with feeding jejunostomy (BOFJ) after PFJ. METHODS: This was a retrospective cohort study of 70 patients who underwent esophagectomy with three-field lymph node dissection for esophageal cancer and treated with PFJ between March 2013 and December 2019 in our hospital. Abdominal dissection was performed under hand-assisted laparoscopic surgery (HALS) from March 2013 to March 2015, and was changed to complete laparoscopic surgery in April 2015. We compared patients with and without BOFJ, and the incidence of BOFJ was evaluated. The primary endpoint was incidence of BOFJ after PFJ. RESULTS: Six patients (8.5%) were diagnosed with BOFJ, all of whom were symptomatic and in the HALS group. In addition, 3 cases displayed histories of recurrent BOFJ (3, 3, and 5 times). Laparotomy was performed in all cases. Subgroup analysis of the HALS group showed a significant difference only in straight-line distance between the jejunostomy and navel as a significant pre- and perioperative factor (117 mm [101-130 mm] vs. 89 mm [51-150 mm], p < 0.001). Furthermore, dividing straight-line distance between the jejunostomy and navel into VD and HD, only VD differed significantly (107 mm [93-120 mm] vs. 79 mm [28-135 mm], p = 0.010), not HD (48 mm [40-59 mm] vs. 46 mm [22-60 mm], p = 0.199). CONCLUSIONS: VD between the jejunostomy and navel was associated with BOFJ after PFJ with HALS esophagectomy. PFJ < 9 cm above the navel during HALS esophagectomy might effectively prevent BOFJ.

Effectiveness and safety of tumor site marking with near-infrared fluorescent clips in colorectal laparoscopic surgery: A case series study.

BACKGROUND: In colorectal laparoscopic surgery, accuracy of tumor marking has been an important but not fully resolved issue. The tattoo marking technique or intraoperative endoscopy have been used but they either carry the risk of accidental intestinal puncture or require either longer operation times, a skilled endoscopist and/or intraoperative colon insufflation. We supposed that tumor site marking with the near-infrared fluorescent clips, ZEOCLIP FS clips (Zeon Medical Co., Ltd., Tokyo, Japan) might overcome disadvantages of both tattoo marking and intraoperative endoscopy-based tumor localization methods. This is the first report on the case series using near-infrared fluorescent marking clip. We summarize the early results in 30 patients, who underwent colorectal laparoscopic surgery; we focus particularly on effectiveness and safety of the method. MATERIALS AND METHODS: Thirty consecutive patients, who underwent laparoscopic surgery for colorectal cancer after previous endoscopic ZEOCLIP FS placement were enrolled from May 2019 till October 2019. The primary endpoint was the rate of intraoperative clip detection and the secondary endpoints were: the rate of adverse effects, percentage of slipped clips and usefulness of plain abdominal radiography to preoperatively confirm the clip retention. Locations of fluorescent clips were identified with a full-color fluorescence laparoscope. All operations and clip placements were performed by the same senior surgeon with sufficient experience in both procedures. RESULTS: Fluorescent clips could be detected in 94.1% of tumor lesions. Three (2.1%) clips dropped before surgery. Plain abdominal radiography was sufficient to assess clip retention in all cases. No adverse effects related to either clip placement or clip detection were observed. CONCLUSION: The ZEOCLIP FS could be easily detected from the serosal side of the intestinal tract when placed 1-2 days before surgery. Fluorescent clip-guided laparoscopy may be considered a safe and effective method for localization of colorectal tumor sites. The Research Registry UIN: researchregistry5400.

Magnetic compression anastomosis for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction: a case report.

BACKGROUND: Postoperative non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction is a rare complication. If endoscopic balloon dilation proves ineffective, patients need re-operation under general anesthesia and experience a high rate of postoperative complications. Magnetic compression anastomosis is a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery. We report a case in which magnetic compression anastomosis was successfully performed to avoid re-operation for non-anastomotic stenosis of the proximal jejunum after total gastrectomy with Roux-en-Y reconstruction. CASE PRESENTATION: A 70-year-old woman was admitted to our hospital for treatment of non-anastomotic stenosis of the proximal jejunum. Open total gastrectomy and Roux-en-Y reconstruction were performed 2 years previously for advanced gastric cancer at another hospital. She complained of anorexia and obstructed passage of food. No recurrence of gastric cancer was identified. Esophagogastroduodenoscopy showed circumferential membranous stenosis of the jejunum 3 cm distal to the esophago-jejunal anastomosis. Endoscopic balloon dilation was performed three times, but proved ineffective. Magnetic compression anastomosis was planned because the stenosis existed near the esophago-jejunal anastomosis and re-operation was a highly invasive procedure requiring intrathoracic anastomosis. Endoscopic balloon dilation preceded placement of the parent magnet on the anal side of the stenosis. Confirming the improvement of stenosis, the parent magnet was placed on the anal side of the stenosis during esophagogastroduodenoscopy. The parent magnet attached to nylon thread was fixed to the cheek to prevent magnet migration. A week after placing the parent magnet, restenosis was confirmed and the daughter magnet was placed via nylon thread on the oral side of the stenosis. The two magnets were adsorbed in the end-to-end direction across the stenosis. Magnets adsorbed in the end-to-end direction moved to the anal side 11 days after placement. Wide anastomosis was confirmed by esophagogastroduodenoscopy. Endoscopic balloon dilation was regularly performed to prevent restenosis after magnetic compression anastomosis. No complications were observed postoperatively. The patient was able to eat normally and successfully reintegrated into society. CONCLUSIONS: Magnetic compression anastomosis could be a feasible procedure to avoid surgery for non-anastomotic stenosis of the proximal jejunum after gastrectomy with Roux-en-Y reconstruction.

Near-infrared fluorescent clip guided gastrectomy: Report of 2 cases (Case reports).

INTRODUCTION: This is the first report on near-infrared fluorescent (NIRF) clip-guided gastrectomy. The NIRF clip, ZEOCLIP FS, emits NIRF signals when excited. We hypothesized that preoperative placement of the ZEOCLIP FS near a gastric lesion would allow fluorescence laparoscopic localization of the clip, and hence, the lesion, during surgery. We report this technique in two cases. CASE PRESENTATION: Case 1: An 81-year-old female was diagnosed with early gastric cancer and a pedunculated 4 cm large hyperplastic polyp that had prolapsed into the duodenum, and was scheduled for laparoscopy-assisted distal gastrectomy, due to the potential risk of dissection of the polyp with the duodenal wall. On the day before surgery, ZEOCLIP FS clips were endoscopically placed at the cancer site and the polyp. The locations of the fluorescent clips were confirmed intraoperatively using a full-color fluorescence laparoscope. CASE 2: An 81-year-old male was scheduled for laparoscopy-assisted total gastrectomy for gastric cancer under fluorescent clip-guidance. Clip locations could not be confirmed during initial intraoperative observation. However, when the stomach wall was raised using forceps during a second observation attempt, the fluorescent clip locations were confirmed. DISCUSSION: In case 1, it was easy to confirm clip location, facilitating complete resection of early gastric cancer without dissecting the polyp. In case 2, the fluorescent clip was located by raising the stomach and adjusting the angle between the stomach wall and the fluorescence laparoscope. CONCLUSION: The positive results of these two cases warrant conducting feasibility studies for use of this method.

Fluoroscopic balloon dilation for early jejunojejunostomy obstruction after gastrectomy with roux-en-Y reconstruction: a case series of three patients.

BACKGROUND: Small bowel obstruction after gastrectomy with Roux-en-Y reconstruction (R-Y reconstruction) is not a rare complication. However, patients who need re-operation for this complication have a high rate of postoperative complications. We report a case series of three patients who underwent fluoroscopic balloon dilation (FBD) for early jejunojejunostomy obstruction (JJO) after gastrectomy with Roux-en-Y reconstruction (R-Y reconstruction). CASE PRESENTATION: Three patients were referred to our hospital for surgery for gastric cancer. Robot-assisted distal gastrectomy with D2 lymph node dissection and antecolic R-Y reconstruction were performed in two patients, and robot-assisted total gastrectomy with D1+ lymph node dissection and antecolic R-Y reconstruction was performed in one patient. The jejunojejunostomy was created as a side-to-side anastomosis using a linear 45-mm stapler. The entry hole was closed with a knotless barbed suture, and serosal-muscle layer suture reinforcement with an absorbable suture was performed at the jejunojejunostomy. Subsequently, all the patients were diagnosed with JJO by computed tomography and upper gastrointestinal series. The average time to JJO from gastrectomy was 5 days (range 2-7); initial clinical symptoms were vomiting in all three cases, with simultaneous upper abdominal pain in one case. We successfully performed FBD in all three cases after unsuccessful conservative treatment using an ileus tube. The clinical symptoms improved soon after FBD, and all the patients were able to avoid re-operation. The average period to FBD from JJO was 10 days (range 4-14). The average procedure time was 46 min (range 29-68), and the average duration to oral intake from FBD was 4 days (range 2-5). The average duration of hospital stay after FBD was 12 days (range 9-15). There were no complications in any of the cases. CONCLUSION: FBD might be a feasible procedure to avoid surgery for early small bowel obstruction after gastrectomy with R-Y reconstruction.

PINPOINT® can be used for photodynamic diagnosis based on 5-aminolevulinic acid-induced protoporphyrinIX in gastric cancer surgery: Report of a case.

INTRODUCTION: Photodynamic diagnosis (PDD) using 5-aminolevulinic acid (5-ALA) has been used as a diagnostic procedure for malignant diseases. Dedicated laparoscopes (e.g., an IMAGE1 Camera System®) are used for this procedure. We report a case treated with laparoscopic total gastrectomy with 5-ALA-PDD using the PINPOINT® system. PRESENTATION OF CASE: A patient in his 80 s with diffuse-type gastric cancer with pyloric stenosis and ascites was admitted to our hospital. Double percutaneous transesophageal gastrotubing (dPTEG) for both gastric decompression and enteral nutrition and two cycles of preoperative chemotherapy with S-1 plus oxaliplatin were performed preoperatively. Additionally, we preoperatively performed an ex vivo experiment that confirmed that the PINPOINT® system can be used to observed protoporphyrin IX (PpIX) fluorescence. Three hours before surgery, 5-ALA hydrochloride was administered through dPTEG. Observation was performed by PINPOINT®, and Aladuck® was used as an excitation light source. Peritoneal nodules and sampled lymph nodes with red fluorescence were observed by 5-ALA-PDD. Accordingly, we gave up a radical operation and laparoscopic total gastrectomy without systematic lymphadenectomy to improve anemia and release pyloric stenosis was performed. The patient's postoperative course was uneventful. DISCUSSION: It is possible that the connection with each of the scopes and an exclusive light source (Aladuck®) enable the easy use of 5-ALA-PDD without dedicated laparoscopy. It is expected that 5-ALA-PDD would show the further spread of gastrointestinal cancer if it could be performed with many types of laparoscopes. CONCLUSION: We found that 5-ALA-PDD-guided surgery can be easily performed in a short time using the PINPOINT® system.

Magnetic compression anastomosis with atypical anastomosis for anastomotic stenosis of the sigmoid colon: a case report.

BACKGROUND: Magnetic compression anastomosis (MCA) is mainly applied in the gastrointestinal and biliary tracts through a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery. Magnets usually adsorb in the end-to-end direction (end-to-end anastomosis), exert a strong magnetic force and create an anastomosis according to the size of the magnets. Regular endoscopic dilation is required to prevent restenosis when the anastomotic size is small. We report a case in which MCA was successfully used to treat anastomotic stenosis of the sigmoid colon; the magnets adsorbed in the side-to-side direction rather than the end-to-end direction and generated a wide anastomosis in a short time that did not require endoscopic dilation. CASE PRESENTATION: An 81-year-old woman was admitted to our hospital to treat anastomotic stenosis of the sigmoid colon for closure of transverse colostomy. Two years prior, the Hartmann operation and drainage were performed at other hospitals due to perforated diverticulitis of the sigmoid colon. Obstruction of the sigmoid colostomy occurred, and a transverse colostomy was performed. One year after the first surgery, high anterior resection was performed, but anastomotic stenosis occurred, causing obstruction. MCA was planned because the patient had a history of multiple operations and was expected to have strong adhesions postoperatively. MCA was safely performed, but two magnets were accidently adsorbed in the side-to-side direction. The magnet position could not be changed. The two magnets were expected to move and adsorb in an end-to-end direction naturally due to bowel movements. The magnets that adsorbed in the side-to-side direction dropped from the anus 5 days after treatment, and the anastomosis was observed by colonoscopy. Three ileus tubes were placed from the transverse colostomy beyond the anastomosis to prevent restenosis. Colonoscopy showed that the anastomosis diameter was wider than expected at 14 days after treatment, and endoscopic dilation was not necessary. No complications were observed in this patient's postoperative course. Finally, closure of the patient's colostomy was successfully performed. CONCLUSIONS: MCA with side-to-side anastomosis generated a wide anastomosis in a short time.

Transanal Total Mesorectal Excision (Ta-TME) in a Rectal Cancer Patient with a History of Abdominal Surgery: A Case Report.

A 65-year-old man was followed up after undergoing Hartmann's operation for the treatment of obstructive colon cancer 1 year earlier. He presented with bloody stool and underwent examination, including lower gastrointestinal endoscopy, and he was diagnosed with rectal cancer. Since he had a history of multiple abdominal surgeries, including Hartmann's operation, severe pelvic adhesions were expected. Thus, in consideration of surgical safety and curability, transanal total mesorectal excision (Ta-TME) was performed. The duration of the surgery was 3 h, and there was minimal blood loss. Histopathological findings did not reveal remnants of cancer in the resected margin, and the patient was discharged on hospital day 7. Rectal cancer has a higher rate of local recurrence than colon cancer. To prevent local recurrence, ensuring a rectal circumferential resection margin (CRM) with TME is essential, which is, however, challenging in obese patients and in those with giant tumors, contracted pelvis, prostatic hypertrophy, etc., since these conditions complicate pelvic surgery. The same is true for patients with a history of multiple abdominal surgeries. It is expected that these problems can be resolved by Ta-TME. In the present case, Ta-TME was extremely useful in rectal cancer surgery for a patient with a history of multiple abdominal surgeries, including Hartmann's operation.

Validation and clinical usefulness of pre- and postoperative systemic inflammatory parameters as prognostic markers in patients with potentially resectable pancreatic cancer.

BACKGROUND: Several preoperative systemic inflammatory parameters, such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), prognostic nutritional index (PNI), and Glasgow prognostic score, have been reported to be associated with the prognosis of solid tumors. In this study, we compared pre- and postoperative hematological inflammatory parameters and validated their prognostic significance in pancreatic cancer patients who underwent surgical resection. METHODS: Clinical records from 211 consecutive pancreatic cancer patients who underwent surgical resection at our institution were retrospectively analyzed. The optimal cutoff values of hematological inflammatory parameters, including lymphocyte count, NLR, PLR, LMR, and PNI, were determined by time-dependent receiver-operating characteristic analysis. RESULTS: The postoperative neutrophil count and serum albumin level were significantly decreased in patients who underwent pancreatoduodenectomy (PD group) and in those who underwent distal pancreatectomy (DP group) compared to the levels at baseline. The postoperative lymphocyte count, monocyte count, and platelet count were significantly increased in the DP group compared to those at baseline. As a result, the postoperative NLR and PNI significantly decreased in both groups. The multivariate analysis identified intraoperative peritoneal washing cytology, administration of adjuvant therapy, tumor size, extrapancreatic nerve plexus invasion, and preoperative PLR as independent prognostic factors for overall survival. CONCLUSIONS: Systemic inflammatory responses were altered after pancreatic resection in pancreatic cancer patients. Preoperative PLR may be a useful prognostic marker in pancreatic cancer patients undergoing surgical resection.

Outcomes in patients with pancreatic cancer as a secondary malignancy: a retrospective single-institution study.

PURPOSE: This study aimed to evaluate the clinicopathological features and oncological outcomes of pancreatic cancer (PC) patients with prior malignancies (2nd primary PC) compared with those of patients without any prior malignancies in their history (1st primary PC). METHODS: We retrospectively reviewed clinical data from 185 PC patients undergoing surgical resection. Patients were divided into the 1st and 2nd primary PC groups. RESULTS: Forty-three patients (23.2%) had a history of prior malignancy. The 2nd primary PC group was significantly older than the 1st primary PC group (mean, 72.1 vs. 65.9 years, respectively, P < 0.001) and was more frequently asymptomatic compared to the 1st primary PC group (67.4 vs. 31.0%, respectively, P < 0.001). The tumor size was larger, and extrapancreatic nerve plexus invasion, venous invasion, and lymph node metastasis were more frequently observed in the 1st primary PC group. The rate of adjuvant therapy administration was lower in 2nd primary PC patients (72.5 vs. 51.2%, P = 0.009). In the survival analysis, no significant difference in overall or disease-free survival was found between the two groups (16.8 vs. 16.4 months, P = 0.725, and 8.7 vs. 9.3 months, P = 0.284, respectively). CONCLUSION: Despite significant surveillance bias, such as earlier detection in 2nd primary PC, the outcomes of patients with 2nd primary PC were comparable to those of patients with 1st primary PC. Further investigation with a larger sample size and matching for patient age and tumor stage in both groups is needed to elucidate the biological features of 2nd primary PC.

A novel fluorescent marking clip for laparoscopic surgery of colorectal cancer: A case report.

INTRODUCTION: In laparoscopic surgery, marking of tumor location has been gaining importance. Tattoo marking has been often used but the technique carries the risk of accidental peritoneal scattering or other organ injury. We have been involved in the development of a novel fluorescent clip for marking tumor sites and supposed that its usage would reduce risks related to other marking methods. CASE PRESENTATION: A 52-year-old man was diagnosed with sigmoid colon cancer and polyp, and was scheduled for laparoscopic sigmoidectomy. On the day before operation, fluorescent clips (ZEOCLIP FS: Zeon Medical co, Ltd, Tokyo) were endoscopically placed around the tumor and polyp sites, 4 clips for each lesion attached every 90 degrees within the colonic lumen, respectively. During the operation, locations of the fluorescent clips were easily confirmed using a full-color fluorescent laparoscope, VISION SENSE (Medtronic Co., U.S.). Curative operation was performed accordingly with the preoperative pathological and radiological findings. The postoperative course was uneventful. DISCUSSION: Locations of intraluminally placed fluorescent clips were clearly and easily recognized through the serosal layer of the intestinal wall using a fluorescent laparoscope. Complications related to dye scattering or intestinal wall/other organ perforation were not observed suggesting that future incorporation of this tumor site marking technique into laparoscopic surgery might be beneficial. CONCLUSION: The fluorescent marking clips were easily placed and recognized with a fluorescent laparoscope. This method is expected to be safe and risks of accidental puncture related to tattoo marking method can be reduced or almost eliminated.

Predictive Factors for Elevated Postoperative Carbohydrate Antigen 19-9 Levels in Patients With Resected Pancreatic Cancer.

AIM: In this study, we investigated the clinical significance of postoperative serum carbohydrate antigen (CA) 19-9 in patients with pancreatic ductal carcinoma (PDAC). PATIENTS AND METHODS: A series of 116 patients with macroscopically curative PDAC resection was retrospectively evaluated. The cut-off level for elevated postoperative CA 19-9 was 37 U/ml. RESULTS: Patients with high postoperative CA19-9 levels had a significantly poorer prognosis than patients with normal postoperative CA19-9 levels, as revealed by the log-rank test. Multivariate analysis identified R1 resection and preoperative serum CA19-9 level ≥400 U/ml independently predicted elevated postoperative CA 19-9 levels. R1 resection and preoperative serum CA19-9 ≥400 U/ml were significantly associated with the recurrence of peritoneal dissemination and hepatic metastasis, respectively, within one year of operation. CONCLUSION: Elevated postoperative serum CA 19-9 level was associated with a poor prognosis and reflected positive resection margins and high preoperative CA 19-9 levels, which indicated presence of occult distant metastasis in patients with PDAC.

Association of Preoperative Platelet-to-Lymphocyte Ratio with Poor Outcome in Patients with Distal Cholangiocarcinoma.

BACKGROUND: Several preoperative systemic inflammatory parameters, such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and Glasgow Prognostic Score, have been reported to be associated with the prognosis of solid tumors. However, there are conflicting survival data regarding these parameters in cholangiocarcinoma. OBJECTIVES: In this study, we performed a retrospective cohort analysis of patients with distal cholangiocarcinoma (DCC) who underwent surgical resection to evaluate the prognostic value of a cluster of preoperative hematological inflammatory parameters for survival. METHOD: Fifty-three patients with DCC who underwent pancreaticoduodenectomy with curative intent were enrolled. The optimal cutoff values of hematological inflammatory parameters, including the absolute lym-phocyte count, NLR, PLR, and LMR, were determined by time-dependent receiver operating characteristic analysis. -Results: The univariate analysis for overall survival (OS) of conventional factors and hematological inflammatory parameters identified that portal vein invasion and PLR had p values of ≤0.1. The univariate analysis for disease-free survival (DFS) identified that lymph node metastasis, PLR, lymphocyte count, and number of positive lymph nodes (≥3) had p values of ≤0.1. These factors were incorporated into the full model and variables were selected using the backward stepwise method. The multivariate analysis identified portal vein invasion and high PLR as independent prognostic factors for OS (p = 0.033 and 0.039, respectively) and high PLR and number of positive lymph nodes (≥3) as independent prognostic factors for DFS (p = 0.016 and 0.004, respectively). CONCLUSIONS: Preoperative PLR assessment may be useful for detecting high-risk DCC patients undergoing surgical resection for aggressive adjuvant therapy.

Rapid progression of a granulocyte colony-stimulating factor-producing liver tumor metastasized from esophagogastric junction cancer: A case report and literature review.

The current study presents the case of a 72-year-old woman with a rapidly enlarged liver metastasis from esophagogastric junction (EGJ) cancer, accompanied by progressive leukocytosis (47,680/µl) and elevated serum granulocyte colony-stimulating factor (G-CSF; 779 pg/ml). The patient underwent right hemihepatectomy 26 months after a total gastrectomy. On the seventh post-operative day the patient's leukocyte count and serum G-CSF level decreased to 4,280/µl and ≤19.5 pg/ml, respectively. Histologically, the lesion was a well to moderately differentiated adenocarcinoma similar to the primary lesion. Therefore, this tumor was clinically diagnosed as a G-CSF-producing liver metastasis from EGJ cancer, although immunohistochemical staining for G-CSF was negative. A right pulmonary nodule detected simultaneously with the hepatic mass was resected four months following the hepatectomy and was diagnosed as a pulmonary metastasis. The patient's leukocyte count was normal at the time of her initial surgery for EGJ cancer, and her clinical course varied for different metastatic sites. The liver metastasis was accompanied by progressive leukocytosis and elevated serum G-CSF and demonstrated rapid tumor growth during a six-month period, whereas the non-G-CSF-producing pulmonary metastasis grew slowly during the same period. In addition 21 reported cases of G-CSF-producing upper gastrointestinal tract cancer were reviewed to elucidate the clinicopathological features of this disease.

Clinical implications of the proliferative ability of the squamous component regarding tumor progression of adenosquamous carcinoma of the pancreas: A preliminary report.

OBJECTIVES: The objectives of this study were to examine the clinicopathological characteristics of patients with adenosquamous carcinoma of the pancreas (ASCP) and assess whether the proliferative ability of the squamous cell carcinoma (SCC) component contributes to either its proportion within the tumor or tumor progression. METHODS: We retrospectively reviewed 12 patients with resected ASCP and compared their clinicopathological characteristics with those of 161 patients with adenocarcinoma of the pancreas (ACP). The Ki-67 indexes of the separate ASCP components were assessed. RESULTS: All the clinicopathological characteristics and outcomes were similar between the ASCP patients and ACP patients. Among the 12 ASCP cases, nine exhibited higher Ki-67 levels in the SCC component than in the corresponding adenocarcinoma (AC) component at primary sites (P = 0.022). The component with a higher Ki-67 level coincided with the predominant component at the primary site in nine of 11 patients. In all 10 patients who presented lymph node metastasis, the metastases almost entirely consisted of either the SCC or AC component. The SCC component was absent from metastatic lymph nodes in five of 10 patients even though the Ki-67 levels at the primary site in four of these patients were higher in the SCC component than in the AC component. CONCLUSIONS: The enhanced proliferative ability of the SCC component of ASCP is reflected by its proportion within the tumor. However, other biological factors might contribute to metastasis in ASCP.

Adenosquamous carcinoma in the biliary tract: association of the proliferative ability of the squamous component with its proportion and tumor progression.

OBJECTIVES: The purpose of this study was to evaluate the association of the proliferative ability of squamous cell carcinoma (SCC) component with its proportion and tumor progression in adenosquamous carcinoma (ASC) in the biliary tract. METHODS: Nine patients with ASC in the biliary tract (four each in the gallbladder and the extrahepatic bile duct and one in the ampulla of Vater) who underwent surgical resection were retrospectively reviewed. RESULTS: The proportion of the SCC component in the primary sites ranged from 30% to 95%. The Ki-67 index of the SCC component was higher than that of the adenocarcinoma component in all cases, regardless of the component ratio in the patients' primary lesions. Predominance of the SCC component in the advancing region of the tumor, in angiolymphatic invasion and in perineural invasion was observed in most of the cases. The component ratio in metastatic lymph nodes differed from that in the corresponding primary lesions in all six cases with lymph node metastasis. Among these cases, the proportion of the SCC component was increased in the metastatic lymph nodes compared with that in the corresponding primary lesion in two cases, whereas the proportion was decreased in four cases. CONCLUSIONS: The SCC component of ASC in the biliary tract displayed a relatively higher proliferative ability, which might be associated with local invasiveness. However, not only the high proliferative ability of the SCC component but also other biological factors might contribute to tumor progression and metastasis in ASC of the biliary tract.

Prognostic significance of intraoperative peritoneal washing cytology for patients with potentially resectable pancreatic ductal adenocarcinoma.

BACKGROUND: The prognostic significance of intraoperative peritoneal washing cytology (IPWC) in pancreatic ductal adenocarcinoma (PDAC) remains controversial, and the treatment strategy for PDAC patients with positive cytology has not been established. OBJECTIVES: The objective of this study was to evaluate the clinical significance of IPWC in PDAC patients. METHODS: This study included a retrospective cohort of 166 patients with curatively resected PDAC who underwent IPWC. RESULTS: Overall, 17 patients (10%) had positive cytology (CY+), and 149 (90%) patients were negative (CY-). Tumor location in the pancreatic body and/or tail and pancreatic anterior capsular invasion were independent predictors of a CY+ status (P = 0.012 and 0.041, respectively). The initial recurrence occurred at the peritoneum with a significantly higher frequency in CY+ patients (50%) than in CY- patients (12%) (P = 0.003). The median overall survival (OS) for CY+ patients was 12 months. The OS rates at 1 and 3 years were significantly higher for CY- patients (75.1% and 35.3%, respectively) versus CY+ patients (47.1% and 17.6%, respectively; P = 0.012). However, one CY+ patient survived for 66 months, and another two CY+ patients have survived for more than three years after surgery without evidence of peritoneal recurrence. In the multivariate analysis, the independent predictors of OS were a CY+ status, lymph node metastasis, and adjuvant chemotherapy. CONCLUSIONS: This study demonstrates that positive IPWC predicts early peritoneal recurrence and a poor prognosis for PDAC patients. However, a small but not insignificant subset of CY+ patients with PDAC may avoid peritoneal carcinomatosis.