Impact of S-1 adjuvant chemotherapy longer than 6 months on survival in patients with resected pancreatic cancer: a nationwide survey by the Japan Pancreas Society based on real-world data.

BACKGROUND: Based on the Japan Adjuvant Study Group of Pancreatic Cancer 01 study, the standard duration of adjuvant chemotherapy with S-1 (an oral 5-fluorouracil prodrug consisting of tegafur, gimeracil, and oteracil) in patients with resected pancreatic ductal adenocarcinoma (PDAC) was considered to be 6 months, but the impact of increasing its duration on postoperative survival was unknown. Here, the authors investigated this question by reviewing real-world data from a large cohort of patients with PDAC. METHODS: In total, 3949 patients who underwent surgery for PDAC during the study period followed by S-1 adjuvant chemotherapy in board-certified institutions were included. Based on the duration of S-1 chemotherapy, two subgroups were defined: a standard-duration group that included patients who were treated for 180 ± 30 days and a longer duration group that included patients who received treatment for >210 days. RESULTS: The median duration of S-1 chemotherapy was 167 days, with a mean ± standard deviation of 200 ± 193 days. After excluding patients who had a recurrence within 210 days after the initiation of adjuvant chemotherapy, postoperative recurrence-free survival (RFS) and overall survival (OS) in the standard-duration group (n = 1473) and the longer duration group (n = 975) were compared. RFS and OS did not differ significantly between the standard-duration and longer duration groups (5-year RFS: 37.8% vs. 36.2% respectively; p = .6186; 5-year OS: 52.8% vs. 53.4%, respectively; p = .5850). The insignificant difference was verified by multivariate analysis and propensity-score matching analysis. CONCLUSIONS: The current findings suggest that extending S-1 adjuvant chemotherapy beyond 6 months has no significant additional effect on survival in patients with PDAC. This could be useful in determining whether to extend S-1 chemotherapy in patients who have completed the standard 6-month treatment.

Efficacy of laparoscopic liver resection for small hepatocellular carcinoma located in the posterosuperior segments: A multi-institutional study using propensity score matching by the Kyushu Study Group of Liver Surgery.

AIM: Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) located in the posterosuperior segments (PS) have generally been considered more difficult than those for HCC in anterolateral segments (AL), but may be safe and feasible for selected patients with accumulated experience. In the present study, we investigated the effectiveness of LLR for single nodular HCCs ≤3 cm located in PS. METHODS: In total, 473 patients who underwent partial liver resection for single nodular HCCs ≤3 cm at the 18 institutions belonging to the Kyusyu Study Group of Liver Surgery from January 2010 to December 2018 were enrolled. The short-term outcomes of laparoscopic partial liver resection and open liver resection (OLR) for HCCs ≤3 cm, with subgroup analysis of PS and AL, were compared using propensity score-matching analysis. Furthermore, results were also compared between LLR-PS and LLR-AL. RESULTS: The original cohort of patients with HCC ≤3 cm included 328 patients with LLR and 145 with OLR. After matching, 140 patients with LLR and 140 with OLR were analyzed. Significant differences were found between groups in terms of volume of blood loss (median, 55 vs. 287 ml, p < 0.001), postoperative complications (0.71 vs. 8.57%, p = 0.003), and postoperative hospital stay (median, 9 vs. 14 days, p < 0.001). The results of subgroup analysis of PS were similar. Short-term outcomes did not differ significantly between LLR-PS and LLR-AL after matching. CONCLUSIONS: Laparoscopic partial resection could be the preferred option for single nodular HCCs ≤3 cm located in PS.

Validity of a model using routinely collected data for identifying infections following gastric, colon, and liver cancer surgeries.

PURPOSE: Validating outcome measures is a prerequisite for using administrative databases for comparative effectiveness research. Although the Japanese Diagnosis Procedure Combination database is widely used in surgical studies, the outcome measure for postsurgical infection has not been validated. We developed a model to identify postsurgical infections using the routinely collected Diagnosis Procedure Combination data. METHODS: We retrospectively identified inpatients who underwent surgery for gastric, colon, or liver cancer between April 2016 and March 2018 at four hospitals. Chart reviews were conducted to identify postsurgical infections. We used bootstrap analysis with backwards variable elimination to select independent variables from routinely collected diagnosis and procedure data. Selected variables were used to create a score predicting the chart review-identified infections, and the performance of the score was tested. RESULTS: Among the 746 eligible patients, 96 patients (13%) had postoperative infections. Three variables were identified as predictors: diagnosis of infectious disease recorded as a complication arising after admission, addition of an intravenous antibiotic, and bacterial microscopy or culture. The prediction model had a C-statistic of 0.885 and pseudo-R2 of 0.358. A cut-off of one point of the score showed a sensitivity of 92% and specificity of 72%, and a cut-off of two points showed a sensitivity of 75% and specificity of 91%. CONCLUSIONS: Our model using routinely collected administrative data accurately identified postoperative infections. Further external validation would lead to the application of the model for research using administrative databases.

Evaluation of Preoperative Magnetic Resonance Cholangiopancreatography in Acute Cholecystitis to Predict Technical Difficulties in Laparoscopic Cholecystectomy.

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging technique that provides high-quality visualization of the biliary tree, including the gallbladder. This study aimed to evaluate the useful-ness of preoperative MRCP for acute cholecystitis in predicting technical difficulties during laparoscopic chole-cystectomy (LC). A total of 168 patients who underwent LC with preoperative MRCP were enrolled in this study. Patients were divided into two groups according to preoperative MRCP findings: the visualized group (n = 126), in which the entire gallbladder could be visualized; and the non-visualized group (n = 42), in which the entire gallbladder could not be visualized. The perioperative characteristics and postoperative complica-tions of the two groups were retrospectively analyzed. Operation time was longer in the non-visualized group (median 101.5 vs. 143.5 min; p < 0.001). The non-visualized group had significantly more intraoperative blood loss than the visualized group (median 5 vs. 10 g; p = 0.05). The rate of conversion to open cholecystectomy was significantly higher in the non-visualized group (1.6 vs. 9.5%; p = 0.03). In conclusion, patients in the non- visualized group showed higher difficulty in performance of LC. Our MRCP-based classification is a simple and effective means of predicting difficulties in performing LC for acute cholecystitis.

Synchronous Total Occlusion of the Celiac Axis and Superior Mesenteric Artery: An Autopsy Case.

Acute mesenteric ischemia (AMI) is often caused by superior mesenteric artery (SMA) embolization. We report a rare case of synchronous celiac axis and SMA embolization in an elderly woman with initially mild abdominal pain. Ultimately, a second contrast-enhanced computed tomography revealed extensive necrosis from the stomach to the transverse colon together with liver ischemia due to hours of occlusion. Multiorgan failure made palliation the only option, and she died the following evening. Autopsy revealed a fragile atherosclerosis-asso-ciated thrombus. Careful examination and repeat diagnostic tests should be performed in patients with mild abdominal symptoms at risk for AMI.

Immunotherapeutic advances in gastric cancer.

Advanced gastric cancers are responsible for overwhelming human suffering and death. Despite the development of combination chemotherapies, the survival rates of patients with gastric cancer remain unsatisfactory. Given the growing evidence of the benefits of immunotherapy as an alternative treatment for other cancers such as advanced melanoma, non-small cell lung cancer, renal cell carcinoma, and refractory Hodgkin's lymphoma, researchers have begun to explore its application in the treatment of gastric cancer. Three types of immunotherapy have shown promising effects against gastric cancer: immune checkpoint inhibitors, chimeric antigen rector (CAR)-T cells, and tumor vaccines. Clinical trials have used either immuno-oncology monotherapies or combination immuno-chemotherapies to improve the overall survival times and objective response rates of patients with gastric cancer. We review the clinical efficacy of immunotherapy including checkpoint inhibitors, CAR­T, and tumor vaccines, in the treatment of gastric cancer. Based on initial evidence, we believe that immunotherapy could positively impact the natural history and improve the outcomes of a subgroup of patients with gastric cancer.

Clinicopathological characteristics of combined hepatocellular cholangiocarcinoma from the viewpoint of patient prognosis after hepatic resection: High rate of early recurrence and its predictors.

AIM: Combined hepatocellular cholangiocarcinoma (cHCC-CCA) is a very rare subtype of primary liver carcinoma; therefore, its clinicopathological characteristics have not yet been elucidated in detail. The aim of the study was to reveal the clinicopathological characteristics and prognostic factors of cHCC-CCA after hepatic resection (HR) METHODS: A total of 124 patients who underwent curative HR for cHCC-CCA between 2000 and 2016 were enrolled in this multi-institutional study conducted by the Kyushu Study Group of Liver Surgery. Clinicopathological analysis was performed from the viewpoint of patient prognosis. RESULTS: A total of 62 patients (50%) had early recurrence within 1.5 years after HR, including 36 patients (58%) with extrahepatic recurrence. In contrast, just four patients (3%) had late recurrence occurring >3 years after HR. The independent predictors of early recurrence were as follows: des-gamma carboxyprothrombin >40 mAU/mL (odds ratio 26.2, P = 0.0117), carbohydrate antigen 19-9>37 IU/l (odds ratio 18.0, P = 0.0200), and poorly differentiated HCC or CCA (odds ratio 11.2, P = 0.0259). CONCLUSIONS: Half of the patients with cHCC-CCA had early recurrence after HR. Preoperative elevation of des-gamma carboxyprothrombin or carbohydrate antigen 19-9 and the existence of poorly differentiated components of HCC or CCA in resected specimens are predictors of its early recurrence.

Training for laparoscopic pancreaticoduodenectomy.

In recent years, laparoscopic procedures have developed rapidly, and the reports of laparoscopic pancreatic resection including laparoscopic pancreaticoduodenectomy (LPD) have increased in number. Although LPD is a complex procedure with high mortality, the training system for LPD remains unestablished. Ensuring patient safety is extremely important, even in challenging surgeries such a LPD. At present, several tools have been developed for surgical education to ensure patient safety preoperatively, such as video learning, virtual reality simulators, and cadaver training. Although LPD is reported as a safe and feasible choice, LPD is still a challenging operation. An LPD training system should be established with a board-certified system.

Improvement of Anal Function by Adipose-Derived Stem Cell Sheets.

AIM: One of the most troublesome complications of anal preserving surgery is anal sphincter dysfunction. The aim of this study was to evaluate functional recovery after implantation of adipose-derived stem cell (ADSC) sheets, novel biotechnology, for an anal sphincter resection animal model. METHODS: Eighteen female Sprague-Dawley rats underwent removal of the nearest half of the internal and external anal sphincter muscle. Nine rats received transplantation with ADSC sheets to the resected area while the remaining rats received no transplantation. The rats were evaluated for the anal function by measuring their resting pressure before surgery and on postoperative days 1, 7, 14, 28, and 56. In addition, the rats were examined for the presence of smooth muscle and also to determine its origin. RESULTS: The improvement of the anal pressure was significantly greater in the ADSC sheet transplantation group compared with the control group. Histologically, at the vicinity of the remaining smooth muscle, reproduction of smooth muscle was detected. Using in fluorescence in situ hybridization, the cells were shown to be from the recipient. CONCLUSION: Regenerative therapy using ADSC sheet has the potential to recover anal sphincter dysfunction due to anorectal surgery.

Predictors of portal and splenic vein thrombosis after laparoscopic splenectomy: a retrospective analysis of a single-center experience.

PURPOSE: Laparoscopic splenectomy (LS) has become the standard operative approach for splenectomy. Portal or splenic vein thrombosis (PSVT) is a serious and common complication after LS, and lethal complications of PSVT can occur when the portal vein is completely occluded by portal vein thrombosis (PVT). We aimed to clarify the predictors of PSVT after LS and to determine which of them were also predictors of PVT. METHODS: A total of 56 consecutive patients who underwent elective LS were enrolled in this study. The patients were divided into two groups based on the presence or absence of PSVT after LS. In addition, patients with PSVT were divided into two groups: a PVT group and a non-PVT group. The preoperative and intraoperative clinical data were compared among the groups. RESULTS: Thirty (53.6%) patients developed PSVT. The splenic vein diameter was the most useful predictor for the development of PSVT, and 10 mm was an accurate splenic vein diameter cut-off value for use as a predictive factor for PSVT. In addition, the splenic vein diameter was the most useful predictor of the development of PVT from splenic vein thrombosis (SVT), and 14 mm was found to be an accurate cut-off value. CONCLUSION: PSVT is a common postoperative complication that is identified on enhanced computed tomography. The splenic vein diameter is not only a predictor of PSVT but also of the development of PVT from SVT.

No-touch isolation techniques for pancreatic cancer.

The rate of recurrence, including liver metastasis is high in pancreatic cancer, even when complete surgical resection is performed as a curative treatment. In patients with pancreatic cancer, the handling and grasping of the pancreas during surgery may increase the risk of liver metastasis, as squeezing may spread cancer cells via the portal vein. A no-touch isolation technique might prevent the spread of cancer cells via the hematogenous metastatic route in patients with pancreatic cancer. However, while no-touch isolation techniques are simple, feasible and, in theory, ideal procedures for the surgical treatment of pancreatic cancer, there have been no randomized controlled prospective studies to validate their advantages and their efficacy remains controversial. It is, therefore, worth investigating the use of no-touch isolation techniques in pancreatic cancer.

Safety and efficacy of postoperative pharmacologic thromboprophylaxis with enoxaparin after pancreatic surgery.

PURPOSE: Pharmacologic thromboprophylaxis is recommended for preventing pulmonary embolism according to some abdominal surgery guidelines. However, few reports have so far described pharmacologic thromboprophylaxis after pancreatic surgery. In addition, concern remains regarding postoperative bleeding due to pharmacologic thromboprophylaxis. We investigated the safety and efficacy of enoxaparin, a low-molecular-weight heparin, as postoperative pharmacologic thromboprophylaxis after pancreatic surgery. METHODS: In this record-based retrospective study, the sample population comprised 151 consecutive patients who underwent pancreatic surgery and received enoxaparin postsurgery at our institute between November 2009 and March 2014. The primary outcome was the incidence of symptomatic pulmonary embolism after surgery, and the secondary outcome was the incidence of bleeding as an adverse effect of enoxaparin injection. RESULTS: No symptomatic pulmonary embolism events occurred during the study. Major and minor bleeding events were experienced in 5 (3.3%) cases each. Four of these major events were caused by the rupture of a pseudoaneurysm with a pancreatic fistula not related to enoxaparin, and all events were treated safely with no mortalities in the study period. We found no factors related to minor bleeding with enoxaparin injection in a statistical comparison. CONCLUSION: The use of enoxaparin is considered to be safe and effective for pulmonary embolism prophylaxis after pancreatic surgery.

Cell sheet technology for the regeneration of gastrointestinal tissue using a novel gastric perforation rat model.

PURPOSE: Anastomotic leakage is a major postoperative complication. While cell sheet technology has been gaining popularity in the clinical field, the utility of cell sheets for containing contaminated enteral perforation remains unclear. We established a new gastric perforation rat model and evaluated the efficacy of the myoblast cell sheet to prevent leakage. METHODS: To establish a suitable rat model, perforations of various sizes were made in the stomach. We then pasted the sheet onto the perforated stomach in our new model. After the operation, the rats were sacrificed and analyzed macroscopically and histologically. Serum levels of C-related protein and hyaluronic acid in the peritoneal cavity washing lavage were also evaluated. RESULTS: An incision 5 mm in length was found to be the most suitable for evaluation of the cell sheet performance. In the rats where the cell sheet had been pasted onto the perforation site, we noted less adhesion in the abdominal cavity and a significant reduction in the hyaluronic acid levels in the peritoneal cavity washing lavage. CONCLUSIONS: We evaluated the efficacy of cell sheets for preventing leakage of enteral contents in a gastric perforation rat model. Myoblast cell sheets were able to markedly reduce the degree of both intra-abdominal adhesion and inflammation.

Analysis of early relaparotomy following living donor liver transplantation.

We retrospectively analyzed the causes, risk factors, and impact of early relaparotomy after adult-to-adult living donor liver transplantation (LDLT) on the posttransplant outcome. Adult recipients who underwent initial LDLT at our institution between August 1997 and August 2015 (n = 196) were included. Any patients who required early retransplantation were excluded. Early relaparotomy was defined as surgical treatment within 30 days after LDLT. Relaparotomy was performed 66 times in 52 recipients (a maximum of 4 times in 1 patient). The reasons for relaparotomy comprised postoperative bleeding (39.4%), vascular complications (27.3%), suspicion of abdominal sepsis or bile leakage (25.8%), and others (7.6%). A multivariate analysis revealed that previous upper abdominal surgery and prolonged operative time were independent risk factors for early relaparotomy. The overall survival rate in the relaparotomy group was worse than that in the nonrelaparotomy group (6 months, 67.3% versus 90.1%, P < 0.001; 1 year, 67.3% versus 88.6%, P < 0.001; and 5 years, 62.6% versus 70.6%, P = 0.06). The outcome of patients who underwent 2 or more relaparotomies was worse compared with patients who underwent only 1 relaparotomy. In a subgroup analysis according to the cause of initial relaparotomy, the survival rate of the postoperative bleeding group was comparable with the nonrelaparotomy group (P = 0.96). On the other hand, the survival rate of the vascular complication group was significantly worse than that of the nonrelaparotomy group (P = 0.001). Previous upper abdominal surgery is a risk factor for early relaparotomy after LDLT. A favorable longterm outcome is expected in patients who undergo early relaparotomy due to postoperative bleeding. Liver Transplantation 22 1519-1525 2016 AASLD.

Triple-drug therapy to prevent pancreatic fistula after pancreatectomy in a rat model.

BACKGROUND: Pancreatic fistula (PF) is one of post-operative complications in pancreatic surgery, but there is no consensus about the optimal treatment for PF. Our group has established a rat model of PF, and we conducted the present investigation to determine the efficacy of the triple-drug therapy (somatostatin analogue, gabexate mesilate, and imipenem/cilastatin) against PF using our rat model. METHODS: In the PF rat model, the triple-drug therapy was administered to the treated (T) group (n = 4), and we compared the results with those of a control (C) group (n = 4). The rats were sacrificed on postoperative day 3 (POD 3) and the levels of amylase and lipase in serum and ascites were measured. The intra-abdominal adhesion was scored. Each pancreas was evaluated pathologically, and inflammation was scored. RESULTS: The ascitic amylase levels on POD 3 were 1982 (1738-2249) IU/L in the C group and significantly lower at 136 (101-198) IU/L in the T group (p = 0.02). The ascitic lipase levels on POD 3 were 406 (265-478) U/L in the C group and significantly lower at 13 (7-17) U/L in the T group (p = 0.02). The intra-abdominal adhesion score on POD 3 was 2 (1-2) in the C group and significantly lower at 0 (0-1) in the T group (p = 0.02). The histological evaluation showed that the average of pancreatic inflammatory score was 8.5 (8-9) in the C group and significantly milder at 5 (5-7) in the T group (p = 0.01). CONCLUSION: Our findings suggest that the triple-drug therapy could be useful as a treatment for PF in clinical settings.

Equal distribution of mesenchymal stem cells after hepatic ischemia-reperfusion injury.

BACKGROUND: Liver ischemia-reperfusion (I/R) injury is one of the major causes of hepatocellular injury-related mortality and morbidity after liver transplantation. Mesenchymal stem cells (MSCs) have been shown to reduce liver I/R injury and improve regeneration. The purpose of the present study was to investigate the difference in the distribution of systemically delivered MSCs in the recipient's liver between the ischemic injury area and nonischemic area. MATERIAL AND METHODS: Fishers' rats (7-8 week of age) were used as donors of MSCs and recipients. Bone marrow-derived MSCs were isolated from the donor's femur. Before systemic administration, MSCs were labeled with the fluorescent dye PKH26. The rats were divided into four groups: (1) I/R injury + MSC group, (2) MSC only, without I/R injury, (3) I/R injury + saline group, and (4) the Sham group. I/R injury was performed by clamping the inflow vascular structures of the left and middle lobes of the recipient's liver for 60 min. The right lobe was considered as a nonischemic part. Subsequently, 1.5 × 10(6) of MSCs or saline (NaCl, 0.9%) was administrated via the rat's tail vein. Thereafter, the rats were killed after days one, three, or seven for the analyses. RESULTS: A fluorescent microscopy assay for labeled MSCs showed positive cells in both ischemic and nonischemic parts of the recipient's liver. The number of cells was significantly higher in the I/R injury + MSC group compared with the only MSC, without I/R injury group. Immunohistochemical staining showed that there was no significant difference in the proliferation of Ki-67-positive cells between the I/R + MSCs and I/R + saline groups. In addition, the serum transaminase levels were not different between the I/R + MSCs and I/R + saline groups. CONCLUSIONS: After partial liver I/R injury, transplanted MSCs migrate equally to the ischemic and nonischemic parts of the recipient's liver. Considering the unique ability of the liver to regenerate, both parts of the liver presumably receive signals for regeneration.

Does the development of chronic kidney disease and acute kidney injury affect the prognosis after living donor liver transplantation?

BACKGROUND AND AIMS: Chronic kidney disease (CKD) and acute kidney injury (AKI) have been discussed as complications following living donor liver transplantation (LDLT). The aim of this study was to clarify the relationships among CKD, AKI, and the prognosis after LDLT. METHODS: This study included 118 patients who underwent LDLT in our department. A low eGFR (<60 mL/min/1.73 m(2) ) was regarded to indicate CKD. AKI 1 and AKI 2 were characterized by an increase in the serum creatinine level of 0.5 and 1.0 mg/dL, respectively, within one wk after LDLT. We investigated the risk factors for and the relevance of CKD and AKI on the prognosis. RESULTS: AKI 1 was associated with sepsis and intra-operative bleeding (p = 0.0032, p = 0.001). AKI 2 was associated with sepsis and hepatitis C infection (p < 0.001, p = 0.027). A pre-operative eGFR of 60-89 and diabetes were the risk factors for the development of CKD in POY 2 (p = 0.018, p = 0.002). AKI 2, sepsis, and diabetes were the risk factors for the patient death within one yr after LDLT (p = 0.010, p = 0.002, p = 0.022). AKI 2 and sepsis were the risk factors for death within two yr after LDLT (p = 0.005, p = 0.018). CONCLUSIONS: Recognizing the risk factors and careful management for preventing both AKI and CKD may improve the prognosis of patients following LDLT.

Relationship between immune function recovery and infectious complications in patients following living donor liver transplantation.

AIM: The ImmuKnow (IK) assay enables the evaluation of peripheral blood CD4(+) adenosine triphosphate activity to facilitate an objective assessment of the cellular immune function in immunosuppressed patients. However, it is unclear whether the IK assay is utilized during the acute postoperative periods following living donor liver transplantation (LDLT). METHODS: The IK values of 43 LDLT recipients were measured during the month following LDLT to evaluate the relationship between the measured IK values and infectious events. RESULTS: The IK values after LDLT were significantly increased compared with the IK values before LDLT ( P < 0.01). During the month following transplantation, the rate of bacterial infection in the recipients with IK values of more than 225 ng/mL was significantly lower than that in the recipients with IK values of 225 ng/mL or less ( 42.1% vs 91.7%, respectively; P < 0.01). The rate of severe infections among the recipients who maintained IK values of more than 150 ng/mL was significantly lower than that among the recipients with IK values of 150 ng/mL or less during the month following transplantation ( 3.7% vs 56.3%, respectively; P < 0.01). CONCLUSION: The immune system of LDLT recipients dramatically improved following transplantation. The IK values of LDLT recipients were associated with the incidence of infectious events during the perioperative period after LDLT. Monitoring IK values was useful during both the acute and long-term postoperative periods.

The pancreas from Aristotle to Galen.

BACKGROUND/PURPOSE: The first description of the pancreas in literature is found in Aristotle's Historia Animalium, but it is modified by "so-called". Therefore, the origin is pursued more extensively. METHODS: The Greek-English Lexicon recommends three treatises as a possible original source. These three and Galen's other papers are investigated. In 2005, Sachs et al. suggested an origin of the pancreas might have derived from the intestinal divination using the avian pancreas. This report is evaluated. RESULTS: The avian pancreas which is the intraperitoneal organ, might have been well known by the intestinal divination, and people have called the organ pankreas or kallikreas. Anatomical dissection on human body was not accepted before the Aristotle's time. "So-called pancreas" in Historia must have been interpolated by Theophrastus. He was the most faithful and reliable disciple of Aristotle and succeeded the Aristotle's school. He and Macedonian ruler of Egypt Ptolemy I had known each other and there had been a strong link between them. The contemporary Herophilus performed many public dissections on both human and animal bodies in Alexandria. He named the various parts of the human body and designated the beginning intestine as duodenum. Yet in his extant works, the pancreas is not found. It is surmised that Herophilus may be the first to recognize the human pancreas, which is fixed with retroperitoneal tissue, and he named it "so-called pancreas". Theophrastus might have interpolated Herophilus' designation in Historia Animalium. Galen also uses "so-called pancreas" to designate the human pancreas. CONCLUSION: Galen's descriptions, that is, "Nature created 'so-called pancreas 'and spread it beneath all vessels" are not generally acceptable but propose the very rare portal vein anomalies. Since the early years of the 20th century, cases with a preduodenal portal vein or a prepancreatic portal vein have been reported. Although the incidence is very rare, its surgical importance is emphasized.

Safety and efficacy of early drain removal and triple-drug therapy to prevent pancreatic fistula after distal pancreatectomy.

OBJECTIVE: Prior studies suggested that early drain removal prevented the development of pancreatic fistula (PF) after pancreaticoduodenectomy (PD), but there has been no corresponding prospective trial for distal pancreatectomy (DP). The purpose of this study was to determine the safety and efficacy of early drain removal and triple-drug therapy (TDT) with gabexate mesilate, octreotide and carbapenem antibiotics to prevent PF after DP in patients at high-risk of developing PF. METHODS: A total 71 patients who underwent a DP were enrolled. We prospectively divided them into two groups: the late-removal group, in which the drain remained in place for at least for 5 days postoperatively (n = 30) and the early-removal group in which the drain was removed on postoperative day 1 (POD1) (n = 41). For the patients with a high drain amylase level (≥10,000 IU/L) and patients with symptomatic intraperitoneal fluid collection, our original TDT was introduced. The primary endpoint was the safety and efficacy of this management, and the secondary endpoint was the incidence of PF. RESULTS: The incidence of clinical PF was significantly lower in the early-removal group (0% vs. the late removal 16%; p < 0.001). In the early-removal group, TDT was administered to 12 patients (29%) and none of the patients needed additional treatment after TDT. CONCLUSIONS: Postoperative management after DP with early drain removal and TDT was safe and effective for preventing PF.