Advanced pancreatic cancer with long-term recurrence-free survival after radical pancreatic resection and subsequent resection of lung metastases twice: A case report.

INTRODUCTION AND IMPORTANCE: Reports on lung resection for recurrence with lung metastases after the surgical treatment of pancreatic cancer have been sporadic, and limited information is currently available on the long-term postoperative course. Furthermore, the significance of the surgical resection of recurrent/metastatic lesions after the resection of pancreatic cancer has not been sufficiently established. We herein present a long-term recurrence-free survivor after perioperative chemotherapy and pancreatic resection for primary pancreatic body cancer who underwent resection for isolated lung metastases twice. CASE PRESENTATION: A 66-year-old woman with locally advanced pancreatic cancer accompanied by invasion of the splenic artery underwent distal pancreatectomy with celiac axis resection following preoperative S1 + gemcitabine therapy. Recurrence with lung metastasis was detected 42 and 62 months after resection of the primary lesion, and lung resection was performed both times. As postoperative adjuvant therapies, S1 + gemcitabine therapy was performed after lung resection. The patient has survived free of recurrence for 11 years after resection of the primary lesion and 5 years and 9 months after the second lung resection. CLINICAL DISCUSSION: A long interval from resection of the primary lesion to the occurrence of lung metastases and the high responsiveness of the patient to chemotherapy may have contributed to her long-term survival. CONCLUSION: This case suggests that if lung metastasis occurring after radical resection of the primary lesion is resected without remnants, aggressive multidisciplinary treatment, including surgical resection with the appropriate selection of cases, may contribute to improvements in patient outcomes.

Laparoscopic approach to recurrence following multiple surgeries for external rectal prolapse: a case report.

INTRODUCTION: The optimal procedure for recurrent external rectal prolapse remains unclear, particularly in laparoscopic approach. In addition, pelvic organ prolapse (POP) is sometimes concomitant with rectal prolapse. We present a case who underwent laparoscopic procedure for the recurrence of full-thickness external rectal prolapse coexisting POP. CASE PRESENTATION: An 81-year-old parous female had a 10-cm full-thickness external rectal prolapse following the two operations: the first was perineal recto-sigmoidectomy and the second was laparoscopic posterior mesh rectopexy. Imaging study revealed that the recurrent rectal prolapse was concomitant with both cystocele and exposed vagina, what we call POP. We planned and successfully performed laparoscopic ventral mesh rectopexy (LVMR) with laparoscopic sacrocolpopexy (LSC) using self-cut meshes without any perioperative complication. CONCLUSION: This is the first report of LVMR and LSC for recurrent rectal prolapse with POP following the perineal recto-sigmoidectomy and laparoscopic posterior mesh rectopexy. Even for recurrent rectal prolapse with POP, our experience suggests that LVMR and LSC could be utilized.

Proposal for a Safe and Functional Pancreaticojejunostomy Technique from a Histopathological Perspective.

BACKGROUND: To prevent leakage of pancreatic juice from the main pancreatic duct (MPD), complete external drainage appears to be the most effective technique. However, because this requires a pancreatic stent tube to be ligated with MPD, duct-to-mucosa pancreaticojejunostomy (PJ) is difficult. From our histopathological examination, a large amount of pancreatic juice is drained from the ducts other than MPD. This study aimed to evaluate our new conceptual technique of PJ after pancreaticoduodenectomy (PD). METHODS: We considered it important to drain pancreatic juice from the branch pancreatic ducts to the intestinal tract and to perform duct-to-mucosa PJ, while pancreatic juice from MPD is completely drained out of the body. We designed a technique that could simultaneously achieve these points. In our technique, which is based on conventional "two-row" anastomosis, a stent tube is fixed with MPD and its surrounding tissue by purse-string suture at the cut surface of the pancreas, and duct-to-mucosa PJ is concomitantly performed. RESULTS: Of 45 patients undergoing PD, 12 of soft pancreas underwent surgery with this technique. According to the classification of the International Study Group on Pancreatic Fistula, a Grade A PF was observed in four patients, whereas no patient had a Grade B or C PF. CONCLUSIONS: We propose our anastomotic technique that could simultaneously prevent PF and keep the pancreatic duct patent.

Requirement of protocol biopsy before and after complete cessation of immunosuppression after liver transplantation.

BACKGROUND: Operational tolerance is defined as long-term acceptance of a transplanted organ after complete cessation of immunosuppression (IS), but may not always protect against antigen-dependent changes in graft morphology. METHOD: IS free patients after living-donor liver transplantation (LDLT) underwent protocol biopsy (tolerance group [Gr-Tol]) and were evaluated for rejection and fibrosis. The degree of fibrosis was compared with those in the patients on maintenance IS group (Gr-IS) and the base line normal liver group (Gr-BS). When bridging fibrosis or progression of fibrosis was observed, IS was reintroduced or increased in Gr-Tol or in the patients in the weaning process. RESULTS: Neither acute nor chronic rejection was observed. The degree of fibrosis, however, was significantly greater in Gr-Tol than those in Gr-IS and Gr-BS. In Gr-Tol, the number of graft infiltrating FOXP3 cells was significantly increased, the interval between LDLT and biopsy plus the donor age was significantly longer, and recipient age at LDLT was significantly younger, compared with those in Gr-IS. However, none of these three parameters correlated with the degree of fibrosis. In 7 of 11 patients in whom IS was reintroduced or increased, the improvement of fibrosis was observed by the subsequent biopsy. CONCLUSION: Grafts of operationally tolerant patients after LDLT did not exhibit acute or chronic rejection, but they exhibited fibrosis. It remains elusive whether fibrosis observed in tolerant grafts is antigen dependent. The finding that after [corrected] the reintroduction or the increase of IS fibrosis was improved supported the possibility that fibrosis in operationally tolerant patients was antigen dependent.

Value of FOXP3 expression in peripheral blood as rejection marker after miniature swine lung transplantation.

BACKGROUND: Outcome for highly immunogenic lung transplantation remains unsatisfactory despite the development of potent immunosuppressants. The poor outcome may be the result of a lack of minimally invasive methods to detect early rejection. There is emerging clinical evidence that, paradoxically, expression of forkhead box P3 (FOXP3, a specific marker for the regulatory T cells) is upregulated within rejecting grafts. METHODS: Orthotopic lung transplantation was performed using miniature swine without immunosuppression. Rejection was monitored by chest radiography and open lung biopsy. Expressions levels of FOXP3, perforin, Fas-L and IP-10 mRNA were quantified in the peripheral blood. In addition, rescue immunosuppressive therapy (steroid plus tacrolimus) was administered on post-operative day (POD) 4 or 6. RESULTS: Early rejection was detected by open lung biopsy, but misdiagnosed by chest radiography on POD 4. Expression of FOXP3 in the peripheral blood reached its highest value as early as POD 4, followed by a decline. Such an increase of FOXP3 was not observed in recipients given high-dose tacrolimus. Neither perforin, Fas-L or IP-10 in the peripheral blood exhibited significant fluctuations in the early phase of rejection. Rescue immunosuppressive therapy from POD 4, when peak FOXP3 was seen, prolonged graft survival (27.2 days, versus 9.1 days without immunosuppression, p < 0.001), in contrast to POD 6, when rejection was suspected by chest radiography (11.5 days, p = not statistically significant [NS]). CONCLUSIONS: In a miniature swine lung transplantation model, the FOXP3 mRNA level in the peripheral blood was upregulated at an early phase of rejection. The clinical implication of this finding remains to be elucidated.