An anatomical review of various superior mesenteric artery-first approaches during pancreatoduodenectomy for pancreatic cancer.

When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as "artery-first" approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA.

Treatment of an Aberrant Arterial Aneurysm with Intralobar Pulmonary Sequestration: A Case Report.

An aberrant arterial aneurysm with pulmonary sequestration is rare. Here, we report about a 35-year-old man who had no symptoms related to pulmonary sequestration. Computed tomography revealed an aberrant arterial aneurysm with an 18 mm in diameter with intralobar pulmonary sequestration, which gradually increased in size to 27 mm over 5 years. The patient underwent thoracic endovascular aortic repair with coil embolization for the aneurysmal distal branches to prevent aneurysm rupture. The postoperative course was unremarkable without a need for lobectomy. During a 1-month follow-up period, the aneurysm shrunk with no endoleaks. Stent-graft placement and coil embolization represent an effective and less invasive treatment option to completely block systemic arterial flow and unexpected retrograde backflow and control the expansion of the aneurysm.

Impact of Fluorine-18 2-Fluoro-2-Deoxy-D-Glucose Uptake on Preoperative Positron Emission Tomography/Computed Tomography in the Lymph Nodes of Patients with Primary Colorectal Cancer.

BACKGROUND/AIMS: Although the diagnostic value of fluorine-18 2-fluoro-2-deoxy-D-glucose (F-18-FDG) positron emission tomography/computed tomography (F-18-FDG-PET/CT) in patients with colorectal cancer (CRC) has been reported, the association between the F-18-FDG uptake in metastatic lymph nodes (FDGLN) and clinicopathological variables has not been fully investigated. We evaluated the diagnostic value of F-18-FDG-PET/CT in detecting LN metastasis from CRC, and the relationship between F-18-FDG-PET/CT-detecting LN metastasis and prognosis. METHODS: We retrospectively analyzed the medical records of 370 patients who underwent preoperative F-18-FDG-PET/CT, followed by surgical resection for CRC between January 2007 and December 2010. We analyzed the sensitivity, specificity, and accuracy of F-18-FDG-PET/CT and CT in diagnosing metastatic LNs. Survival was analyzed in 115 patients with stage III CRC. RESULTS: The sensitivity, specificity, and accuracy for detecting metastatic LNs using F-18-FDG-PET/CT were 56.8, 90.3, and 74.2%, and those for contrast-enhanced CT were 38.4, 95.5, and 65.0%, respectively. The accuracy of F-18-FDG-PET/CT was significantly associated with tumor depth and lymphatic involvement. In the survival analysis, cancer-specific survival and the disease-free survival were significantly shorter in patients with stage III CRC with FDGLN than in those without FDGLN. CONCLUSION: F-18-FDG-PET/CT had low sensitivity and high specificity for detecting metastatic LNs from CRC. FDGLN independently predicted poor prognosis in patients with stage III CRC.

Impact of portal vein invasion and resection length in pancreatoduodenectomy on the survival rate of pancreatic head cancer.

BACKGROUND/AIMS: A positive surgical margin is a poor prognosis factor. Resection of the invaded portal vein (PV) may be necessary to achieve a negative surgical margin during pancreaticoduodenectomy (PD). This study clarifies the intraoperative and long-term survival of patients who received PD with PV resection compared to without. METHODOLOGY: Between July 1992 and March 2012, a retrospective analysis of 119 patients undergoing PD with or without PV resection for pancreatic head cancer was performed. Main outcome measures were perioperative mortality and survival rate of PD with and without PV resection. RESULTS: Perioperative mortality was not different between PD (1 of 51 cases: 2.0%) and PD with PV resection (3 of 68 cases: 4.4%) (p = 0.462). Patients without resection had a significantly better prognosis than patients with PV resection (p = 0.0052). Patients on whom >2.1 cm of the PV was resected (n = 34) had a worse cumulative survival rates than patients with a resection of <2.1 cm (n = 19) (p = 0.0380). Patients with no invasion of PV wall (n = 18) had a significantly higher survival rate than positive PV wall invasion (n = 49) (p =0.039). CONCLUSIONS: Patients with PV resection had a significantly worse prognosis than patients without PV resection. Some patients survived more than 5 years post-operation after PD with PV resection. PV resection contributes to attaining complete tumor resection.

Change over Time in the Risk of Death among Japanese COVID-19 Cases Caused by the Omicron Variant Depending on Prevalence of Sublineages.

To assess temporal changes to the risk of death in COVID-19 cases caused by the Omicron variant, we calculated age-standardized case fatality rates (CFR) in patients aged ≥40 years over nine diagnostic periods (3 January to 28 August 2022) in ten Japanese prefectures (14.8 million residents). Among 552,581 study subjects, we found that there were 1836 fatalities during the isolation period (up to 28 days from date of onset). The highest age-standardized CFR (0.85%, 95% confidence interval (CI):0.78-0.92) was observed in cases diagnosed in the second 4-week period (January 31 to February 27), after which it declined significantly up to the 6th 4-week period (0.23%, 95% CI: 0.13-0.33, May 23 to June 19). The CFR then increased again but remained at 0.39% in the eighth period (July 18 to August 28). The CFR in cases with the BA.2 or BA.5 sublineages in the age range 60-80 years was significantly lower than that with BA.1 infections (60 years: 0.19%, 0.02%, 0.053%, respectively; 70 years: 0.91%, 0.33%, 0.39%; ≥80 years: 3.78%, 1.96%, 1.81%, respectively). We conclude that the risk of death in Japanese COVID-19 patients infected with Omicron variants declined through February to mid-June 2022.

Adjuvant chemotherapy can prolong recurrence-free survival but did not influence the type of recurrence or subsequent treatment in patients with colorectal liver metastases.

BACKGROUND: Although liver resection is the only potentially curative treatment for colorectal liver metastases, recurrence is frequent. We previously published the early results of a randomized controlled phase 3 trial showing that adjuvant therapy with uracil-tegafur and leucovorin significantly prolongs recurrence-free survival. This study sought to elucidate the impact of adjuvant chemotherapy on patient survival after an additional follow-up period, building upon the results of our previous study. METHODS: After resection for colorectal liver metastases, patients were randomly assigned in a 1:1 ratio to receive adjuvant uracil-tegafur and leucovorin or surgery alone. Patients assigned to the uracil-tegafur and leucovorin group received 5 cycles of uracil-tegafur and leucovorin within 8 weeks after surgery. RESULTS: Patients were assigned to an adjuvant uracil-tegafur and leucovorin (n = 90) or a surgery alone (n = 90) group; 3 patients were excluded because of protocol violations. After a median follow-up period of 7.36 years (95% confidence interval, 6.93-7.87), 60 (68.2%) patients in the uracil-tegafur and leucovorin group and 61 (68.5%) patients in the surgery alone group developed recurrences. The median recurrence-free survival was 1.45 years (95% confidence interval, 0.96-2.16) in the uracil-tegafur and leucovorin group and 0.70 years (95% confidence interval, 0.44-1.07) in the surgery alone group. The locations and treatments of the first recurrences did not differ between the groups, nor did the overall survival (hazard ratio, 0.86; 95% confidence interval, 0.54-1.38; P = .54). The overall survival was significantly longer in patients who underwent curative repeated resection than in patients who received non-surgical treatment (hazard ratio, 0.25; 95% confidence interval, 0.15-0.40; P < .0001). CONCLUSION: Adjuvant uracil-tegafur and leucovorin significantly prolonged the recurrence-free survival but not the overall survival. The repeated resection was the most important factor influencing overall survival.

Stent graft treatment for ruptured pseudoaneurysms of the splanchnic arteries after pancreaticoduodenectomy: a case report.

BACKGROUND: Hemorrhage due to a ruptured splanchnic pseudoaneurysm followed by the formation of a postoperative pancreatic fistula is the most severe complication of a pancreatectomy, sometimes leading to a fatal outcome. Stent graft placement to control the hemorrhage due to the pseudoaneurysm is a validated treatment option, but once the stent graft is infected, infection control is complicated. We report a case of a ruptured pseudoaneurysm of the splanchnic artery after pancreaticoduodenectomy to evaluate the stent graft treatment. CASE PRESENTATION: A 77-year-old man underwent pylorus-preserving pancreaticoduodenectomy for suspected distal bile duct cancer. Hemorrhage from a pseudoaneurysm of the common hepatic artery due to the formation of the pancreatic fistula was detected on postoperative day 9, and a stent graft was successfully placed with the preservation of hepatic arterial blood flow. On postoperative day 12, new-onset hemorrhage from a pseudoaneurysm of the right hepatic artery developed, and a stent graft was similarly placed, but immediately occluded. Refractory pancreatic and biliary fistulas developed and required continuous drainage. On postoperative day 85, computed tomography revealed the presence of air within the latter stent graft, which indicated infection of the stent graft. The patient died due to sepsis caused by the graft infection. CONCLUSION: Stent graft placement for the treatment of hemorrhage of a pseudoaneurysm secondary to a postoperative pancreatic fistula, following pancreaticoduodenectomy, is an effective treatment option as it achieves immediate hemostasis and maintains end-organ perfusion. However, stent graft infection is the most detrimental complication.

Acute Type B Aortic Dissection Associated with Acute Pancreatitis, Pancreatic Pseudocysts, and Acalculous Cholecystitis.

Acute aortic dissection can result in fatal conditions when associated with organ malperfusion. A rare complication of aortic dissection with organ malperfusion is ischemic pancreatitis with cholecystitis. Here, we present the case of acute type B aortic dissection complicated by concurrent acute ischemic pancreatitis and acalculous cholecystitis. Prompt diagnosis and specific multidisciplinary treatment are crucial to improving patient outcomes in cases of visceral ischemia.

F-18 fluorodeoxyglucose accumulation in an inflammatory pseudotumor of the spleen.

We report on a case with an inflammatory pseudotumor of the spleen, which showed a moderate accumulation of F-18 fluorodeoxyglucose (FDG) in the tumor. F-18 FDG accumulated mainly in the peripheral portion of this tumor that showed abundant hypercellular inflammatory cells histopathologically. Splenic inflammatory pseudotumors should be recognized as F-18 FDG-avid benign tumors of the spleen.

Using the supercharge technique to additionally revascularize the gastric tube after a subtotal esophagectomy for esophageal cancer.

BACKGROUND: Maintaining sufficient blood flow to the gastric tube after a subtotal esophagectomy for esophageal cancer is crucial for decreasing esophagogastric anastomotic leakage. METHODS: After subtotal esophagectomy for esophageal cancer, the supercharge technique was performed in 21 esophageal reconstruction patients to additionally revascularize the gastric tube using the splenic artery and vein, external carotid artery, and internal jugular vein. Operative results of the supercharge group were retrospectively compared with those of the control group (patients not receiving the technique). RESULTS: Both operation time and operative blood loss in the supercharge group were significantly longer and larger than those of the control group. However, the incidence of anastomotic leakage was significantly lower in the supercharge group than in the control group. CONCLUSION: This practical supercharge technique reduces leakage during esophageal anastomosis.

High F-18 fluorodeoxyglucose accumulation in solid pseudo-papillary tumors of the pancreas.

We report two cases of young women with a solid pseudo-papillary tumor of the pancreas which having cystic and hemorrhagic components with marked calcification on computed tomography and magnetic resonance imaging. F-18 fluorodeoxyglucose positron emission tomography revealed abnormally increased accumulation of F- 18 fluorodeoxyglucose in the pancreas tail tumors, especially in the non-calcified solid portion of the tumors. These patients underwent elective resection of the masses and distal pancreatectomy and were diagnosed with solid pseudo-papillary tumors by histopathological analysis. There was no evidence of distant metastasis on follow-up after surgery and they showed no histopathological findings suggesting malignancy. These cases suggest that solid pseudo-papillary tumor may show high uptake of F-18 fluorodeoxyglucose.

Excision of the urachal remnant using the abdominal wall-lift laparoscopy: A case report.

INTRODUCTION: Here, we report the surgical excision of the urachal remnant using the abdominal wall-lift laparoscopy with a camera port in the umbilicus, combined with a small Pfannenstiel incision to optimally treat the bladder apex. PRESENTATION OF CASE: A 21-year-old woman presented with periumbilical discharge and pain on urination. Contrast enhanced CT and MRI showed an abscess in the umbilical region that was connected to the bladder via a long tube-like structure. It was diagnosed as an infected urachal sinus. Partial excision of the umbilical fossa followed by dissection of the urachal remnant was easily performed using the abdominal wall-lift laparoscopy from the umbilicus down to the bladder without pneumoperitoneum or additional trocar placement. A Pfannenstiel incision was made above the pubis to get access to the junction between the urachal remnant and the bladder. Under direct vision, we succeeded in accurately dividing the remnant tract, and we adequately closed the bladder opening with absorbable sutures. This method has the advantage of easily closing peritoneal defects after excision of the urachal remnant with direct sutures under a laparoscopic view from the umbilicus. Cosmetic satisfaction was obtained postoperatively. DISCUSSION AND CONCLUSION: Urachal sinus excision using the abdominal wall-lift laparoscopy seems to surpass the previously reported methods in term of safety, cosmetics, and adequacy of surgical procedures.

Retrocecal hernia successfully treated with laparoscopic surgery: A case report and literature review of 15 cases in Japan.

INTRODUCTION: Retrocecal hernia is rare and involves strangulation ileus, and therefore, frequently requires emergency surgery following conservative therapy. PRESENTATION OF CASE: We report an interesting case of a retrocecal hernia in a 65-year-old man, with a history of diabetes mellitus. The patient was admitted to our hospital with severe periumbilical pain and nausea. Abdominal computed tomography revealed an intestinal obstruction at a pericecal site, and dilatation of the small bowel at the oral side of the obstruction. The patient was initially treated with conservative therapy using long intestinal tube placement. On the 12th hospital day, the patient's symptoms had not resolved, and laparoscopic surgery was performed. We diagnosed a retrocecal hernia based on laparoscopic findings and repaired it. The patient was discharged without complications on the 7th postoperative day. DISCUSSION AND CONCLUSION: Using laparoscopic exploration and suturing, we were able to perform a minimally invasive operation that may have promoted an earlier hospital discharge.

Silk suture granuloma with false-positive findings on PET/CT accompanied by peritoneal metastasis after colon cancer surgery.

INTRODUCTION: Suture granuloma is a rare benign tumor caused by suture material, which usually appears several months or years after surgery. PRESENTATION OF CASE: A 71-year-old man underwent sigmoidectomy and partial hepatectomy (S6) for sigmoid colon cancer and synchronous liver metastasis at a previous hospital. At 4 postoperative months, surveillance computed tomography (CT) revealed a suspicious tumor at the hepatic resection stump. He was referred to our hospital for further examinations and treatments. Positron emission tomography/CT (PET/CT) revealed abnormal hepatic F-18 fluorodeoxyglucose (FDG) uptake below the diaphragm at the S5/S8 surface. Peritoneal metastasis was suspected and surgery was performed. White nodules were found in the Douglas pouch. A diagnosis of adenocarcinoma was confirmed by frozen section analysis of the nodules. He underwent a partial hepatectomy (S5/S8) and partial resection of the diaphragm. Pathological examination showed that the liver tumor was a foreign body granuloma that included silk suture material. DISCUSSION: Although postoperative PET/CT surveillance is useful following malignant tumor resection, it is important to note that PET/CT false-positive findings are possible. Furthermore, PET/CT cannot detect small peritoneal metastases, necessitating a thorough abdominal examination. CONCLUSION: In cases of malignancy, the possibility of postoperative suture granuloma should be considered. In addition, a thorough surgical examination of the abdomen should be performed in cases of suspected recurrence.

Adjuvant Oral Uracil-Tegafur with Leucovorin for Colorectal Cancer Liver Metastases: A Randomized Controlled Trial.

BACKGROUND: The high recurrence rate after surgery for colorectal cancer liver metastasis (CLM) remains a crucial problem. The aim of this trial was to evaluate the efficacy of adjuvant therapy with uracil-tegafur and leucovorin (UFT/LV). METHODS: In the multicenter, open-label, phase III trial, patients undergoing curative resection of CLM were randomly assigned in a 1:1 ratio to either the UFT/LV group or surgery alone group. The UFT/LV group orally received 5 cycles of adjuvant UFT/LV (UFT 300mg/m2 and LV 75mg/day for 28 days followed by a 7-day rest per cycle). The primary endpoint was recurrence-free survival (RFS). Secondary endpoints included overall survival (OS). RESULTS: Between February 2004 and December 2010, 180 patients (90 in each group) were enrolled into the study. Of these, 3 patients (2 in the UFT/LV group and 1 in the surgery alone group) were excluded from the efficacy analysis. Median follow-up was 4.76 (range, 0.15-9.84) years. The RFS rate at 3 years was higher in the UFT/LV group (38.6%, n = 88) than in the surgery alone group (32.3%, n = 89). The median RFS in the UFT/LV and surgery alone groups were 1.45 years and 0.70 years, respectively. UFT/LV significantly prolonged the RFS compared with surgery alone with the hazard ratio of 0.56 (95% confidence interval, 0.38-0.83; P = 0.003). The hazard ratio for death of the UFT/LV group against the surgery alone group was not significant (0.80; 95% confidence interval, 0.48-1.35; P = 0.409). CONCLUSION: Adjuvant therapy with UFT/LV effectively prolongs RFS after hepatic resection for CLM and can be recommended as an alternative choice. TRIAL REGISTRATION: UMIN Clinical Trials Registry C000000013.

Expression and prognostic roles of beta-catenin in hepatocellular carcinoma: correlation with tumor progression and postoperative survival.

PURPOSE: Although hepatocellular carcinoma (HCC) is the most common primary malignant tumor of the human liver, the molecular changes and mechanisms that regulate its development and progression remain unclear. In the present study, we investigated the correlation between beta-catenin expression and clinical outcome in 51 patients with relatively small (maximal diameter < 30 mm), solitary HCCs. EXPERIMENTAL DESIGN: The tumors were classified according to histological tumor differentiation (grade I, 11 tumors; grade II, 28 tumors; grade III, 12 tumors). Using immunohistochemical methods to detect nuclear accumulation of beta-catenin, we investigated the correlation between beta-catenin expression and clinical outcome and compared the correlation with cyclin D1, Ki-67, and E-cadherin. RESULTS: Focal or generalized nuclear beta-catenin expression was observed in 36.4% (4 of 11) of the grade I tumors, 39.3% (11 of 28) of the grade II tumors, and 25% (3 of 12) of the grade III tumors. Nuclear beta-catenin-positive grade III tumors were associated with significantly poorer survival (P = 0.004), whereas none of the patients with nuclear beta-catenin-negative grade I tumors died. With regard to proliferative activity, positive nuclear beta-catenin staining correlated significantly with an increased Ki-67 labeling index in grade I (P < 0.0001) and grade III (P = 0.0045) tumors and with reduced epithelial cadherin expression in the cell membrane (P < 0.001). In contrast, no association with the expression of cyclin D1, one of the target factors of beta-catenin, was detected. CONCLUSIONS: Our present data suggest that beta-catenin plays important roles in promoting tumor progression by stimulating tumor cell proliferation and reducing the activity of cell adhesion systems and is associated with a poor prognosis, especially in patients with poorly differentiated HCCs.

Right aortic arch with left lung cancer: focusing on left recurrent laryngeal nerve.

We report a case of a 64-year-old Japanese man with an anomalous right aortic arch who had left lung cancer. We performed lobectomy and mediastinal lymphadenectomy, paying attention to the pathway of left recurrent laryngeal nerve. The left recurrent laryngeal nerve hooked around from the left dorsal to the right ventral part of the left ductus arteriosus, which connected the left pulmonary artery with the aortic diverticulum.

Reconstruction of small bile ducts using a parachute technique.

Benign or malignant stricture of extrahepatic bile ducts may result when small intrahepatic bile ducts are anastomosed to the jejunal loop after resection of extrahepatic bile ducts, hepatic parenchyma, and intrahepatic bile ducts. We applied a parachute technique, which has been used for fine vascular anastomosis, to hepaticojejunostomy in eight patients with either extrahepatic bile duct carcinoma or intrahepatic cholangiocellular carcinoma. One to four small bile ducts were anastomosed to the jejunal loop. No patient experienced a complication due to this anastomosis. Postoperative elevation of the serum bilirubin was transient, and all patients were discharged within 36 days after surgery. Although the follow-up period in this series is not yet long enough to evaluate the long-term outcome of this technique, the ease of the hepaticojejunostomy and good short-term results warrant farther clinical investigation of this technique.