Reduced-port robotic pancreaticoduodenectomy with optimized surgical field deployment: early results of single-site plus-two ports method.

BACKGROUND: The adoption of Robotic Pancreaticoduodenectomy (RPD) is increasing globally. Meanwhile, reduced-port RPD (RPRPD) remains uncommon, requiring robot-specific techniques not possible with laparoscopy. We introduce a unique RPRPD technique optimizing surgical field exposure. METHODS: Our RPRPD utilizes a single-site plus-two ports technique, facilitated by a single-port platform through a 5-cm incision. The configuration of robotic arms (arm1, arm2, arm3, and arm4) were strategically designed for optimal procedural efficiency, with the arms2 and arm3, alongside the assistant trocar, mounted on the single-port platform, while the arms1 and arm4 were positioned laterally across the abdomen. Drainage was established via channels created at the arm1 and arm4 insertion sites. A "gooseneck traction" was principally employed with the robotic instrument to prop up the specimen rather than grasp, improving the surgical field's visibility and access. Clinical outcomes of patients who underwent RPRPD performed between August 2020 and September 2023 by a single surgeon across two centers in Taiwan and Japan were reviewed. RESULTS: Fifty patients underwent RPRPD using the single-site plus-two ports technique. The gooseneck traction technique enabled goodsurgical field deployment and allowed for unrestricted movement of robotic arms with no collisions with the assistant instruments. The median operative time was 351 min (250-488 min), including 271 min (219-422 min) of console time and three minutes (2-10 min) of docking time. The median estimated blood loss was 80 mL (1-872 mL). All RPRPD procedures were successfully performed without the need for conversion to open surgery. Postoperative major morbidity (i.e., Clavien-Dindo grade ≥ IIIa) was observed in 6 (12%) patients and median postoperative hospital stay was 13 days. CONCLUSIONS: The single-site plus-two ports RPRPD with the gooseneck traction proves to be a safe, feasible option, facilitating surgical field visibility and robotic arm maneuverability.

[A Case of Curative Resection of a Retroperitoneal Liposarcoma].

A 55-year-old woman had been admitted to a hospital with abdominal bloating. Retroperitoneal liposarcoma was suspected and diagnosed as not resectable. She was then referred to our hospital with dyspnea and difficulties with movement due to the huge mass. An abdominal CT revealed a large mass originating in the left retroperitoneum. The tumor occupied most of the abdominal cavity, resulting in the displacement of her organs. However, there was no evidence of infiltration of the tumor into the aorta and inferior vena cava. Under a provisional diagnosis of retroperitoneal liposarcoma, a surgical resection was undertaken. The resected specimen had a maximum diameter of 48 cm and weighed 14 kg. Histopathological examination revealed a differentiated liposarcoma. The patient remains alive 6 months after the operation, without recurrence.

[Three Cases of Conversion Surgery for Unresectable Gastric Cancer with Multiple Liver Metastases].

We herein report 3 cases of advanced gastric cancer with multiple liver metastases who was successfully treated with systemic chemotherapy and underwent conversion surgery with liver resection. There were 2 males and 1 female patients with a range 68 to 74 years of age. Two patients received S-1 plus oxaliplatin therapy and 1 received S-1 plus cisplatin therapy. All patients survived after 5-49 months postoperatively.

[Conversion Surgery following Second-Line Chemotherapy for Unresectable Gastric Cancer].

We retrospectively analyzed clinicopathological and survival data of 8 patients with unresectable gastric cancer who underwent conversion surgery(CS)following second-line chemotherapy from April 2013 to December 2020. There were 7 males and 1 female patients with a median age of 69(64-76)years old. Five patients had 1 unresectable factor, 2 had 2 unresectable factors, and 1 had 3 unresectable factors. All patients achieved R0 resection. The median survival time(MST) of patients with CS following second-line chemotherapy was significantly longer than that without CS(73.4 vs 12.3 months, respectively). The MST of patients with CS following first-line chemotherapy was significantly longer than that without CS (22.9 vs 12.3 months, respectively). This study suggested that CS following first- or second-line chemotherapy may improve survival duration for unresectable gastric cancer.

[A Case of Locally Advanced, Pancreatic Mixed Acinar-Endocrine Carcinoma(MAEC) Resected using Superficial Femoral Vein Grafts for Portal Reconstruction].

A 46-year-old woman with epigastric pain was found to have a tumor of the pancreatic head. Computed tomography(CT) revealed a plethoric and poorly-marginated, 7 cm tumor in the pancreatic head. The superior mesenteric vein(SMV)was infiltrated from the duodenal inferior margin and a 6 cm occlusion extended to the merger with the splenic vein. Diagnostic criteria identified locally advanced pancreatic cancer(UR-P)with a limitation in portal reconstruction. Endoscopic ultrasoundguided fine needle aspiration(EUS-FNA)diagnosed mixed acinar-endocrine carcinoma(MAEC). Due to rarity, a chemotherapy protocol has not been established. Thus, the first option for treatment was resection. CT showed that the required graft was 7 cm in length, with SMV 0.5 cm in diameter at the intestinal side and 1.4 cm in diameter at the hepatic side; accordingly, the superficial femoral vein (SFV)was selected for use. Compared to the external iliac vein, the graft is slightly thinner and about 10 cm can be harvested. This graft is useful for cases that require reconstruction of the distal SMV.

[A Case of Splenic Lymph Node Metastasis from the Distal Bile Duct Carcinoma Seven Years after a Curative Resection].

We report a case of splenic lymph node recurrence 7 years after a distal bile duct carcinoma. A 70s man underwent pylorus ring-preserving pancreaticoduodenectomy for distal bile duct carcinoma in 20XX. The pathological diagnosis was T2N0M0, Stage Ⅱ(Japanese Classification of the Biliary Tract Cancers 5th edition). Then, S-1 was administered as an adjuvant chemo- therapy 1month later and continued for 3 years. At 7 years postoperatively, the serum CEA level was elevated(CEA 77.0 ng/ mL), and FDG-PET showed high-grade accumulation in the splenic hilum lymph node, which was diagnosed as lymph node recurrence. Because it was a solitary metastasis and had a long recurrence-free period, tumor resection was not performed, and the patient opted for a nonsurgicaltreatment. No recurrence occurred to date. Recurrent resection is rarely performed for splenic lymph node metastasis.

[Portal Stent for Gastrointestinal Bleeding Caused by Portal Stenosis after Hepato-Biliary-Pancreatic Surgery].

It is known that gastrointestinalbl eeding occurs due to portalstenosis as a complication in the hepato-biliary-pancreatic region at later postoperative stages. Our department has treated 5 portal stent cases since 2015. The pressure difference between the hepatic side and intestinalside at the portalstenosis site decreased from 9-14(median: 10)cmH2O to 0-6 (median: 2)cmH2O in all cases before and after placement of the stent, resulting in hemostasis(observation period 4-18 months, median: 12 months). In surgery of the hepato-biliary-pancreatic regions, veins flowing into the portal vein are also incised by dissection of the hepatoduodenal ligament. Accordingly, it has been inferred that when the portal vein becomes stenotic, the collateralroutes flow into the portalvein at the hepatic portalsite in a hepatopetalmanner through the cholangiojejunal anastomosis site from the mesenteric veins of the elevated jejunum, and the submucosal weak collateral routes collapse, causing gastrointestinal bleeding. Rebleeding is highly likely in cases with only endoscopic treatment and embolization of collateralroutes. On the other hand, it is thought that portalstenting is a radicaltreatment and is thus the first option for management.

[Conversion Surgery after Etoposide/Cisplatin(EP)Therapy for Huge Pancreatic Neuroendocrine Carcinoma - A Case Report].

Neuroendocrine carcinoma(NEC)is known as rapid tumor growth, high grade malignancy and poor prognosis. We report a case of huge pancreatic NEC successfully performed conversion surgery after EP therapy. A 70-year-old female, was presented to our hospital with appetite loss. CT scan revealed huge tumor, 15 cm in diameter, locating at the pancreas with possible involvement to liver, stomach, common hepatic artery, left gastric artery and gastroduodenal artery. Peritoneal dissemination and para-aortic lymph node metastasis were also suspected. EUS-FNA showed neuroendocrine carcinoma with almost 100%positive staining rate of Ki-67. We immediately started etoposide/cisplatin(EP)therapy. After 6 courses of EP, the tumor shrank remarkably and peritoneal disseminations were disappeared. Common hepatic artery and gastroduodenal artery became free from the tumor. However, after 7 courses of EP, CT and PET-CT revealed tumor re-growth. Also renal impairment could not afford to continue EP therapy. Therefore we decided to perform conversion surgery. In the guideline in Japan, there is no content specialized for surgical treatment for NEC. Moreover, second-line of chemotherapy for NEC has not been established. In the future, accumulation of NEC cases will contribute to develop effective multidisciplinary treatment.

[A Case of Pancreatic Metastasis from Pulmonary Pleomorphic Carcinoma].

We report a case of pancreatic metastasis of pulmonary pleomorphic carcinoma with duodenal invasion after left lower lobectomy. A 65-year-old male underwent left lower lobectomy for left lung cancer in 2016. The final pathological finding was a diagnosis is of pleomorphic carcinoma, pT2bN0M0, stageⅡA. The patient rejected postoperative chemotherapy for 10 months after lung surgery, and he was admitted to our hospital with poor oral intake. CT revealed that the tumor was located in the 2nd part of the duodenum, was about 7 cm in diameter, and was suspected to invade the superior mesenteric vein (SMV). Gastroendoscopy revealed whole-circumference stenosis at the 2nd part of the duodenum. The biopsy was suspicious of duodenal metastasis from pulmonary pleomorphic carcinoma. We scheduled pancreaticoduodenectomy with reconstruction of the portal vein. Regarding the intraoperative findings, the tumor was palpated at the 2nd part of the duodenum, and the tumor invaded the transverse colon and right urinary duct. The SMV had been invaded from the gastro-colic trunk to the root of the ileocolic vein. Therefore, pancreaticoduodenectomy, reconstruction of the portal vein with replacement of the graft of the left external iliac vein, right hemicolectomy, and right ureteral resection were performed. Regarding the pathological findings, the tumor existed in the pancreatic parenchyma and invaded the duodenal mucosa. The tumor cells were similar to those in a previous pulmonary pleomorphic carcinoma. The final pathological diagnosis was pancreatic metastases from pulmonary pleomorphic carcinoma. Surgical reports of metastatic pancreatic tumor have been observed sporadically; however, those reports were of pancreatic metastasis of renal cancer, and there are few reports of resection of pancreatic metastasis. This is a very valuable case of pancreatic metastasis from pulmonary pleomorphic carcinoma that could be resected.

[Pancreaticoduodenectomy in a Patient with Severe Hyperbilirubinemia - A Case Report].

Although the safety of pancreaticoduodenectomy(PD)with hyperbilirubinemia has been reported, the permissible value of preoperative serum bilirubin is unknown. A 58-year-old man developed obstructive jaundice due to duodenal adenocarcino- ma. The initial serum bilirubin value was 26.8mg/dL, and preoperative biliary drainage was performed. However, the serum bilirubin value only decreased to 17.7mg/dL. The other liver function tests were normal. Therefore, we decided to perform PD despite persistent severe hyperbilirubinemia. The postoperative course was uneventful and the bilirubin value improved. He was discharged 17 days after the operation. In the present case, we safely performed PD despite severe jaundice after adequate preoperative liver function evaluation. The attempt to reduce the bilirubin value before surgery did not appear to affect the postoperative course.

[Strategy for Unresectable Pancreatic Cancer with Stenosis of the Duodenum - A Case Report].

Unresectable(UR)pancreatic cancer often causes duodenal obstruction. Case 1: A 58-year-old man was diagnosed with UR pancreatic cancer with obstruction of the 3rd duodenal portion. A duodenum 2nd portion jejunum bypass was performed, and FOLFIRINOX was introduced and continued over 6 months. Case 2: A 74-year-old man was diagnosed with UR pancreatic cancer with obstruction of the duodenum near the Treitz ligament. A duodenum 3rd portion jejunum bypass was performed, and gemcitabine plus nab-paclitaxel was introduced. After 8 courses of GN, adjuvant surgery was performed. Both patients resumed oral intake within a few days after bypass, their performance statuses(PS)were improved, and their body weights increased. Because a duodenal jejunum bypass is more physiological than a gastro-jejunum bypass and duodenal stent, stable ingestion is enabled, and they are stable enough for early initiation of chemotherapy.

[Primary Prophylactic Administration of Pegfilgrastim in FOLFIRINOX Therapy for Locally Advanced Pancreatic Carcinoma].

FOLFIRINOX therapy has a high response rate for pancreatic carcinoma, but has serious adverse effects. FOLFIRINOX therapy was administered to 11 patients with locally advanced pancreatic carcinoma at our hospital. We investigated the usefulness of primary prophylactic administration of pegfilgrastim(PegG). In the group receiving PegG, as well as with onset of neutropenia and thrombocytopenia, febrile neutropenia was reduced. Rates of anorexia and fatigue were also lower than in those who did not receive PegG. The PegG group maintained a high average relative dose intensity, as well as a high response rate. Primary prophylactic administration of PegG in FOLFIRINOX therapy is valid for pancreatic carcinoma.

A case of robotic distal pancreatectomy for solitary fibrous tumor of the pancreas.

Solitary fibrous tumor (SFT) is a spindle cell tumor driven by the NAB2-STAT6 fusion gene. While it can originate from any soft tissue, primary SFT of the pancreas is rare with limited reports. A 36-year-old man came to our department due to abdominal pain. Computed tomography revealed a circular mass with weak peripheral enhancement and an internal cyst in the pancreatic tail. Diagnosis was not confirmed through endoscopic ultrasound-guided biopsy, and differential diagnoses included acinar cell carcinoma and pancreatic neuroendocrine tumor. A robotic distal pancreatectomy with splenectomy was performed, and the patient was discharged 11 days postoperatively. Histopathological examination showed an irregular arrangement of spindle cells, and immunohistochemical staining was positive for CD34 and STAT6, confirming an SFT diagnosis with low metastatic risk. Robotic surgery effectively managed this tumor.

Reversible pore size control of elastic microporous material by mechanical force.

Nanoporous materials, such as zeolites, activated carbons, and metal-organic frameworks (MOFs), are peculiar platforms in which a variety of guest molecules are stored, reacted, and/or separated. The size of the nanopores is essential to realize advanced functions. In this work, we demonstrate a very simple but innovative method for the control of nanopore size, that is, reversible and continuous control by mechanical force loaded to soft nanoporous materials. The elastic properties of several microporous materials, including zeolites, zeolite-templated carbon (ZTC), activated carbon, and MOFs (e.g., ZIF-8), are examined and it is found that ZTC is a material that is suitable for the aforementioned idea thanks to its extraordinary soft properties compared to the others. The original pore size of ZTC (1.2 nm) can be contracted to 0.85 nm by using a relatively weak loading force of 135 MPa, whereas the other microporous materials barely contracted. To demonstrate the change in the physical properties induced by such artificial deformation, in situ gas adsorption measurements were performed on ZTC with and without loading mechanical force, by using CO2, CH4, and H2, as adsorbates. Upon the contraction by loading 69 or 135 MPa, CO2 adsorption amount is increased, due to the deepening of the physisorption potential well inside the micropores, as proved by the increase of the heat of adsorption. Moreover, the adsorption amount is completely restored to the original one after releasing the mechanical force, indicating the fully reversible contraction/recovery of the ZTC framework against mechanical force. The experimental results are theoretically supported by a simulation using Grand Canonical Monte Carlo method. The similar adsorption enhancement is observed also on CH4, whereas H2 is found as an exception due to the weak interaction potential.

Right lateral approach to the superior mesenteric artery in robotic pancreaticoduodenectomy.

Ninomiya and colleagues introduced a novel approach to the superior mesenteric artery in robotic pancreaticoduodenectomy. The right lateral approach allows repositioning of the superior mesenteric artery to the right-most surface, facilitating safer artery division and simplifying detachment around the superior mesenteric vein, potentially reducing operative time and minimizing blood loss.

Predicting conversion surgery in patients with locally advanced pancreatic cancer after modified FOLFIRINOX treatment.

BACKGROUND: /Objective: FOLFIRINOX therapy (FFX) for locally advanced pancreatic cancer (LAPC) is increasingly recognized as a potent neoadjuvant therapy that enables transition to conversion surgery (CS). However, predictors of CS achievement after chemotherapy are controversial. This study aimed to demonstrate the efficacy of CS after modified FFX (mFFX) in patients with LAPC and to identify and score predictors of CS. METHODS: From January 2014 to December 2018, patients with LAPC who received mFFX as a first-line treatment were screened. Patients' overall survival was compared with and without CS. Moreover, the predictors for CS were analyzed to create scores for the CS factors. RESULTS: Forty-three patients received mFFX, including 20 patients who underwent CS (CS group, 46.5%). R0 resection was achieved in 16 patients (80%). The median survival time was 39.2 months (95% confidence interval [CI] 17.3-53.8) for the CS group and 16 months (95% CI 10.5-22.6) for the non-CS group (P < 0.001; hazard ratio 0.25, 95% CI 0.12-0.54). Since an average relative dose intensity of ≥90%, tumor reduction of ≥35%, and carbohydrate antigen 19-9 reduction of ≥70% or normalization were associated with successful transition to CS in the multivariate analysis, these factors were scored (CS score, range 0-3). All of the patients in the CS group fell into the 2-3 category, compared with 2 of 23 patients in the non-CS group (P < 0.001). CONCLUSION: CS after FFX contributes to the long-term survival of patients with LAPC. The CS score could be an indicator for transition to CS.

Time course of changes in the human Achilles tendon properties and metabolism during training and detraining in vivo.

The purpose of this study was to investigate the time course of changes in human tendon properties and metabolism during resistance training and detraining. Nine men (21-27 years) completed 3 months of isometric plantar flexion training and another 3 months of detraining. At the beginning and on every 1 month of training and detraining periods, the stiffness, blood circulation (blood volume and oxygen saturation), serum procollagen type 1 C-peptide (P1P; reflects synthesis of type 1 collagen), echointensity (reflects collagen content), and MRI signal intensity (reflects collagen structure) of the Achilles tendon were measured. Tendon stiffness did not change until 2 months of training, and the increase (50.3%) reached statistical significance at the end of the training period. After 1 month of detraining, tendon stiffness had already decreased to pre-training level. Blood circulation in the tendon did not change during the experimental period. P1P increased significantly after 2 months of training. Echointensity increased significantly by 9.1% after 2 months of training, and remained high throughout the experiment. MRI signal intensity increased by 24.2% after 2 months and by 21.4% after 3 months of training, but decreased to the pre-training level during the detraining period. These results suggested that the collagen synthesis, content, and structure of human tendons changed at the 2-month point of training period. During detraining, the sudden decrease in tendon stiffness might be related to changes in the structure of collagen fibers within the tendon.

Refractory Acute Antibody Mediated Rejection in Liver Transplant After Desensitization of Preformed Donor Specific Antibody-Validity of Bortezomib and Everolimus: A Case Report.

Here, we report a case of living donor liver transplantation (LDLT) complicated with severe acute antibody-mediated rejection (aAMR), although desensitization was performed for preformed donor-specific anti-human leukocyte antigen antibody (DSA). LDLT was performed in a 59-year-old woman with alcoholic cirrhosis with a graft from her 60-year-old husband as a living donor. She had reproductive history of 4 gravidity and parity with her husband. Preoperative serologic studies showed positive complement-dependent cytotoxic crossmatch and anti-human leukocyte antigen-A26 antibody was identified as DSA. Desensitization for preformed DSA with rituximab and plasma exchange was performed before LDLT. We decided to perform LDLT using her husband right liver as living donor graft since the DSA mean fluoro-intensity was down to negative range. The immunosuppressive regimen was comprised with steroid and tacrolimus. However, the recipient developed acute cellular rejection on day 5 after LDLT, followed by severe aAMR. Re-administration of rituximab followed by 4 courses of plasma exchange failed to treat aAMR. The DSA mean fluoro-intensity was successfully suppressed after bortezomib was administered however impaired serologic liver function test and cholestasis were remained. The liver function test and cholestasis in the graft were improved after Everolimus was administered. The recipient was discharged on postoperative day 196. In conclusion, we report a case of LDLT who developed aAMR after desensitization of preformed DSA and was successfully treated with intensive therapy with bortezomib and everolimus.

The Efficacy of S-1 as Adjuvant Chemotherapy for Resected Biliary Tract Carcinoma: A Propensity Score-Matching Analysis.

Even though S-1 is a widely used chemotherapeutic agent, there is no evidence for its use in an adjuvant setting for biliary tract carcinoma (BTC). Patients who underwent surgical treatment for BTC between August 2007 and December 2018 were selected. Propensity score matching was performed between patients who received S-1 as adjuvant chemotherapy (S-1 group) and those who underwent surgical treatment alone (observation group). Of 170 eligible patients, 38 patients were selected in each group after propensity score matching. Among those in the matched cohort, both the median recurrence-free survival (RFS) and overall survival (OS) in the S-1 group were significantly longer than those in the observation group (RFS, 61.2 vs. 13.1 months, p = 0.033; OS, not available vs. 28.2 months, p = 0.003). A multivariate analysis of the OS revealed that perineural invasion and adjuvant S-1 chemotherapy were independent prognostic factors. According to a subgroup analysis of the OS, the S-1 group showed significantly better prognoses than the observation group among patients with perineural invasion (p < 0.001). S-1 adjuvant chemotherapy might improve the prognosis of BTC, especially in patients with perineural invasion.