High-power and high-efficiency operation of 1.3 µm-wavelength InP-based photonic-crystal surface-emitting lasers with metal reflector.

We demonstrate high-output-power and high-efficiency operation of 1.3-µm-wavelength InP-based photonic-crystal surface-emitting lasers (PCSELs). By introducing a metal reflector and adjusting the phase of the reflected light via optimization of the thickness of the p-InP cladding layer, we successfully achieve an output power of approximately 400 mW with the slope efficiency of 0.4 W/A and the wall-plug efficiency of 20% under CW conditions. In addition, this PCSEL exhibits a narrow circular beam with a divergence angle below 1.6° even at high output powers under CW conditions at temperatures from 15°C to 50°C. We have also demonstrated an output power of over 12 W under pulsed conditions at room temperature.

Increased Piezo1 expression in myofibroblasts in patients with symptomatic carotid atherosclerotic plaques undergoing carotid endarterectomy: A pilot study.

OBJECTIVES: We aimed to investigate Piezo1 expression in myofibroblasts in symptomatic and asymptomatic patients undergoing carotid endarterectomy and its relationship with atherosclerotic plaque formation. METHODS: This cross-sectional study analyzed carotid plaques of 17 randomly selected patients who underwent carotid endarterectomy from May 2015 to August 2017. In total, 51 sections (the most stenotic lesion, and the sections 5-mm proximal and distal) stained with hematoxylin-eosin and elastica-Masson were examined. Immunohistochemistry was performed using antibodies to Piezo1. The Piezo1 score of a section was calculated semiquantitatively, averaged across 30 randomly selected myofibroblasts in the fibrous cap of the plaque. RESULTS: Of 17 patients (mean age: 74.2 ± 7.1 years), 15 were men, 9 had diabetes mellitus, and 13 had hypertension. Symptomatic patients had higher mean Piezo1 score than asymptomatic patients (1.78 ± 0.23 vs 1.34 ± 0.17, p < .001). Univariate linear regression analyses suggested an association between plaque rupture, thin-cap fibroatheroma and microcalcifications and the Piezo1 score (p = .001, .008, and 0.003, respectively). CONCLUSIONS: Increased Piezo1 expression of myofibroblasts may be associated with atherosclerotic carotid plaque instability. Further study is warranted to support this finding.

Comparison of Body Fluid Volumes Determined by Kinetic Modeling and by Bioimpedance Spectroscopy.

INTRODUCTION: The bioimpedance spectroscopy (BIS) method is used in individual patients requiring body fluid volume measurement. In a hemodialysis facility, however, regular screening of body fluid volumes is also necessary. Such screening, by kinetic modeling, may become possible by calculating distribution volumes of urea and uric acid from regular blood test results. OBJECTIVE: The aim is to compare uric acid distribution volumes with BIS-extracellular volume, urea distribution volume with BIS-total body water, and difference between urea and uric acid distribution volumes with BIS-intracellular volume. METHODS: We reanalyzed stored blood test data of 53 hemodialysis patients obtained together with BIS data of the same patients in our previous study. RESULTS: Significant correlations were found between urea distribution volume and total body water predicted by the BIS method, between uric acid distribution volume and extracellular volume predicted by the BIS method, and between the difference of uric acid distribution volume from urea distribution volume and intracellular volume predicted by the BIS method. In Bland-Altman analysis, comparison of each pair showed no systematic error. The mean difference between each pair was minimal. CONCLUSION: Fluid volumes in different body compartments can be estimated by kinetic modeling as well as by the BIS method.

Consensus Guidelines for the Use of Fluorescence Imaging in Hepatobiliary Surgery.

OBJECTIVE: To establish consensus recommendations for the use of fluorescence imaging with indocyanine green (ICG) in hepatobiliary surgery. BACKGROUND: ICG fluorescence imaging has gained popularity in hepatobiliary surgery in recent years. However, there is varied evidence on the use, dosage, and timing of administration of ICG in clinical practice. To standardize the use of this imaging modality in hepatobiliary surgery, a panel of pioneering experts from the Asia-Pacific region sought to establish a set of consensus recommendations by consolidating the available evidence and clinical experiences. METHODS: A total of 13 surgeons experienced in hepatobiliary surgery and/or minimally invasive surgery formed an expert consensus panel in Shanghai, China in October 2018. By the modified Delphi method, they presented the relevant evidence, discussed clinical experiences, and derived consensus statements on the use of ICG in hepatobiliary surgery. Each statement was discussed and modified until a unanimous consensus was achieved. RESULTS: A total of 7 recommendations for the clinical applications of ICG in hepatobiliary surgery were formulated. CONCLUSIONS: The Shanghai consensus recommendations offer practical tips and techniques to augment the safety and technical feasibility of ICG fluorescence-guided hepatobiliary surgery, including laparoscopic cholecystectomy, liver segmentectomy, and liver transplantation.

Narrow-band Imaging Examination of Microvascular Architecture of Subcapsular Hepatic Tumors.

BACKGROUND: Intraoperative ultrasonography is the golden standard method for evaluation of liver tumors during hepatectomy. However, in laparoscopic surgery, accurate assessment of tumors may be difficult, particularly if the lesion is located nearby the liver surface because of the challenges in handling the intraoperative ultrasound and the lack of tactile sensation. In this study, we demonstrate the preliminary results of examining the microvascular architecture of subcapsular hepatic tumors using laparoscopic narrow-band imaging (NBI) to distinguish between malignant and benign tumors. MATERIALS AND METHODS: Thirty-five lesions were examined by NBI during laparoscopic hepatectomy for the presence of abnormal microvasculature on the liver surface in relation to hepatic tumors from January 2016 to August 2018. The microvascular findings were correlated with tumor localization and pathological diagnosis. RESULTS: The 35 examined nodules included 11 hepatocellular carcinoma, 18 colorectal liver metastasis, and six benign nodules. The mean tumor diameter was 26.3 (3-70) mm, and the distance from the liver surface to the tumor was 0.5 (0-5) mm. Microvessels on the liver surface were clearly visualized by NBI, consistent with malignant tumor localization. The tumors were thoroughly examined for the presence of three pathological microvascular features (enlargement, tortuosity, and heterogeneity). Abnormal microvascular patterns were found in 90.9% of hepatocellular carcinoma and 77.8% of colorectal liver metastasis, whereas neither normal sites nor benign lesions displayed microvascular abnormality. CONCLUSIONS: This study suggests that observing the microvessel image on the liver surface by NBI could be useful in tumor localization and differentiation between benign and malignant lesions.

Intraductal papillary neoplasms of the bile duct consist of two distinct types specifically associated with clinicopathological features and molecular phenotypes.

Intraductal papillary neoplasm of the bile duct (IPNB) is a grossly visible papillary biliary neoplasm with morphological variations and occasional invasion. Recently a new classification of IPNB into type 1 and type 2 was proposed in which the type 1 IPNBs consist of fine papillary neoplastic glands and the type 2 IPNBs consist of complex branching glands, seldom with foci of solid-tubular components. However, clinicopathological and molecular characteristics of these types of IPNBs are yet to be identified. We aimed to uncover clinicopathological and molecular characteristics of the types of IPNBs. Thirty-six IPNBs were studied retrospectively. Clinicopathological features as well as molecular alterations of 31 genes were evaluated by means of targeted next-generation sequencing and immunohistochemical examination of expression of mucin and cancer-associated molecules. The 36 IPNBs were classified into 22 of type 1 and 14 of type 2. The type 1 IPNBs were associated with a non-invasive phenotype, intestinal and oncocytic subtypes, development in the intrahepatic bile duct, overt mucin production, and a relatively good prognosis. The type 2 IPNBs were associated with an invasive phenotype, the pancreatobiliary subtype, development within the extrahepatic bile duct, and worse prognosis compared with the type 1 IPNBs. In the molecular analysis, recurrent mutations were found in TP53 (34.3%), KRAS (31.4%), STK11 (25.7%), CTNNB1 (17.1%), APC (14.3%), SMAD4 (14.3%), GNAS (11.4%), PBRM1 (11.4%), ELF3 (8.6%), KMT2C (8.6%), NF1 (8.6%), PIK3CA (8.6%), ARID1A (5.7%), ARID2 (5.7%), BAP1 (5.7%), BRAF (5.7%), EPHA6 (5.7%), ERBB2 (5.7%), ERBB3 (5.7%), KMT2D (5.7%), and RNF43 (5.7%). Mutations in KRAS and GNAS were enriched in the type 1 IPNBs, whereas mutations in TP53, SMAD4, and KMT2C were enriched in the type 2 IPNBs. These results indicate that IPNBs consist of two distinct types of neoplasms specifically associated with clinicopathological features and molecular phenotypes. © 2020 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Tumoral calcinosis due to severe hyperphosphatemia and secondary hyperparathyroidism without vascular calcification in a hemodialysis patient.

We report a case of a 32-year-old man who was undergoing chronic hemodialysis and had hyperphosphatemia and secondary hyperparathyroidism (SHPT) with multiple tumoral calcinosis (TC) lesions refractory to drug therapy. Total parathyroidectomy and autotransplantation were performed, and he recovered from TC within 3 months. Several soft-tissue calcifications were present, but neither computed tomography (CT) before diagnosis nor CT performed 12 months after surgery detected evidence of vascular calcification (VC), despite persistence of hyperphosphatemia. This patient had a high calcium (Ca) × phosphate (P) product and calciprotein particles, and high serum Ca and P levels are important risk factors for both TC and VC. P plays a crucial role in regulation of VC, but the absence of VC in our case suggests a specific circumstance in which VC does not progress even under a high phosphatemic state, and that P alone may be insufficient for VC progression. TC in our patient was probably due to severe SHPT and continuous high serum P and Ca × P product levels, but the absence of VC suggests that the pathophysiologic process leading to VC requires further investigation, particularly in chronic kidney disease.

Increased neutrophil-lymphocyte ratio predicts recurrence in patients with well-differentiated pancreatic neuroendocrine neoplasm based on the 2017 World Health Organization classification.

BACKGROUND: The prognostic values of inflammation-based markers in well-differentiated pancreatic neuroendocrine neoplasms, diagnosed according to the new 2017 World Health Organization classification, have remained unclear. Therefore, we assessed the ability to predict the recurrence of such markers after curative resection in patients with these neoplasms. METHODS: Circulating/systemic neutrophil-lymphocyte, monocyte-lymphocyte, platelet-lymphocyte, and platelet-white cell ratios were evaluated in 120 patients who underwent curative resection for well-differentiated pancreatic neuroendocrine neoplasms without synchronous distant metastasis between 2001 and 2018. Recurrence-free-survival and overall survival were compared using Kaplan-Meier analysis and log-rank tests. Univariate or multivariate analyses, using a Cox proportional hazards model, were used to calculate hazard ratios with 95% confidence intervals. RESULTS: Univariate analysis demonstrated that preoperative neutrophil-lymphocyte ratio, tumor size, European Neuroendocrine Tumor Society TMN classification, 2017 World Health Organization classification, and venous invasion were associated with recurrence. The optimal preoperative neutrophil-lymphocyte ratio cut-off value was 2.62, based on receiver operating characteristic curve analysis. In multivariate analysis, a higher preoperative neutrophil-lymphocyte ratio (HR = 3.49 95% CI 1.05-11.7; P = 0.042) and 2017 World Health Organization classification (HR = 8.81, 95% CI 1.46-168.2; P = 0.015) were independent recurrence predictors. CONCLUSIONS: The circulating/systemic neutrophil-lymphocyte ratio is a useful and convenient preoperative prognostic marker of recurrence in patients with well-differentiated pancreatic neuroendocrine neoplasm based on the 2017 World Health Organization classification.

Efficacy of Carotid Artery Stenting Performed under General Anesthesia with Somatosensory Evoked Potential Monitoring.

OBJECTIVES: During carotid artery stenting (CAS), hemodynamics may be affected by the carotid sinus reflex in some cases. Although general anesthesia has been reported to stabilize intraoperative hemodynamics, the patient's neurological condition must be assessed indirectly. Therefore, we investigated the changes in intraoperative hemodynamics and perioperative complications of CAS under general anesthesia and evaluated the efficacy of somatosensory evoked potential (SEP) monitoring in detecting a reduction in perfusion during CAS. MATERIALS AND METHODS: From April 2011 to August 2016,57 consecutive patients who underwent CAS under general anesthesia were evaluated. The follow-up period ranged from 3 to 8 years. During CAS, anesthesiologists monitored and managed the hemodynamics. SEP monitoring was performed during the CAS procedure in all patients. RESULTS: Intraoperative hypotension (systolic blood pressure ≤ 100 mmHg) was evident in 16 patients (28.1%), and 13 patients (22.8%) experienced intraoperative bradycardia; however, all of these cases were promptly managed under general anesthesia. None of the patients showed systolic blood pressure < 50 mmHg from baseline. Regarding perioperative complications, none of the patients exhibited myocardial infarction or postoperative hyperperfusion symptoms, and there was no mortality. Among 21 patients (36.8%) with a decrease in the intraoperative SEP, 3 (5.3%) exhibited transient ischemic symptoms and 1 (1.8%) had postoperative infarction. CONCLUSIONS: CAS under general anesthesia is a safe and effective management option in terms of intraoperative hemodynamic stability. In addition, our findings indicate that SEP monitoring could be helpful in evaluating transient postoperative cerebral ischemia or cerebral infarction after CAS.

[A Case of Remnant Gastric Cancer with Mesojejunal Lymph Node Metastasis].

A 62-year-old man underwent radical surgery for the treatment of remnant gastric cancer with mesojejunal lymph node metastasis. According to the 15th edition of the Japanese Gastric Cancer Association, a histological diagnosis of B-35-A, type 3, tub2>tub1, pT3(SS), pN3a(10/37), cM0, CY0, pStage ⅢB was made. All lymph node metastases were recognized in the mesojejunum. Adjuvant chemotherapy with S-1 plus docetaxel was initiated after 4 weeks of surgery. The patient is still alive without recurrence after 1 year of surgery. Thus, radical surgery with dissection of the mesojejunum and intensive adjuvant chemotherapy might improve the prognosis in a remnant gastric cancer patient with mesojejunal lymph node metastasis.

[Complete Response to Neoadjuvant Chemotherapy with Imatinib of a Large Gastric GIST-A Case Report].

A 54-year-old woman was presented with the intraabdominal mass to our hospital. Abdominal CT showed 22 cm tumor of the stomach with invasion to the pancreas and the spleen. Upper GI endoscopy showed submucosal tumor at the stomach body, and endoscopic US showed low echoic tumor. The tumor was diagnosed as gastric GIST by biopsy with c-kit positive cells. After 4 months of neoadjuvant therapy with imatinib, she underwent total gastrectomy, distal pancreatectomy and splenectomy. Histopathologically, there were no viable tumor cells in the resected specimen. The patient has no evidence of recurrence at 8 months post operation.

Six autoantibodies as potential serum biomarkers of hepatocellular carcinoma: A prospective multicenter study.

Serum autoantibodies have been reported to react with tumor-associated antigen (TAA) in various cancers. This multicenter study evaluated the diagnostic and prognostic value of six autoantibodies against a panel of six hepatocellular carcinoma (HCC)-associated antigens, including Sui1, p62, RalA, p53, NY-ESO-1 and c-myc. A total of 160 patients with HCC and 74 healthy controls were prospectively enrolled from six institutions. Serum antibody titers were determined by enzyme-linked immunosorbent assays. The sensitivities were 19% for Sui1, 18% for p62, 17% for RalA, 11% for p53, 10% for NY-ESO-1 and 9% for c-myc. Overall sensitivity of the TAA panel (56%) was higher than that of α-fetoprotein (41%, P < .05). The combined sensitivity of the TAA panel and α-fetoprotein was significantly higher than that of α-fetoprotein alone (P < .001). The difference in overall survival of TAA panel-positive and panel-negative patients was significant when the Stage I/II patients were combined (P = .023). Overall survival was worse in NY-ESO-1 antibody-positive than in NY-ESO-1 antibody-negative patients (P = .002). Multivariate analysis found that positivity for the TAA panel was independently associated with poor prognosis (P = .030). This TAA panel may have diagnostic and prognostic value in the patients with HCC.

Discovery of ORN0829, a potent dual orexin 1/2 receptor antagonist for the treatment of insomnia.

Here, we present the design, synthesis, and SAR of dual orexin 1 and 2 receptor antagonists, which were optimized by balancing the antagonistic activity for orexin receptors and lipophilicity. Based on the prototype compound 1, ring construction and the insertion of an additional heteroatom into the resulting ring led to the discovery of orexin 1 and 2 receptor antagonists, which were 3-benzoyl-1,3-oxazinane derivatives. Within these derivatives, (-)-3h enabled a high dual orexin receptor antagonistic activity and a low lipophilicity. Compound (-)-3h exhibited potent sleep-promoting effects at a po dose of 1 mg/kg in a rat polysomnogram study, and optimal PK properties with a rapid Tmax and short half-lives in rats and dogs were observed, indicating a predicted human half-life of 0.9-2.0 h. Thus, (-)-3h (ORN0829; investigation code name, TS-142) was selected as a viable candidate and is currently in clinical development for the treatment of insomnia.

Minimally invasive esophagectomy and radical lymph node dissection without recurrent laryngeal nerve paralysis.

BACKGROUND: We introduce a novel operative technique to dissect lymph nodes adjacent to the recurrent laryngeal nerve, referred to as the "native tissue preservation" technique. Using this technique, there was no damage to the recurrent laryngeal nerve, which is maintained in its anatomical position. METHODS: From September 2016 to December 2018, minimally invasive esophagectomy was performed in the left lateral decubitus position in 87 patients with esophageal cancer. The native tissue preservation technique for lymphadenectomy around the recurrent laryngeal nerve was used, and all patients were evaluated for recurrent laryngeal nerve paralysis. RESULTS: Minimally invasive esophagectomy was completed in all patients without conversion to thoracotomy. Although an extended lymphadenectomy was performed in all patients, there were no grade II or higher complications (Clavien-Dindo classification) and no incidence of recurrent laryngeal nerve paralysis. CONCLUSION: The native tissue preservation technique may reduce the incidence of recurrent laryngeal nerve paralysis after minimally invasive esophagectomy with radical lymph node dissection.

Virtual reality with three-dimensional image guidance of individual patients' vessel anatomy in laparoscopic distal pancreatectomy.

PURPOSE: Three-dimensional virtual endoscopy (3DVE) has the potential advantage of enhanced anatomic delineation and spatial orientation during laparoscopic procedures. In the present study, we aimed to evaluate the impact of 3DVE guidance in laparoscopic distal pancreatectomy (LDP). METHODS: Thirty-eight patients presenting to our hospital with a variety of pancreatic tumors underwent preoperative computed tomography scanning to clearly define the major peripancreatic vasculature and correlate it with a 3DVE system (SYNAPSE VINCENT: Fujifilm Medical, Tokyo, Japan). This map served as the guide during preoperative planning, surgical education, and simulation and as intraoperative navigation reference for LDP. Operative records and pathological findings were analyzed for each procedure. Operative parameters were compared between the 38 patients in this study and 8 patients performed without 3DVE guidance at our institution. RESULTS: The 3DVE navigation system successfully created a preoperative resection map in all patients. Relevant peripancreatic vasculature displayed on the system was identified and compared during the intervention. The mean blood loss in LDP performed under 3DVE guidance versus LDP without 3DVE was 168.5 +/- 347.6 g versus 330.0 +/- 211.4 g, p = 0.008 while and the operative time was 171.9 +/- 51.7 min versus 240.6 +/- 24.8 min, p = 0.001. CONCLUSIONS: 3DVE in conjunction with a "laparoscopic eye" creates a preoperative and intraoperative three-dimensional data platform that potentially enhances the accuracy and safety of LDP.

Preventing clinically relevant pancreatic fistula with combination of linear stapling plus continuous suture of the stump in laparoscopic distal pancreatectomy.

BACKGROUND: Pancreatic fistula is one of the serious complications for patients undergoing distal pancreatectomy, which leads to significant morbidity. The aim of our study is to compare linear stapling closure plus continuous suture with linear stapling closure alone during laparoscopic distal pancreatectomy (LDP) in terms of clinically relevant postoperative pancreatic fistula (POPF) rate. METHODS: Twenty-two patients underwent LDP at our institution between 2011 and 2013. Twelve patients had linear stapling closure with peri-firing compression (LSC) alone compared with ten patients who had linear stapling closure, peri-firing compression plus continuous suture (LSC/CS) for stump closure of remnant pancreas in LDP. Biochemical leak and clinically relevant POPF were compared between both groups. RESULTS: POPF occurred in 4 of 12 (33.3%) patients with linear stapling closure while no patient developed a clinically relevant POPF in the triple combination of linear stapling, peri-firing compression plus continuous suture group (p = 0.043).1 patient (8.3%) in the LSC group and 5 patients (50%) in the LSC/CS group had evidence of a biochemical leak. There were no significant differences in operative time (188.3 vs 187.0 min) and blood loss (135 vs. 240 g) between both groups but there was a significantly of shorter length of hospital stay (11.9 vs. 19.9 days) in LSC/CS group (p = 0.037). There was no mortality in either group. CONCLUSIONS: The triple combination of linear stapling, peri-firing compression plus continuous suture in LDP has effectively prevented occurrence of clinically relevant ISGPF POPF. TRIAL REGISTRATION: The study was retrospectively registered September 30, 2019 at Showa University Ethics Committee as IRB protocol numbers 2943.

Individualized procedures for splenic artery dissection during laparoscopic distal pancreatectomy.

BACKGROUND: There are no established standard criteria for choosing the most appropriate procedure of splenic artery dissection during laparoscopic distal pancreatectomy (LDP). The aim of this study was to evaluate the clinical benefits of individualized procedures for splenic artery dissection during LDP based on the variations in arterial structure visualized on preoperative three-dimensional computed tomography (3D-CT). METHODS: Patients who underwent LDP following 3D-CT at a single center were retrospectively evaluated. 3D-CT images were used to construct virtual 3D laparoscopic images for surgical planning. The splenic artery was classified into two major anatomic types: type S that curves and runs suprapancreatic and type D that runs straight and dorsal to the pancreas. Splenic artery dissection was planned according to these two variations, with type S dissected using an suprapancreatic approach and type D using a dorsal approach. RESULTS: Type-specific dissection was applied for 30 patients: 25 (83%) with type S and 5 (17%) with type D splenic artery anatomies. In 25 (83%) patients, the splenic artery was successfully dissected using the planned surgical procedure, whereas the surgical plan had to be altered in 5 cases (17%) due to difficulty in dissecting the splenic artery. CONCLUSION: The individualized procedures for splenic artery dissection according to anatomic variations visualized on 3D-CT images can help improve the success and safety of LDP.

Laparoscopic partial liver resection improves the short-term outcomes compared to open surgery for liver tumors in the posterosuperior segments.

PURPOSE: The aim of this study was to compare the clinical outcomes between laparoscopic partial liver resection and open partial hepatectomy for tumors in the posterosuperior segments. METHODS: The clinical outcomes of patients who underwent either laparoscopic (n = 20) or open (n = 44) resection in segments 7/8 of the liver were initially evaluated. Because of disparities in the background characteristics, a case-matched study (1:1) was conducted. In addition, a comparative study of the patients who met the institutional criteria for laparoscopic partial hepatectomy was performed. RESULTS: In the case-matched study, the laparoscopic technique required a longer operation time (p = 0.001), but was associated with less intraoperative blood loss (p = 0.021), a lower incidence of major complications (p = 0.014), higher levels of serum albumin on postoperative days 3 and 7 (p = 0.031 and p = 0.035), and earlier discharge (p = 0.001) than open resection. The results of the latter study were similar to those of the case-matched analysis. CONCLUSIONS: Laparoscopic partial hepatectomy was a feasible procedure for treating tumors in the posterosuperior segments without compromising oncological safety and yielded better short-term outcomes than open techniques. In addition, this study provides concrete selection criteria for laparoscopic partial hepatectomy for difficult lesions.

Combination of longitudinal pancreaticojejunostomy with coring-out of the pancreatic head (Frey procedure) and distal pancreatectomy for chronic pancreatitis.

PURPOSE: The Frey procedure is an effective surgery for chronic pancreatitis (CP) patients who have pancreatic head lesions with dilation of the main pancreatic duct. However, pancreatic tail lesions can cause relapsing pancreatitis after the procedure. Therefore, additional distal pancreatectomy (DP) might complement the therapeutic effect of the Frey procedure in controlling inflammation of the pancreatic tail. The Frey procedure with DP (Frey + DP) is indicated for inflammatory lesions in the pancreatic head and tail. In this study, we assessed the usefulness of Frey + DP using the retrospective clinical data of our cases. METHODS: The clinical outcomes were compared between CP patients who underwent the Frey procedure (N = 44) and Frey + DP (N = 13) from January 2005 to April 2016. RESULTS: Frey + DP showed similarly good therapeutic effects to the Frey procedure with regard to the postoperative stay, morbidity, mortality, pain relief and nutrition, although the Frey + DP had a longer operative time, more bleeding and higher incidence of diabetes mellitus than the Frey procedure because of the additional DP. One patient in the Frey group received additional DP because of recurrent pain due to the tail lesion. CONCLUSION: Frey + DP can be a promising treatment for CP patients with pancreatic head and tail lesions.

[A Case of Peritoneal Metastasis Resection from GIST of the Small Intestine with Focal Resistance Against Imatinib Mesylate].

A 69-year-old man was referred to our institute for the surgical resection of focal resistant peritoneal GIST during imatinib administration. He had been diagnosed with GIST of the small intestine with liver and peritoneal metastases, and imatinib treatment was initiated. Shortly after imatinib administration, the primary lesion perforated, and thus, partial resection of the small intestine was performed. Imatinib treatment was resumed after the first surgery, and he achieved partial response. However, computed tomography scans obtained 7 months after the first surgery showed focal progression, a peritoneal metastasis near the right kidney. Under the diagnosis of focally imatinib-resistant GIST, local resection of the metastatic tumor was performed. In this case, an exon 11 mutation of c-kit was noted initially. After the imatinib treatment, an additional point mutation was observed in exon 18 that caused resistance to imatinib. Therefore, imatinib treatment was reinitiated after the second surgery, and other metastases were well controlled. In case of GIST with multiple metastases, appropriate treatment should be selected based on the resistance of each lesion.