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.

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.

[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.

[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.

[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.

[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.