Perineoplasty for anal incontinence after obstetric anal sphincter injury repair: a case report.

BACKGROUND: The rectal and vaginal walls are typically sutured if severe perineal lacerations with rectal mucosal damage occur during vaginal delivery. In case of anal incontinence after the repair, re-suturing of the anal sphincter muscle is standard procedure. However, this procedure may not result in sufficient improvement of function. CASE PRESENTATION: A 41-year-old woman underwent suture repair of the vaginal and rectal walls for fourth-degree perineal laceration at delivery. She was referred to our department after complaining of flatus and fecal incontinence. Her Wexner score was 15 points. Examination revealed decreased anal tonus and weak contractions on the ventral side. We diagnosed anal incontinence due to sphincter dysfunction after repair of a perineal laceration at delivery. We subsequently performed sphincter re-suturing with perineoplasty to restructure the perineal body by suturing the fascia located lateral to the perineal body and running in a ventral-dorsal direction, which filled the space between the anus and vagina and increased anal tonus. One month after surgery, the symptoms of anal incontinence disappeared (the Wexner score lowered to 0 points), and the anorectal manometry values increased compared to the preoperative values. According to recent reports on the anatomy of the female perineal region, bulbospongiosus muscle in women does not move toward the midline to attach to the perineal body, as has been previously believed. Instead, it attaches to the ipsilateral surface of the external anal sphincter. We consider the fascia lateral to the perineal body to be the fascia of the bulbospongiosus muscle. CONCLUSIONS: In a case of postpartum anal incontinence due to sphincter dysfunction after repair of severe perineal laceration, perineoplasty with re-suturing an anal sphincter muscle resulted in improvement in anal sphincter function. Compared to conventional simple suture repair of the rectal wall only, this surgical technique may improve sphincter function to a greater degree.

Combined rehabilitation therapy with botulinum toxin to the upper limbs for acute spinal cord injury: A case report.

INTRODUCTION: Patients with spinal cord injury (SCI) and incomplete paralysis may experience muscle immobilization due to functional impairment of agonist and antagonist muscles. This can induce spasticity and pain, with the risk of contracture increasing as the period of immobilization increases. This could be aggravated by pain, which interferes with rehabilitation. There is no established treatment for pain and joint contractures caused by acute SCI. Botulinum therapy plays a role in relieving muscle tension. Here, we report a case of acute SCI in which botulinum therapy was administered. CASE PRESENTATION: The patient experienced a C5-cervical SCI due to a road traffic accident, with marked paralysis in the upper and lower limbs below the C5 level. The patient had persistent elbow flexion since the SCI and complained of excruciating pain, making adequate rehabilitation difficult. Botulinum toxin was administered to the biceps and brachialis muscles 15 days after the SCI. After administration, the patient experienced a reduction in pain with relaxation of the elbow flexor muscles, and rehabilitation treatment was resumed. This patient's contracture did not worsen, his pain decreased, and he was able to initiate self-feeding training. DISCUSSION: In this case, occupational and physical therapy was administered with botulinum therapy. Together, they successfully reduced pain. Botulinum therapy provides analgesia and muscle relaxation and may lead to functional recovery, and we believe that treatment can be considered even in the acute phase.

Long-term outcomes after spleen-preserving distal pancreatectomy with splenic vessels preservation or resection: A nationwide survey of the Japanese Society of Pancreatic Surgery.

BACKGROUND: Spleen preserving distal pancreatectomy is achieved by either splenic vessel resection or splenic vessel preservation. However, the long-term outcomes of spleen-preserving distal pancreatectomy with splenic vessel resection and spleen-preserving distal pancreatectomy with splenic vessel preservation are not well known. This study aimed to evaluate the long-term outcomes of spleen-preserving distal pancreatectomy with splenic vessel resection and spleen-preserving distal pancreatectomy with splenic vessel preservation. METHODS: The study included a total of 335 patients who underwent spleen-preserving distal pancreatectomy during the study period and underwent computed tomography or magnetic resonance imaging 3 and 5 years after surgery in the Japan Society of Pancreatic Surgery member institutions. We evaluated the diameter of the perigastric and gastric submucosal veins, patency of the splenic vessels, and splenic infarction. Preoperative backgrounds and short- and long-term outcomes were compared between the 2 groups. RESULTS: Forty-four (13.1%) and 291 (86.9%) patients underwent spleen-preserving distal pancreatectomy with splenic vessel resection and spleen-preserving distal pancreatectomy with splenic vessel preservation, respectively. There were no significant differences in short-term outcomes between the 2 groups. Regarding long-term outcomes, the prevalence of perigastric varices was higher (P = .006), and platelet count was lower (P = .037) in the spleen-preserving distal pancreatectomy with splenic vessel resection group. However, other complications, such as gastric submucosal varices, postoperative splenic infarction, gastrointestinal bleeding, reoperation, postoperative splenectomy, and other hematologic parameters, were not significantly different between the 2 groups 5 years after surgery. In terms of the patency of splenic vessels in spleen preserving distal pancreatectomy with splenic vessel preservation cases, partial or complete occlusion of the splenic artery and vein was observed 5 years after surgery in 19 (6.5%) and 55 (18.9%) patients, respectively. CONCLUSION: Perigastric varices and thrombocytopenia were observed more in spleen-preserving distal pancreatectomy with splenic vessel resection, yet late clinical events such as gastrointestinal bleeding and splenic infarction are acceptable for spleen-preserving distal pancreatectomy with splenic vessel preservation.

Laparoscopic and open minor liver resection for hepatocellular carcinoma with clinically significant portal hypertension: a multicenter study using inverse probability weighting approach.

BACKGROUND: Liver resection offers substantial advantages over open liver resection (OLR) for patients with hepatocellular carcinoma (HCC) in terms of reduced intraoperative blood loss and morbidity. However, there is limited evidence comparing the indications and perioperative outcomes with the open versus laparoscopic approach for resection. This study aimed to compare postoperative outcomes between patients undergoing laparoscopic liver resection (LLR) and OLR for HCC with clinically significant portal hypertension (CSPH). METHODS: A total of 316 HCC patients with CSPH (the presence of gastroesophageal varices or platelet count < 100,000/ml and spleen diameter > 12 cm) undergoing minor liver resection at eight centers were included in this study. To adjust for confounding factors between the LLR and OLR groups, an inverse probability weighting method analysis was performed. RESULTS: Overall, 193 patients underwent LLR and 123 underwent OLR. After weighting, LLR was associated with a lower volume of intraoperative blood loss and the incidence of postoperative complications (including pulmonary complications, incisional surgical site infection, and paralytic ileus) compared to the OLR group. The 3-, 5-, and 7-year postoperative recurrence-free survival rates were 39%, 26%, and 22% in the LLR group and 49%, 18%, and 18% in the OLR group, respectively (p = 0.18). And, the 3-, 5-, and 7-year postoperative overall survival rates were 71%, 56%, and 44% in the LLR group and 76%, 51%, 44% in the OLR group, respectively (p = 0.87). CONCLUSIONS: LLR for HCC patients with CSPH is clinically advantageous by lowering the volume of intraoperative blood loss and incidence of postoperative complications, thereby offering feasible long-term survival.

Postoperative computed tomography findings predict re-drainage cases after early drain removal in pancreaticoduodenectomy.

PURPOSE: This study aimed to investigate the risk factors for re-drainage in patients with early drain removal after pancreaticoduodenectomy (PD). METHODS: This study retrospectively analyzed 114 patients who underwent PD and prophylactic drain removal on postoperative day (POD) 4 between January 2012 and March 2021. We analyzed the risk factors for re-drainage according to various factors. Peri-pancreaticojejunostomic fluid collection (PFC) index and pancreatic cross-sectional area (CSA) were evaluated using computed tomography on POD 4. The PFC index was calculated by multiplying the length, width, and height at the maximum aspect. RESULTS: Among the 114 patients, 15 (13%) underwent re-drainage due to postoperative pancreatic fistula. Multivariate analysis identified a PFC index ≥ 8.16 cm3 on POD 4 (odds ratio [OR], 20.40, 95%CI 2.38-174.00; p = 0.006) and pancreatic CSA on POD 4 ≥ 3.65 cm2 (OR, 16.40, 95%CI 1.57-171.00; p = 0.020) as independent risk factors for re-drainage. CONCLUSION: A careful decision might be necessary for early drain removal in patients with a PFC index ≥ 8.16 cm3 and pancreatic CSA ≥ 3.65 cm2.

Effect of early administration of tolvaptan on pleural effusion post-hepatectomy.

PURPOSE: This study evaluated the efficacy of tolvaptan administration at the early stage after hepatectomy to control pleural effusion and improve the postoperative course. METHODS: Patients were administered tolvaptan (7.5 mg) and spironolactone (25 mg) from postoperative day 1 to postoperative day 5 (tolvaptan group, n = 68) for 13 months. Early administration of tolvaptan was not provided in the control group (n = 68); however, diuretics were appropriately administered according to the patient's condition. The amount of pleural effusion on computed tomography on postoperative day 5 was compared between the two groups. RESULTS: The amount of pleural effusion and increase in body weight on postoperative day 5 showed significant differences in both groups (p < 0.001 and p = 0.019, respectively). However, the rate of pleural aspiration and the duration of postoperative hospitalization were comparable between the groups. The amount of intraoperative blood loss and lack of early administration of tolvaptan were identified as independent risk factors contributing to pleural effusion on multivariate analysis. CONCLUSION: Early administration of tolvaptan to patients after hepatectomy was found to be capable of controlling postoperative pleural effusion and increase in body weight, but it did not reduce the rate of pleural aspiration or the hospitalization period.

Impact of Trinal Histological Glandular Differentiation Grade on the Prognosis of Patients with Intrahepatic Cholangiocarcinoma: a Multicenter Retrospective Study.

INTRODUCTION: It is unclear whether the histological glandular differentiation (HGD) score that evaluates the tumor grade of two dominant components is prognostic for survival in patients with intrahepatic cholangiocarcinoma (ICC). METHOD: We retrospectively analyzed the clinical and histopathologic data of 235 consecutive patients with histologically confirmed ICC following hepatectomy at 5 university hospitals in the Kansai region of Japan. RESULTS: Survival was statistically significantly stratified by trinal HGD grade (p < 0.05). Median disease-free survival (DFS) of patients with high HGD grade was significantly shorter compared with moderate HGD grade (13.0 vs 31.2 months, respectively; p = 0.004). By Cox proportional hazards regression analysis, HGD grade had the fifth-highest hazard ratio (HR = 1.77, p = 0.002) for DFS after vascular and/or biliary invasion, extrahepatic invasion, lymph node metastasis and multiple tumors. Multivariate logistic regression analysis revealed four predictors of early recurrence after hepatectomy (lymph node metastasis: odds ratio [OR] = 3.74, p = 0.001; tumor size > 50 mm: OR = 2.80, p = 0.002; HGD grade, high: OR = 2.11, p = 0.012; and vascular or biliary tract invasion: OR = 2.11, p = 0.048). CONCLUSION: Trinal HGD grade had a significant prognostic impact on the survival of patients with ICC after radical hepatectomy.

Response Prediction Model of Atezolizumab plus Bevacizumab in Patients with Unresectable Hepatocellular Carcinoma: Multicenter Retrospective Study.

INTRODUCTION: Atezolizumab plus bevacizumab (ATZ+BV) treatment has become the first-line regimen for unresectable hepatocellular carcinoma (u-HCC). Prediction of response to it might be clinically beneficial. Using peripheral blood parameters, we aimed to construct a prediction model for ATZ+BV treatment. METHODS: Clinical records of 119 patients with u-HCC treated by ATZ+BV were retrospectively analyzed. The primary outcome measurement was defined as any-size reduction at the initial image evaluation. Using baseline values of peripheral blood parameters, a prediction model was constructed by univariate and multivariate logistic regression analysis. Validation was performed internally by bootstrap method. RESULTS: The primary outcome was achieved in 46 patients. Univariate analysis showed that C-reactive protein (CRP), alpha-fetoprotein (AFP), des-gamma-carboxy prothrombin (DCP), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR) were possible predictors. CRP and DCP, and NLR and PLR had correlation (correlation coefficient >0.3), so we used CRP and NLR as representative factors, respectively. Multivariate analysis constructed the following prediction model: Logit = 1.62-0.61×[CRP] -0.38×[Log10AFP] -0.37×[NLR]. Bootstrapped median (95% confidence interval) of coefficients of CRP, Log10AFP, NLR were -0.64 (-1.46 ∼ -0.11), -0.40 (-0.82 ∼ -0.03), and -0.38 (-0.74 ∼ -0.05), respectively. The area under the receiver operating characteristic curve (95% confidence interval) was 0.73 (0.60-0.80). Median overall survival of the favorably and unfavorably predicted groups were 17.0 and 11.0 months (p = 0.03), respectively. DISCUSSION: In patients with u-HCC treated by ATZ+BEV, a prediction model constructed using baseline values of CRP, AFP, and NLR had impact on any-size reduction at the initial image evaluation and on prognosis.

Colonization of the gastric juice by Candida spp. promotes surgical site infection after hepatectomy.

PURPOSE: Candida spp. cause opportunistic infections in conditions of immunodeficiency. Here, we investigated the relationship between colonization of the gastric juice by Candida spp. and surgical site infection (SSI) in hepatectomy. METHODS: Consecutive hepatectomy cases between November 2019 and April 2021 were enrolled. Gastric juice samples (collected intraoperatively through a nasogastric tube) were cultured. We compared factors related to patient background, blood test findings, surgical findings, and postoperative complications between the Candida + group (positive for colonization of the gastric juice by Candida spp.) and the Candida - group (negative). In addition, we identified the factors that contribute to SSI. RESULTS: There were 29 and 71 patients in the Candida + and Candida - groups, respectively. The Candida + group was significantly older (average age: Candida + 74 years vs. Candida - 69 years; p = 0.02) and contained more patients negative for the hepatitis B and C virus (Candida + 93% vs. Candida - 69%; p = 0.02). SSI was significantly more common in the Candida + group (Candida + 31% vs. Candida - 9%; p = 0.01). Postoperative bile leakage and colonization of the gastric juice by Candida spp. were independent predictors of SSI. CONCLUSION: Colonization of the gastric juice by Candida spp. is a risk factor for SSI after hepatectomy.

Clinical impact of postoperative malnutrition after pancreaticoduodenectomy: prediction based on estimated functional remnant pancreatic volume, prognostic nutritional index, and body mass index.

BACKGROUND: The present study aimed to evaluate the association between estimated functional remnant pancreatic volume (eFRPV) and postoperative malnutrition after pancreaticoduodenectomy (PD). METHODS: The medical records of 131 patients who underwent PD and preoperative computed tomography were retrospectively reviewed. Onodera's prognostic nutritional index (PNI) was assessed 6-months after PD. Patients with PNI values of at least 45 were included in the non-malnutrition group, while those with values <45 and <40 were included in the mild and severe malnutrition groups, respectively. Associations between eFRPV and postoperative nutritional status were evaluated to identify factors predictive of severe malnutrition after PD. RESULTS: Fifty-three patients (40%) were included in the non-malnutrition group, while 38 (29%) and 40 (31%) were included in the mild and severe malnutrition groups, respectively. Overall survival was significantly shorter in the severe malnutrition group (p < 0.001). The eFRPV was significantly lower in the severe malnutrition group (p = 0.003; Jonckheere-Terpstra trend test, p < 0.001). In the multivariate analysis, eFRPV ≤55.2 mL·HU (odds ratio [OR] = 5.20; p = 0.004), preoperative PNI ≤41.9 (OR = 6.37; p = 0.010), and body mass index ≤19.1 kg/m2 (OR = 3.43; p = 0.031) were independent predictors of severe malnutrition after PD. CONCLUSION: The current results indicate that eFRPV may predict low PNI values after PD.

Preoperative Predictive Nomogram Based on Alanine Aminotransferase, Prothrombin Time Activity, and Remnant Liver Proportion (APART Score) to Predict Post-Hepatectomy Liver Failure after Major Hepatectomy.

INTRODUCTION: Post-hepatectomy liver failure (PHLF) is a serious complication associated with major hepatectomies. An accurate prediction of PHLF is necessary to determine the feasibility of major hepatectomy. This study aimed to assess the association between PHLF and preoperative laboratory and computed tomography (CT) findings. METHODS: Medical records of 65 patients who underwent major hepatectomy and preoperative CT were retrospectively reviewed. We evaluated future remnant liver volume evaluation models and remnant liver hemodynamics, which were assessed by arterial enhancement fraction (AEF) by using preoperative CT. Variables, including CT findings, were compared between patients with and without PHLF after major hepatectomy, and the preoperative PHLF-predicting nomogram was constructed using multivariate logistic regression. RESULTS: The PHLF group included 21 patients (32.3%). The AEF was not significantly different between the two groups. In the future remnant liver volume evaluation models, future remnant liver proportion (fRLP) had the highest concordance index (C-index) in the receiver operating characteristic curve analysis (C-index, 0.755). Multivariate analysis of preoperative evaluable factors revealed that alanine aminotransferase levels (p = 0.034), prothrombin time activity (p = 0.021), and fRLP (p = 0.012) were independent predictive factors of PHLF. A nomogram (APART score) was constructed using these three factors, with a receiver operating curve showing a C-index of 0.894. According to the APART score, scores of 51-60 indicated moderate risk (40.0%), and scores over 60 indicated a high risk of PHLF (83.3%) (p < 0.001). DISCUSSION: The APART score may help predict PHLF in patients indicated for major hepatectomies.

Surgical Outcomes for Hepatocellular Carcinoma in Patients with Child-Pugh Class B: a Retrospective Multicenter Study.

BACKGROUNDS: Liver resection for hepatocellular carcinoma (HCC) in patients with Child-Pugh class (CPC) B increases the incidence of postoperative complication and in-hospital death and decreases the disease-free survival (DFS) and overall survival (OS) compared with those with CPC A. Conversely, some selected patients possibly gained benefits for liver resection. METHODS: Clinical records of 114 patients with CPC B who underwent liver resection for HCC were retrospectively reviewed. The risk of postoperative complications (Clavien-Dindo classification grade of ≥ II), postoperative recurrence, and death was analyzed. RESULTS: Postoperative complications occurred in 36 patients (31.6%), and 2 died within 90 days postoperatively due to the liver and respiratory failure, respectively. Multivariate analysis indicated that albumin-bilirubin (ALB) grade III and extended operation time were found as independent risk factors for postoperative complications. The DFS and OS rates at 3/5 years after liver resection were 30.8%/25.3% and 68.4%/48.9%, respectively. Multivariate analysis indicated that the extended blood loss, high α-fetoprotein (AFP) level (≥ 200 ng/mL), and Barcelona Clinic Liver Cancer stage C were found to be independent risk factors for postoperative recurrence. The high AFP level was also an independent prognostic factor for OS. Patients with high AFP levels had postoperative recurrence within 2 years and a higher number of extrahepatic recurrences than those with low AFP levels (< 200 ng/mL). CONCLUSION: For patients with HCC with CPC B who were scheduled for liver resection, ALBI grade III and high AFP level should be considered as unfavorable outcomes after liver resection.

High abundance of Lachnospiraceae in the human gut microbiome is related to high immunoscores in advanced colorectal cancer.

INTRODUCTION: The tumor microenvironment (TME) in colorectal cancer (CRC) includes the gut microbiome, immune cells, angiogenic factors, and fibroblasts and plays a major role in cancer progression. The Immunoscore (IS) is based on tumor infiltration by immune cells that are known prognostic biomarkers for CRC. However, the interrelation between the IS, microbiome, and other TME factors in human CRC remains unclear. PATIENTS AND METHODS: A cohort of 94 patients with CRC was examined at the Shiga University of Medical Science Hospital in Japan. The expression levels of CD3, CD8, CD31, and alpha-smooth muscle actin (α-SMA) in the primary tumor were evaluated by immunohistochemistry. The IS was calculated based on the results of the CD3 and CD8 staining assays. Microbiomes in patients with CRC were examined by amplicon sequencing. RESULTS: The expression levels of α-SMA and tumor-infiltrating lymphocytes in patients with CRC were negatively correlated (P = 0.006). A high IS was associated with high abundance of Lachnospiraceae in the microbiomes of patients with CRC. CONCLUSION: Lymphocyte infiltration into the primary tumor was marked by reduced density of cancer-associated fibroblasts and enrichment of the Lachnospiraceae family in the gut microbiome, which may influence CRC progression.

Effect of the Gastrojejunostomy Position on the Postoperative Amount of Oral Intake in Pancreaticoduodenectomy.

INTRODUCTION: We investigated the effect of the gastrojejunostomy position on the postoperative oral intake in patients who have undergone pancreaticoduodenectomy (PD). METHODS: We investigated 119 patients who underwent PD between June 2013 and December 2019 and examined the effect of the horizontal and vertical distance rates of the gastrojejunostomy position on the postoperative oral intake. The patients were categorized as having poor or good oral intake based on whether their intake was up to half the required calorie intake. RESULTS: There were significant differences in the number of cases with grade B or C postoperative pancreatic fistula (good, 20.3% vs. poor, 60.0%; p < 0.001), horizontal distance rate (good, 0.57 vs. poor, 0.48; p = 0.02), and postoperative hospitalization period (good, 15 vs. poor, 35 days; p < 0.001). However, there was no significant difference in the vertical distance rate (good, 0.67 vs. poor, 0.71; p = 0.22). The horizontal distance rate was the independent risk factor for postoperative poor oral intake at 2-3 weeks (risk ratio, 3.69; 95% CI: 1.48-9.20). DISCUSSION: The oral intake was greater in patients whose gastrojejunostomy position in PD was farther from the median, suggesting the necessity of intraoperative placement of the gastrojejunostomy position as far from the median as possible.

Preoperative Physical Activity Level Measurement by Accelerometer for Predicting Post-Hepatectomy Complications: A Prospective Observational Study.

INTRODUCTION: Recently, accelerometers have received much attention around the world. This study examined whether the preoperative physical activity level measured by an accelerometer could be a useful predictor of post-hepatectomy complications. METHODS: Between December 2016 and December 2020, the physical activity levels of 185 patients were measured using an accelerometer 3 days before hepatectomy and from postoperative day 1 to 7. The patients without postoperative complications (n = 153) and those with postoperative complications (n = 32) were compared using either the χ2 test or Fisher's exact test for nominal variables; continuous variables were analyzed using either Student's t test or Mann-Whitney U test. Differences were considered statistically significant when the p value was <0.05. Risk factors for postoperative complications following hepatectomy were also investigated. RESULTS: The number of patients with an anatomical resection was significantly higher in patients with postoperative complications (p = 0.001). Furthermore, laparoscopic hepatectomy was performed in 65.4% of patients without postoperative complications and in 25.0% of those with postoperative complications; the difference was statistically significant (p < 0.001). The average preoperative physical activity level was 150.6 kcal/day in patients without postoperative complications and 84.5 kcal/day in those with postoperative complications (p = 0.001). Multivariate analysis identified blood loss, operative time, and preoperative physical activity level as independent risk factors for postoperative complications. DISCUSSION/CONCLUSION: Patients with lower preoperative physical activity levels are at a high risk of developing postoperative complications after hepatectomy. Hence, preoperative physical activity level measurement may be useful in predicting post-hepatectomy complications.

Clinical effect of home enteral tube feeding supplementation on nutritional status after esophagectomy with retrosternal gastric tube reconstruction.

Body weight loss and poor nutritional status are frequently observed after esophageal cancer surgery. The aim of this study was to pilot an investigation on the impact of home enteral tube feeding supplementation (HES) for up to 3 months after esophageal cancer surgery. We retrospectively reviewed consecutive 67 esophageal cancer patients who underwent esophagectomy with gastric tube reconstruction. We started HES from April 2017. The patients were divided into 2 groups. Among 67 patients, 40 patients underwent HES between April 2017 and November 2020 (HES group). Other 27 patients who underwent esophagectomy between January 2012 and March 2017 were not administered HES (C group). Thereafter, multiple factors concerning patient nutritional status at long-term follow-up were evaluated. The baseline characteristics were balanced between the two groups. There were no significant differences in nutritional status scores before esophagectomy. The percentage weight loss was less in the HES group compared with the C group both at 3 months and 1 year after surgery: 7.3% (-7.6 to 15.2), 7.7% (-4 to 13.9) in the HES group and 10.6% (-3.6 to 29.1), 10.8% (-5.8 to 20.0) in C group (P < 0.05, P < 0.05). In the patients with anastomotic stenosis, the percentage weight loss was less in the HES group compared with the C group: 7.2% (2.0-14.9) and 14.6% (6.2-29.1), P < 0.05. HES may improve early weight loss in postesophagectomy patients.

[Clinical Outcomes of Treatment for Esophageal Cancer Recurrence after Surgery].

Many cases with esophageal cancer recurrence have worse clinical survival. Treatment with immune checkpoint inhibitor (ICI)has been reported to result in significantly longer overall survival. We investigated the clinical outcomes in 30 patients with esophageal cancer recurrence who underwent neoadjuvant chemotherapy followed by surgery, chemotherapy, and chemoradiotherapy. Results: Of the 30 patients investigated, 25 were men. Median patient age was 70(range 52-84)years. The recurrence sites are as follows: 17 in locoregional, 5 in lung, 2 in bone, 3 in liver, and 5 in others. The overall survival in early recurrence(within 6 months after surgery)cases and multiple recurrence cases were significantly shorter than that in later recurrence(>6 months after surgery)and single recurrence(p=0.031, p<0.01). Of 30 recurrence cases, 9 cases (30%)achieved complete response(CR). Five of CR cases were treated by chemotherapy with ICI. In esophageal cancer recurrence, treatment with ICI showed good response and survival benefit. In future, the indication of ICI is evaluated for adjuvant therapy after surgery.

[A Case of Postoperative Anastomotic Leakage with Septic Shock after Esophageal Cancer Surgery Treated by Two Stage Operation Using Ileocolic Reconstruction].

The patient was a 60s male. He underwent esophagectomy and gastric tube reconstruction for Barrett's esophageal cancer( pT3N1M0, pStage Ⅲ). Postoperatively, anastomotic leakage and mediastinitis resulted in septic shock. On the 8th day after first surgery, he transferred to our hospital. At the time of admission, qSOFA was 3 points. We judged to be difficult to treat with conservative treatment. Emergency right thoracotomy drainage underwent with resection of the esophagogastric anastomosis and cervical esophagostomy construction. He was discharged on the 55th postoperative day with home enteral nutrition. He underwent presternal ileocolic reconstruction on the 97th day after right thoracotomy drainage. On the 19th day after reconstruction, oral intake was started. The general condition is good without recurrence, and oral intake is sufficient at 1 year after reconstruction. We report a case of anastomotic leakage with septic shock after esophageal cancer surgery successfully treated by 2 stage ileocolic reconstruction.

The Change in the Fibrosis-4 Index for the Assessment of Liver Fibrosis After Pancreaticoduodenectomy.

OBJECTIVES: Nonalcoholic fatty liver is a complication of pancreaticoduodenectomy (PD); however, liver fibrosis after PD is not well documented. Therefore, we estimated the hepatic fibrotic index of nonalcoholic fatty liver after PD. METHODS: We retrospectively examined the electronic medical records of patients who had underwent PD and had computed tomography (CT) records preoperatively and 6 months postoperatively between 2011 and 2019 at the Shiga University of Medical Science Hospital. RESULTS: Overall, 115 patients were enrolled. After 6 months from PD, body mass index significantly decreased from 21.90 to 19.57 kg/m2 (-10.6%). The Fibrosis-4 (FIB-4) index significantly increased from 1.756 to 2.384 (P < 0.001). The FIB-4 grade significantly worsened. Contrarily, neither the albumin-bilirubin (ALBI) score nor the ALBI grade demonstrated significant differences. The CT attenuation value significantly decreased (P < 0.001) from 57.6 to 49.5. Multivariate analysis predicted a high preoperative FIB-4 index, high ALBI index, and hypo-CT attenuation value (<30 HU) as risk factors for a high postoperative FIB-4 index. CONCLUSIONS: The FIB-4 index worsened when the follow-up period was only 6 months, regardless of the eternalness in the ALBI score. Liver fibrosis should be assessed using the FIB-4 index for a long-term survivorship after PD.