Clinical impact of high-quality testing for peritoneal lavage cytology in pancreatic cancer.

In pancreatic ductal adenocarcinoma (PDAC) patients, the importance of peritoneal lavage cytology, which indicates unresectability, remains controversial. This study sought to determine whether positive peritoneal lavage cytology (CY+) precludes pancreatectomy. Furthermore, we propose a novel liquid biopsy using peritoneal lavage fluid to detect viable peritoneal tumor cells (v-PTCs) with TelomeScan F35, a telomerase-specific replication-selective adenovirus engineered to express green fluorescent protein. Resectable cytologically or histologically proven PDAC patients (n = 53) were enrolled. CY was conducted immediately following laparotomy. The resulting fluid was examined by conventional cytology (conv-CY; Papanicolaou staining and MOC-31 immunostaining) and by the novel technique (Telo-CY; using TelomeScan F35). Of them, 5 and 12 were conv-CY+ and Telo-CY+, respectively. All underwent pancreatectomy. The two double-CY+ (conv-CY+ and Telo-CY+) patients showed early peritoneal recurrence (P-rec) postoperatively, despite adjuvant chemotherapy. None of the three conv-CY+ Telo-CY- patients exhibited P-rec. Six of the 10 Telo-CY+ conv-CY- patients (60%) relapsed with P-rec. Of the remaining 38 double-CY- [conv-CY-, Telo-CY-, conv-CY± (Class III)] patients, 3 (8.3%) exhibited P-rec. Although conv-CY+ status predicted poor prognosis and a higher risk of P-rec, Telo-CY was more sensitive for detecting v-PTC. Staging laparoscopy and performing conv-CY and Telo-CY are needed to confirm the indication for pancreatectomy.

Portal vein wedge resection and patch venoplasty with autologous vein grafts for hepatobiliary-pancreatic cancer.

BACKGROUND: Advanced hepatobiliary-pancreatic cancer often invades critical blood vessels, including the portal vein (PV) and hepatic artery. Resection with tumor-free resection margins is crucial to achieving a favorable prognosis in these patients. Herein, we present our cases and surgical techniques for PV wedge resection with patch venoplasty using autologous vein grafts during surgery for pancreatic ductal adenocarcinoma (PDAC) and perihilar cholangiocarcinoma (PhCC). CASE PRESENTATION: Case 1: 73-year-old female patient with PDAC; underwent subtotal stomach-preserving pancreatoduodenectomy, with superior mesenteric vein wedge resection and venoplasty with the right gonadal vein. Case 2: 67-year-old male patient with PDAC; underwent distal pancreatectomy and celiac axis resection, with PV wedge resection and venoplasty with the middle colic vein. Case 3: 51-year-old female patient with type IV PhCC; underwent left hepatectomy with caudate lobectomy and bile duct resection, with hilar PV wedge resection and venoplasty with the inferior mesenteric vein (IMV). Case 4: 69-year-old male patient with type IIIA PhCC; underwent right hepatopancreatoduodenectomy, with hilar PV resection and patch venoplasty with the IMV. All patients survived for over 12 months after the surgery, without local recurrence. CONCLUSIONS: PV wedge resection and patch venoplasty is a useful technique for obtaining tumor-free margins in surgeries for hepatobiliary-pancreatic cancer.

Crohn's disease-related anal fistula cancer diagnosed by examination under anesthesia: a case report.

BACKGROUND: As the number of patients with inflammatory bowel disease (IBD) increases, the incidence of IBD-related colorectal cancer (CRC) is also on the rise. Crohn's disease (CD)-related CRC has been reported to have a poorer prognosis than sporadic CRC, and the early detection of CD-related CRC is difficult. Japanese patients with CD are reported to have a higher frequency of anorectal cancer than the Western population; however, methods for early diagnosis have not yet been established because of perianal pain during the examination. CASE PRESENTATION: We report a case of CD-related anal fistula cancer that was detected early by surveillance examination under anesthesia (EUA). The patient was a 37-year-old man, diagnosed with CD at the age of 15 years and started medical treatment. However, due to poor disease control, the intestinal tract remained highly inflamed and the patient continued to have over 10 bowel movements per day. He was referred to our hospital for surgical treatment after a colonoscopy (CS), which revealed multiple active ulcers and stenoses. Since three perianal seton drainage tubes had been placed around his anus since the age of 33 years, we decided to perform an EUA to rule out cancer coexistence in the anorectal region. After a random biopsy of the rectum by CS under general anesthesia, we resected and curetted multiple perianal fistulas as much as possible and reinserted the seton drainage tubes. Pathological examination of the fistula tract revealed adenocarcinoma in one tract, indicating the coexistence of anal fistula cancer. Based on the diagnosis of multiple intestinal stenoses and anal fistula cancer due to CD, we performed hand-assisted laparoscopic total colectomy, rectal amputation, extensive perineal resection, and reconstruction using a left rectus abdominis flap. CONCLUSION: In a long-term CD patient with anorectal lesions, we performed an EUA to diagnose the coexistence of anal fistula cancer at an early stage, and surgical resection was achieved. EUA is effective for the early detection and treatment of CD-related CRC and may contribute to an improved prognosis.

[A Case Report-A Successful Case of Distal Pancreatectomy with En Bloc Celiac Axis Resection for Locally Advanced Pancreatic Cancer with an Aberrant Right Hepatic Artery].

In cases of pancreatic cancer with anatomical variations of the hepatic artery, it is important to evaluate the hemodynamics of each case for surgical indication. We report the case of a 68-year-old man with locally advanced pancreatic cancer and an aberrant right hepatic artery who underwent distal pancreatectomy with celiac axis resection(DP-CAR). He was admitted to our institute due to abdominal discomfort. A CT scan showed pancreatic cancer invading the common hepatic artery. He underwent chemoradiotherapy with a diagnosis of locally advanced pancreatic cancer. After the tumor downstaging, we performed DP-CAR, which included a gastroduodenal artery and a proper hepatic artery resection. Even though delayed gastric emptying was observed after the operation, he was discharged on postoperative day 36.

[FOLFIRI plus RAM Therapy in Later Line of Unresectable Colorectal Cancer].

FOLFIRI plus ramucirumab(RAM)therapy has been reported to be effective and safe in the RAISE trial as second-line treatment for unresectable colorectal cancer. It is hypothesized that RAM may be effective in patients with PD treated with FOLFIRI plus bevacizumab(Bev)due to different mechanism of action from that of Bev, which is also an angiogenesis inhibitor. From January 2017 to December 2021, we conducted a retrospective study of 6 patients who had PD with 5-FU, oxaliplatin, irinotecan, or Bev as first or second-line treatment at our institution and who received FOLFIRI plus RAM in later line treatment. The 6 cases consisted of 3 patients in the third-line treatment, 1 patient in the fourth-line treatment, and 2 patients in the sixth-line treatment. The anti-tumor effect was PD in all cases in the third-line and fourth-line treatment, but the 2 patients of sixth-line treatment were controlled diseases.

Single-Incision Laparoscopic Cholecystectomy: a Single-Centre Experience of 1469 Cases.

BACKGROUND: Despite having once been extensively used for cosmetics or pain reduction, the use of single-incision laparoscopic cholecystectomy (SILC) has declined in recent years due to technical difficulties and a reported increase in complications. Since the introduction of SILC in 2009, our hospital has been actively involved with this technique. Our experience suggests that SILC is not a difficult procedure and can be safe and useful, with particularly excellent cosmetic outcomes. This study retrospectively details the outcomes of SILC at our hospital. METHOD: Data on 1469 cases of SILC performed on a waitlist basis at Osaka Police Hospital from May 2009 to December 2020 were collected and retrospectively analysed. RESULTS: The median operative time and blood loss were 96 min and 0 mL, respectively. A total of 46 patients (3.1%) required conversion surgery, including 36 needing additional ports and 10 requiring laparotomy. Intraoperative complications included common bile duct injury in 1 patient (0.07%) and right hepatic artery injury in 1 patient (0.07%), with no other organ injury. Postoperative Clavien-Dindo 3 or higher complications were observed in 18 patients (1.2%). Incisional hernias occurred in 15 patients (1.0%). The median postoperative hospital stay was 3 days. CONCLUSION: This study showed that SILC can be performed safely without any increase in complications, as reported previously. Granted that it is performed safely, SILC may be a useful technique due to its superior cosmetic outcomes or pain reduction.

Laparoscopic mesh removal for mesh infection related to pararectal incision of previous appendectomy after laparoscopic total extraperitoneal inguinal hernia repair: A case report.

A 67-year-old man with a history of appendectomy 40 years ago underwent single-incision laparoscopic surgery for total extraperitoneal inguinal hernia repair. Postoperatively, the pararectal incisional scar obtained from the appendectomy was infected; thus, antibiotic therapy and drainage were performed. However, the infection persisted. After 5 postoperative months, the mesh was laparoscopically removed at a sufficient distance from the infected site. No enterocutaneous fistula was observed. After 1 year and 10 months, no recurrence of hernia or infection was observed. Thus, laparoscopic mesh removal is feasible. Infection of a 40-year-old incision rarely results in mesh infection. Therefore, in pararectal incision, the extent of mesh coverage should be considered; if the overlap is large, changing the technique by not covering the incision may be necessary.

Effectiveness of frailty screening and perioperative team management of colectomy patients aged 80 years or more.

BACKGROUND: We aimed to clarify usefulness of the modified Frailty Index 11 (mFI-11) for assessing risk of postoperative complications (POCs) and effectiveness of perioperative management team (POMT) intervention for improving postoperative status of frail aged patients requiring colorectal cancer (CRC) surgery. METHODS: We compared, retrospectively, surgical outcomes among 151 consecutive CRC surgery patients aged ≥80 years. Patients were grouped by mFI-11 scores and by POMT intervention (vs. no POMT intervention). RESULTS: POCs were more prevalent, postoperative stays were longer, and discharge status was poorer among high-risk (mFI-11 ≥ 3/11) patients without POMT intervention than among low-risk (mFI-11 ≤ 2/11) patients (p = 0.04, p = 0.02, p < 0.01). Multiple POCs occurred less frequently and performance of activities of daily living was better for high-risk patients with (vs. those without) POMT intervention (p = 0.04, p = 0.03). CONCLUSION: POMT intervention appears beneficial for frail aged patients scheduled for CRC surgery.

Long-term outcomes of single-incision versus multiport laparoscopic totally extra-peritoneal inguinal hernia repair: a single-institution experience of 186 consecutive cases.

PURPOSE: This retrospective study was conducted to compare the long-term outcomes of single-incision totally extraperitoneal (S-TEP) inguinal hernia repair and conventional multiport totally extraperitoneal (M-TEP) inguinal hernia repair. METHODS: The study population included 186 consecutive patients (S-TEP, n = 149; M-TEP, n = 37) who underwent elective surgery for inguinal hernia at Osaka Police Hospital between 2011 and 2013. RESULTS: No significant between-group difference was found in patient or hernia characteristics or in perioperative outcomes, with the exception of age (S-TEP group vs. M-TEP group: median 69 [IQR 60-75] years vs. 64 [55-69] years, respectively; P = 0.019). Furthermore, no significant between-group difference was found in follow-up time (5.5 [3.0-5.8] vs. 5.4 [3.1-5.7] years, P = 0.839), recurrence rate (0.6 vs. 2.4%, P = 0.358), chronic pain (1.2 vs. 0%, P = 1.000), feeling the mesh (2.3 vs. 7.1%, P = 0.142), or movement limitation (0.6 vs. 0%, P = 1.000). All chronic symptoms were "mild but not bothersome." A metachronous contralateral inguinal hernia developed in 8.1% of patients. CONCLUSION: The long-term outcomes of S-TEP repair were comparable to those of M-TEP, with rates of recurrence, chronic pain, feeling the mesh, and movement limitation falling within acceptable limits.

Long-term outcomes of single-incision versus multiport laparoscopic colectomy for colon cancer: results of a propensity score-based analysis.

BACKGROUND: Long-term outcomes of single-incision laparoscopic colectomy (SILC) for colon cancer (CC), as practiced in real-world settings, especially in relation to disease stage, have not been established. We examined, retrospectively, both short- and long-term outcomes of SILC versus those of multiport laparoscopic colectomy (MPLC) performed for CC in a propensity-score-matched cohort. METHODS: The study involved 263 patient pairs matched 1:1 from among 691 patients who, between January 2008 and May 2014, underwent either SILC or MPLC for a primary solitary CC at our hospital. Short-term and long-term operative outcomes were compared between the two groups. RESULTS: Operation time was the only surgical outcome that varied significantly between the two groups (p = 0.0004). Overall 5-year cancer-specific survival (CSS) in the SILC group was 93.7 (95% CI 89.6-96.2)%, and CSS per pathological stage (I, II and III) was 98.5 (90.0-99.8)%, 96.0 (88.2-98.7)%, and 88.3 (79.6-93.6)%, respectively, whereas overall 5-year CSS in the MPLC group was 93.3 (89.4-95.9)%, and CSS per pathological stage was 100%, 95.4 (88.3-98.3)%, and 84.1 (74.1-90.8)% (p = 0.5278, 0.2679, 0.7666, and 0.9073), respectively. Overall 3-year disease-free survival (DFS) in the SILC group was 94.0 (90.2-96.4)%, and 3-year DFS per pathological stage was 98.6 (90.4-99.8)%, 90.1 (81.4-95.0)%, and 79.0 (69.4-86.2)%, respectively, whereas overall 3-year DFS in the MPLC group was 93.2 (89.4-95.7)%, and 3-year DFS per pathological disease stage was 100%, 94.5 (87.4-97.7)% and 75.5 (64.7-83.8)% (p = 0.2829, 0.7401, 0.4335 and 0.8518), respectively. Thus, oncological outcomes did not differ significantly between groups. Incisional hernia occurred in 21 (8.0%) SILC group patients and 17 (6.5%) MPLC group patients, without a significant between-group difference (p = 0.6139). CONCLUSION: Our data indicate that perioperative and oncological outcomes of SILC performed for CC are comparable to those of MPLC performed for CC.

Circulating MicroRNAs in Gastrointestinal Cancer.

Gastrointestinal cancer (GIC) is a common disease and is considered to be the leading cause of cancer-related death worldwide; thus, new diagnostic and therapeutic strategies for GIC are urgently required. Noncoding RNAs (ncRNAs) are functional RNAs that are transcribed from the genome but do not encode proteins. MicroRNAs (miRNAs) are short ncRNAs that are reported to function as both oncogenes and tumor suppressors. Moreover, several miRNA-based drugs are currently proceeding to clinical trials for various diseases, including cancer. In recent years, the stability of circulating miRNAs in blood has been demonstrated. This is of interest because these miRNAs could be potential noninvasive biomarkers of cancer. In this review, we focus on circulating miRNAs associated with GIC and discuss their potential as novel biomarkers.

Risk Factors for Lymph Node Metastasis in Pathological T1b Colorectal Cancer.

BACKGROUND/AIM: The rate of lymph node metastasis (LNM) of colorectal carcinoma (CRC) with a submucosal (SM) invasion depth of 1000 µm or more can reach 12.5%, which is the most common reason for additional resection in daily practice. Other studies have reported that the rate of LNM is less than 2%, regardless of the depth of invasion, if the lesions show good histology, lymphovascular infiltration is negative, and tumor budding is limited. The purpose of this study was to investigate new risk factors for LNM in T1b colorectal cancer. PATIENTS AND METHODS: The 239 patients who were diagnosed with pathological T1b CRC after colorectal surgical resection at the Osaka Police Hospital in Japan between January 2008 and December 2018 were retrospectively reviewed in this study. RESULTS: The LNM rate was 11.3% (27/239). The variables identified as being significant factors using multivariate analysis were: i) lymphatic invasion (Ly)-positive [odds ratio (OR)=5.97; 95% confidence interval (CI)=2.27-15.74], ii) female gender (OR=3.49; 95%CI=1.38-8.85), and iii) left-sided colorectal involvement (OR=4.98; 95%CI=1.22-20.39). If none of these risk factors were present with T1b, the LNM rate was 0% (0/28). CONCLUSIONS: Ly-positive, female gender, and left-sided colorectal involvement could be risk factors for LNM in T1b CRC.

[Effect of Endoscopic Resection on Prognosis in T1b Colorectal Cancer].

With the advancement of endoscopic resection(ER)of colorectal cancer, surgical resection after ER has been increasing. This study evaluated the effects of initial ER on short- and long-term outcomes in T1b colorectal cancer. This retrospective cohort study enrolled patients with pathological T1b colorectal cancer who underwent colorectal surgical resection between 2008 and 2018. A total of 239 eligible patients were divided into 2 groups: patients initially treated using surgical resection with lymph node dissection(LND)(surgery alone, n=142)and patients treated using initial ER and additional surgical resection with LND(surgery after ER, n=97). No significant differences were observed in short-term outcomes(ie, operative time, blood loss, or postoperative complications)or the long-term outcomes(ie, recurrence rate, overall survival rate, or recurrence free survival rate)between groups.

[A Case of Carcinomatous Meningitis from Gastric Cancer with Improvement of QOL by Ventriculoperitoneal Shunt].

In cases where carcinomatous meningitis leads to hydrocephalus and increases intracranial pressure, patients present with exacerbated pain and several neurological symptoms. It is reported that multidisciplinary therapy, including radiation therapy, drug therapy, and surgery, is performed for patients with carcinomatous meningitis; however, it is rarely successful. Ventriculoperitoneal shunting(V-P shunt)is a surgical intervention that might relieve the pain temporarily and improve the quality of life. VPS should be taken into consideration in line with patients' and their families' intentions since the overall survival is fairly short.

Role of single-incision laparoscopic surgery in the management of small bowel obstruction.

BACKGROUND: Small bowel obstruction (SBO) arises on various backgrounds, and the surgical procedure is often modified intraoperatively as needed. Single-incision laparoscopic surgery (SILS) is less invasive than conventional multiport laparoscopic surgery (MPS) and reported to be equally safe and efficient. We have been applying SILS to SBO requiring surgical treatment, and we conducted a retrospective study to clarify the role of SILS in the management of SBO. METHODS: Thirty-four consecutive patients were identified for inclusion in the study through a review of hospital records of patients having undergone surgery for SBO between May 2013 and June 2018. Patients with tumor- or hernia-related SBO were excluded. We also identified, for comparison, a group of patients who had undergone open surgery for SBO during the preceeding 5-year period. The primary study endpoint was the SILS completion rate, and analyses were performed to identify risk factors for conversion to open surgery and perioperative complications. RESULTS: The SILS completion rate was 70.6% (24/34 patients), with conversion open surgery required for the remaining 10 (29.4%) patients. Conversion was necessitated by limited working space in 5 (50%) patients, discovery of massive necrosis in 3 (30%), and non-detection of the responsible lesion in 2 (20%). Univariable analysis showed an American Society of Anesthesiologists Physical Status score (p = 0.020) and severe intra-abdominal adhesions (p = 0.007) to be risk factors for conversion. Conversion to open surgery (vs complete SILS) was significantly associated with increased operation time (p = 0.018), blood loss (p = 0.021), postoperative stay (p = 0.010), and postoperative complications (p = 0.004). Open surgery was significantly associated with increased postoperative stay (p = 0.026) and postoperative complications (p = 0.011). CONCLUSION: SILS appears to be a reasonable surgical treatment option for selected patients with SBO.

[Single-Incision Laparoscopic Colectomy for Descending Colon Cancer in a Patient with a Horseshoe Kidney].

A 67-year-old woman presented with bloody stools to a local physician. Lower gastrointestinal endoscopy revealed a type 3 all-circumferential tumor at descending colon. She was diagnosed with descending colon cancer and referred to our hospital for surgery. Preoperative computed tomography(CT)revealed a horseshoe kidney. We performed single-incision laparoscopic colectomy for descending colon cancer(cT3cN0cM0, cStageⅡa)complicated by a horseshoe kidney. The surgery was performed safely without any additional injuries. In patients with horseshoe kidneys, abnormalities have been reported in the running of the blood vascular system and the renal pelvis and ureter systems. Thus, sufficient understanding of the anatomic abnormality by preoperative examinations, such as 3D-CT, is essential for performing surgery safely.

[A Case of Multidisciplinary Treatment for a Recurrent Gastrointestinal Stromal Tumor of the Stomach].

The standard treatment for unresectable or recurrent gastrointestinal stromal tumor(GIST)is tyrosine kinase inhibitor(TKI). It is reported that resection of metastatic lesions after TKI administration prolongs progression free survival, but its influence on overall survival is not clarified. We experienced a case of GIST with peritoneal dissemination for which TKI administration and 2 local resections were effective. The patient was a man in his 70's. We started chemotherapy with imatinib for GIST with peritoneal dissemination. However, it was discontinued due to the occurrence of interstitial pneumonia. Dissemination was evaluated as radically resectable on the images. After the interstitial pneumonia was alleviated, surgery was performed. Although sunitinib was introduced at 2 months postoperatively, recurrent peritoneal dissemination was detected at 32 months postoperatively, and treatment was then changed to regorafenib. Regorafenib treatment reduced the tumor size; however, Grade 3 albuminuria was detected 16 months after treatment initiation and, thus, this treatment was discontinued. Subsequently, the tumor enlarged again. Because there was only 1 recurrent lesion, we performed radical resection. Postoperatively, a reduced dose of regorafenib was re-administered. At present, 9 months after the re-surgery, the patient is alive without recurrence.

[A Case of Primary Duodenal Adenocarcinoma in the Fourth Portion].

A 66-year-old woman admitted for nausea was found to have a type 2 tumor with stenosis at the fourth portion of the duodenum by upper gastrointestinal series and endoscopy, which was diagnosed as an adenocarcinoma by endoscopic biopsy. Abdominal computed tomography(CT)showed an irregular thick wall at the fourth portion of the duodenum but without metastasis or invasion to the adjacent vessels. We examined the lymph nodes around the pancreatic head intraoperatively and partially resected the duodenum and jejunum based on the diagnosis of negative swollen nodes. The definitive diagnosis was primary tubular adenocarcinoma of the fourth portion of the duodenum, T3, N0, M0, Stage ⅡA. Reports of primary cancer of the fourth portion of the duodenum are very rare, and we include a discussion of the current literature.

[Nodular Lymphocyte-Predominant Hodgkin Lymphoma(NLPHL)Which Originate from the Mesentery-A Series of Two Cases].

Nodular lymphocyte-predominant Hodgkin lymphoma(NLPHL)is a subtype of Hodgkin lymphoma. It is uncommon in Japan, and only a few cases of NLPHL originating from the mesentery have been reported. Most patients with NLPHL present in the early stage, but some patients have malignancy at initial presentation. We should perform staging laparotomy for the diagnosis and treatment of cases in which a lymph node biopsy is difficult.

[Case Series of the TAS-102 plus Bevacizumab(Bev)Combination Therapy in Unresectable Advanced Colorectal Cancer].

A phase-Ⅱtrial of TAS-102 plus bevacizumab(Bev)combination therapy showed a progression-free survival(PFS)of 3.7-4.6 months. Here, we report 12 cases of unresectable advanced recurrent colorectal cancer treated with TAS-102 plus Bev therapy at our hospital between June 2017 and February 2020. The median PFS was 6 months(2-12). Adverse events greater than Grade 3 were neutropenia(33.3%), febrile neutropenia(8.3%), thrombocytopenia(8.3%), and vomiting (8.3%). The frequency of non-hematotoxicity was low. In conclusion, the TAS-102 plus Bev therapy may be a useful option for the late-line treatment of unresectable advanced recurrent colorectal cancer.