Clinical Impact of the Charlson Comorbidity Index on the Efficacy of Salvage Photodynamic Therapy Using Talaporfin Sodium for Esophageal Cancer.

Introduction Photodynamic therapy (PDT) is a salvage treatment for local failure after chemoradiotherapy for esophageal cancer. Salvage PDT is the treatment available for vulnerable patients with various comorbidities at risk of salvage esophagectomy. This study assessed the impact of the Charlson comorbidity index (CCI) on the outcomes of salvage PDT using talaporfin sodium (TS) for esophageal cancer. Metohds Consecutive patients with esophageal cancer who underwent salvage TS-PDT from 2016 to 2022 were included in this retrospective study. We investigated the local complete response (L-CR), progression-free survival (PFS) and overall survival (OS) and evaluated the relationship between the CCI and therapeutic efficacy. Results In total, 25 patients were enrolled in this study. Overall, 12 patients (48%) achieved an L-CR, and the 2-year PFS and OS rates were 24.9% and 59.4%, respectively. In a multivariate analysis, a CCI ≥1 (p=0.041) and deeper invasion (p=0.048) were found to be significant independent risk factors for not achieving an L-CR. To evaluate the efficacy associated with comorbidities, we divided the patients into the CCI=0 group (n=11) and the CCI ≥1 group (n=14). The rate of an L-CR (p=0.035) and the 2-year PFS (p=0.029) and OS (p=0.018) rates in the CCI ≥1 group were significantly lower than those in the CCI=0 group. Conclusion This study found that the CCI was negatively associated with the efficacy of salvage TS-PDT for esophageal cancer.

Reconstruction using a free jejunal patch flap in salvage head and neck surgery after radiotherapy.

BACKGROUND: Chemoradiotherapy is a standard treatment for functional preservation in patients with advanced head and neck carcinoma. However, chemoradiotherapy increases the risk of postoperative complications. AIMS/OBJECTIVES: We report the usefulness of reconstruction using a free jejunal patch flap in treating recurrence or residual head and neck carcinoma after radiotherapy. Furthermore, we investigated the factors for the occurrence of postoperative complications in patients who underwent salvage surgery using a free flap transfer. MATERIAL AND METHODS: This study included 41 patients with head and neck carcinoma who underwent salvage surgery using a free flap transfer, including 11 patients who underwent reconstruction using a free jejunal patch flap. Prognostic analysis was performed for the development of complications. RESULTS: Ten jejunal patch flaps survived without microvascular problems. One patient underwent revision reconstructive surgery because of flap failure. However, no patient had a pharyngocutaneous fistula. Oral intake could be resumed in all patients at a median 14 days postoperatively. Multivariate logistic regression analysis indicated that the use of cutaneous flaps was significantly associated with the development of complications. CONCLUSIONS AND SIGNIFICANCE: Free jejunal patch flaps can be considered useful for head and neck reconstruction after radiotherapy for early intake resumption and complication prevention.

High Pretreatment Mean Corpuscular Volume Can Predict Worse Prognosis in Patients With Esophageal Squamous Cell Carcinoma who Have Undergone Curative Esophagectomy: A Retrospective Multicenter Cohort Study.

Objective: To establish the prognostic value of mean corpuscular volume (MCV) in patients with esophageal squamous cell carcinoma (ESCC) who have undergone esophagectomy. Background: The MCV increases in patients with high alcohol and tobacco consumption. Such a lifestyle can be a risk factor for malnutrition, comorbidities related to those habits, and multiple primary malignancies, which may be associated with frequent postoperative morbidity and poor prognosis. Methods: This study included 1673 patients with ESCC who underwent curative esophagectomy at eight institutes between April 2005 and November 2020. Patients were divided into normal and high MCV groups according to the standard value of their pretreatment MCV. Clinical background, short-term outcomes, and prognosis were retrospectively compared between the groups. Results: Overall, 26.9% of patients had a high MCV, which was significantly associated with male sex, habitual smoking and drinking, multiple primary malignancies, and malnutrition, as estimated by the body mass index, hemoglobin and serum albumin values, and the Geriatric Nutritional Risk Index. Postoperative respiratory morbidity (P = 0.0075) frequently occurred in the high MCV group. A high MCV was an independent prognostic factor for worse overall survival (hazard ratio, 1.27; 95% confidence interval, 1.049-1.533; P = 0.014) and relapse-free survival (hazard ratio, 1.23; 95% confidence interval, 1.047-1.455; P = 0.012). Conclusions: A high MCV correlates with habitual drinking and smoking, malnutrition, and multiple primary malignancies and could be a surrogate marker of worse short-term and long-term outcomes in patients with ESCC who undergo esophagectomy.

Current status of trauma surgery at a Japanese prefectural academic institute: improved organization in a regional prefecture.

PURPOSES: Balancing scheduled surgery and trauma surgery is difficult with a limited number of surgeons. To address the issues and systematize education, we analyzed the current situation and the effectiveness of having a trauma team in the ER of a regional hospital. METHODS: This retrospective study analyzed the demographics, traumatic variables, procedures, postoperative morbidities, and outcomes of 110 patients who underwent trauma surgery between 2012 and 2019. The trauma team was established in 2016 and our university hospital Emergency Room (ER) opened in 2012. RESULTS: Blunt trauma accounted for 82% of the trauma injuries and 39% of trauma victims were transported from local centers to our institute. The most frequently injured organs were in the digestive tract and about half of the interventions were for hemostatic surgery alone. Concomitant treatments for multiple organ injuries were performed in 31% of the patients. The rates of postoperative severe complications (over Clavien-Dindo IIIb) and mortality were 10% and 13%, respectively. Fourteen (12.7%) of 24 patients who underwent damage-control surgery died, with multiple organ injury being the predominant cause of death. CONCLUSION: Systematic education or training of medical students and general surgeons, as well as the co-operation of the team at the regional academic institute, are necessary to overcome the limited human resources and save trauma patients.

Endoscopic filling with polyglycolic acid sheets and fibrin glue of persistent fistula after esophagectomy.

BACKGROUND: Treatment of anastomotic leakage in reconstruction after esophagectomy remains challenging. This report presents a new endoscopic filling method for persistent fistula after failure of conservative treatment of leakage caused by anastomotic insufficiency. METHODS: 10 of 14 patients, in whom post-esophagectomy leakage had failed to resolve after 2 weeks of conservative treatment, underwent endoscopic filling with polyglycolic acid (PGA) sheet and fibrin glue into the anastomotic leakage site, using a delivery tube and endoscopic catheter, respectively. RESULTS: Each patient underwent jejunostomy, to secure nutrition. The leakage was resolved in all 10 patients. The mean number of PGA - fibrin glue procedures was 1.7. The mean period from the first application to the resumption of oral intake was 31.6 days, from the final application it was 14.7 days. CONCLUSIONS: The reported filling method offers a new endoscopic approach for persistent fistula after esophagectomy when conservative treatment of leakage has failed.

Nasogastric administration of lenvatinib solution in a mechanically ventilated patient with rapidly growing anaplastic thyroid cancer.

SUMMARY: A 54-year-old woman was referred to our hospital with a cervical tumor. CT revealed a cervical tumor extending to the upper mediastinum, tracheal deviation and tumor infiltration in the cervical vessels. She was followed-up because no diagnosis of malignancy was made by cytology. However, 2 months later, a CT scan showed enlargement of the tumor and tracheal stenosis, and a surgical biopsy was performed and she was diagnosed with anaplastic thyroid cancer (ATC). The tracheal tube with tracheal stenosis could not be removed due to the rapid growth of the tumor, necessitating management by mechanical ventilation. Due to the difficulty of surgical resection, she was treated with lenvatinib. A lenvatinib solution was made and administered via a nasogastric tube. After lenvatinib treatment, the tumor volume decreased and the tracheal stenosis improved. The tracheal tube was removed and oral intake became possible. She was discharged and received ambulatory lenvatinib therapy. The tumor was significantly reduced in size, but gradually grew and was exposed through the cervical wound 6 months later. Esophageal perforation occurred 10 months after the start of treatment. Lenvatinib was re-administered via a nasogastric tube. Eleven months later, the patient died of massive bleeding from the exposed cervical tumor. Patients with advanced ATC may require management with mechanical ventilation for airway stenosis or with a nasogastric tube for esophageal stenosis and perforation. We experienced a case in which lenvatinib was safely administered via a nasogastric tube while performing mechanical ventilation. LEARNING POINTS: An anaplastic thyroid cancer patient under mechanical ventilator management was treated with lenvatinib via a nasogastric tube. The lenvatinib solution can easily be prepared and administered via a nasogastric tube. The lenvatinib solution was effective for a patient with difficulty in oral intake. Lenvatinib could also improve the prognosis of an anaplastic thyroid cancer patient with severe airway and esophageal trouble.

Utility of thoracic cage width in assessing surgical difficulty of minimally invasive esophagectomy in left lateral decubitus position.

BACKGROUND: This study aimed to assess the surgical difficulty of minimally invasive esophagectomy in the left lateral decubitus position for patients with esophageal cancer from the perspective of short-term outcomes, including operation time, blood loss, and morbidity. MATERIALS AND METHODS: The initial 44 consecutive patients with esophageal cancer who underwent minimally invasive esophagectomy were statistically analyzed retrospectively. Thoracic cage area was measured from preoperative computed tomography as a factor affecting the surgical difficulty of minimally invasive esophagectomy, as well as other patient characteristics. Correlations with short-term outcomes including chest operation time, blood loss, and morbidity rate were then examined. RESULTS: In univariate analyses, smaller area of the upper thoracic cage width correlated with prolonged thoracic procedure time (p = 0.0119) and greater blood loss during thoracic procedures (p = 0.0283), but area of the lower thoracic cage showed no correlations. History of respiratory disease was associated with thoracic procedure time (p < 0.0001), but not blood loss. In multivariate analysis, small area of the upper thoracic cage was independently associated with prolonged thoracic procedure time (p = 0.0253). Small upper thoracic cage area was not directly correlated with morbidity rate, but prolonged thoracic procedure time was associated with increased blood loss (p < 0.0001) and morbidity rate (p = 0.0204). Empirical time reduction (p = 0.0065), but not blood loss, was associated with thoracic procedure time. However, area of the upper thoracic cage did not correlate with empirical case number. In multivariate analysis, area of the upper thoracic cage (p = 0.0317) and empirical case number (p = 0.0193) correlated independently with thoracic procedure time. CONCLUSION: A small area of the upper thoracic cage correlated significantly with prolonged thoracic procedure time and increased thoracic blood loss for minimally invasive esophagectomy in the left lateral decubitus position, suggesting the surgical difficulty of minimally invasive esophagectomy in the left lateral decubitus position.

Two cases of bile duct carcinoma patients who underwent the photodynamic therapy using talaporfin sodium (Laserphyrin®).

The efficacy of adjuvant photodynamic therapy (PDT) using the new photosensitizer, talaporfin sodium (TPS) has been clinically examined in some patients with bile duct carcinoma (BDC). Based on our previous cohorts, a prospective clinical trial was attempted; however, only two cases were ultimately enrolled in 27 months. A 664-nm semiconductor laser (100 J/cm2) was applied through an endoscope to the tumor lesion within 6 h of an intravenous injection of 40 mg/m2 TPS according to the protocol for lung cancer. Case 1 was an 82-y.o. female patient with BDC at the left hepatic duct with biliary obstruction, percutaneous transhepatic biliary drainage (PTBD) was achieved, and the patient did not consent to surgery. She was followed up for 15 months to search for non-surgical treatments and eventually received PDT. Although mild photosensitivity occurred, she was discharged without severe adverse events. Biliary stenosis markedly extended and a PTBD tube was scheduled at 1 month. However, cancer immediately metastasized to the liver and she died 155 days after PDT. Case 2 was a 70-y.o. female with perihilar BDC and multiple biliary stenoses. Multiple biliary stenting was considered to be difficult. She received PDT and no adverse events were observed. Biliary stenoses markedly improved and multiple stenting was successfully performed. On day 132, she died of cancer progression. These two cases demonstrated the safety and efficacy of biliary malignant stenosis soon after PDT; however, long-term survival and a sufficient quality of life were not achieved. The combination of the PDT protocol and system chemotherapy or brachytherapy needs to be examined in clinical trials for advanced stage BDC.

Aortoesophageal fistula: review of trends in the last decade.

We reviewed articles on aortoesophageal fistula (AEF) published between January, 2009 and December, 2018. Postoperative aortic disease was the most common cause of AEF, followed by primary aortic aneurysm, bone ingestion, and thoracic cancer. Thoracic endovascular aortic repair (TEVAR) was the most common initial therapy for primary aortic disease, rather than graft replacement. Secondary AEF developed between 1 and 268 months, and between 1 and 11 months after the initial therapy for aortic disease and thoracic cancer, respectively. TEVAR trended to be preferred over surgery for aortic lesions because of its minimal invasiveness and certified hemostasis. In contrast, esophagectomy was preferred for esophageal lesions to remove the infectious source. A combination of surgery for the aorta (TEVAR, graft replacement or repair) and esophagus (esophagectomy, esophageal stent or repair) was usually adopted. Each graft replacement or esophagectomy was associated with a favorable prognosis for aortic or esophageal surgery, and the combination of graft replacement and esophagectomy generally improved the prognosis remarkably. Antibiotic therapy was given to 65 patients, with 20 receiving multiple antibiotics aimed at strong effects and the type of antibiotic described as broad-spectrum in 29 patients. Meropenem, vancomycin, and fluconazole were the most popular antibiotics used to prevent graft or stent infection. In conclusion, graft replacement and esophagectomy can achieve a favorable prognosis for patients with AEF, but strong, broad-spectrum antibiotic therapy might be required to prevent sepsis after surgery.

Esophageal Position Affects Short-Term Outcomes After Minimally Invasive Esophagectomy: A Retrospective Multicenter Study.

BACKGROUND: Anatomical esophageal position may affect the short-term outcomes after minimally invasive esophagectomy (MIE). A previous single-institutional retrospective study suggested that the presence of a left-sided esophagus (LSE) made MIE more difficult and increased the incidence of postoperative complications. METHODS: The current study was a multicenter retrospective study of 303 patients with esophageal cancer who underwent MIE at six esophageal cancer high-volume centers in Kyushu, Japan, between April 2011 and August 2016. The patients were divided into the LSE (66 patients) and non-LSE groups (237 patients) based on the esophageal position on computed tomography images obtained with the patients in the supine position. RESULTS: Univariate analysis showed that patients with LSE were significantly older than those with non-LSE (69 ± 8 vs. 65 ± 9 years; P = 0.002), had a significantly greater incidence of cardiovascular comorbidity (65.2% vs. 47.7%; P = 0.013), and a significantly longer operating time (612 ± 112 vs. 579 ± 102 min; P = 0.025). Logistic regression analysis verified that LSE was an independent risk factor for the incidence of pneumonia (odds ratio 3.3, 95% confidence interval 1.254-8.695; P = 0.016). CONCLUSIONS: The presence of a LSE can increase the procedural difficulty of MIE and the incidence of morbidity after MIE. Thus, careful attention must be paid to anatomical esophageal position before performing MIE.

Resected Intrahepatic Cholangiocarcinoma with Anaphylactic Shock from a Preoperative Liver Function Test before Hepatectomy.

The indocyanine green test is a reliable liver function examination before major hepatectomy, and anaphylaxis is rarely a concern. A 65-year-old male patient without epigastralgia was diagnosed with a 2.2-cm intrahepatic cholangiocarcinoma. He had no history of allergic reactions. Some liver dysfunction was indicated by the laboratory data; however, there was no marked obstructive jaundice and the liver functional reserve was maintained by technetium-99m galactosyl serum albumin. The indocyanine green test was routinely performed, but the patient immediately demonstrated severe anaphylaxis due to indocyanine green administration. He had cardiorespiratory arrest, but recovered after immediate resuscitation. Although acute renal and respiratory failure was significant, the patient recovered at day 10 after the event, and his liver function and other organ functions were improved. Then, the scheduled left hepatectomy with caudate and extrahepatic duct resection was successfully performed without issues. The patient exhibited no allergic response against the administration of antibiotics or other drugs and the postoperative course was uneventful. The patient was discharged on day 17. The tumor was diagnosed as stage III intrahepatic cholangiocarcinoma and R0 resection was accomplished. Preoperative management, including the liver functional loading test, should be carefully carried out before major hepatectomy.

Drainage Tubeless (DRESS) Bypass Surgery as the Best Palliative Care for Unresectable Thoracic Esophageal Cancer with and without Esophago-Respiratory Fistula.

Approximately half of the patients with esophageal cancer are diagnosed at an advanced stage with inoperable disease. The technique of bypass surgery, which is one of the palliative procedures for esophageal cancer, usually requires the insertion of a drainage tube for clearing secretions from the blind remnant esophagus. Since the artificial drainage tube is sometimes problematic for the patient after discharge from the hospital, drainage tubeless (DRESS) surgery might be preferable. The authors demonstrated the utility of DRESS bypass surgery by adding esophagostomy in the right supraclavicular region in three patients with unresectable esophageal cancer with and without esophago-respiratory fistula. All patients had been able to take per-orally and discharged the hospital. Two of three patients are alive with per-oral intake at 1 year later. This DRESS bypass surgery technique, which has not hardly reported in the literature, could release the patients from the tube trouble after the discharge from the hospital and give the patients the better quality of life.

A cohort study on the risk of hepatectomy and pancreatectomy after history of abdominal surgery on other organs.

BACKGROUNDS/AIMS: The present study analyzed the postoperative outcomes in patients who underwent hepatectomy or pancreatectomy, with a history of intra-abdominal surgery involving other organs, to elucidate surgical efficacy. METHODS: We examined the perioperative parameters in 28 patients who underwent hepatectomy (n=12) and pancreatectomy (n=16) after receiving prior abdominal organ resection (esophagectomy, n=2; gastrectomy, n=5; resection of small intestine, n=2; appendectomy, n=5; colorectal resection, n=9; hepatectomy, n=1; cholecystectomy, n=3; splenectomy, n=2, pancreatectomy ,right adrenectomy, nephrectomy and myoma uteri, n=1 each). RESULTS: Age, gender, a history of comorbidities, and primary diseases were not significantly different between the groups. The present operation was predominantly indicated for liver metastases in all patients undergoing hepatectomy. Several diseases were detected in pancreaticoduodenectomy (PD) patients. Laboratory data were not significantly different between groups. Although operating time and blood loss during hepatectomy did not differ significantly between the groups, the operating time was significantly longer in patients undergoing PD compared with distal pancreatectomy (p<0.05). Red cell blood transfusion was most frequently used in patients who underwent major hepatectomy and PD (p<0.05). The prevalence of postoperative complications was not significantly different between groups. Hospital death was not observed and the period of hospital stay did not differ between groups. CONCLUSIONS: Carefully scheduled hepatectomy or pancreatectomy is safe even in cases with prior abdominal surgery under the present strategy.

Geriatric Nutritional Risk Index as a prognostic factor in patients with esophageal squamous cell carcinoma -retrospective cohort study.

PURPOSE: The Geriatric Nutritional Risk Index (GNRI) is a new index recently introduced to predict the risk of nutrition-related complications and mortality. Our aim is to examine the association between the GNRI and long-term prognosis in patients with esophageal squamous cell carcinoma (ESCC) who underwent esophagectomy. METHODS: The present study enrolled consecutive 216 patients with ESCC who underwent esophagectomy. The GNRI at admission to the hospital was calculated as follows: (1.489 × albumin, g/l) + (41.7 × present/ideal body weight). The characteristics and long-term prognosis were compared between four groups: the severe risk (GNRI: <82), moderate risk (GNRI: 82 to <92), low risk (GNRI: 92 to <98) and no risk (GNRI: >98) groups. The 5-year overall survival and independent prognostic factors were investigated, respectively. RESULTS: A decreased GNRI significantly correlated with unfavorable overall survival (p < 0.001). In all patients, a multivariate analysis demonstrated that the severe and moderate risk groups (GNRI: <92) (hazard ratio 0.50; p = 0.002), T factor (≥T2) (hazard ratio 0.52; p = 0.026), and N positive factor (hazard ratio 0.47; p = 0.004) were independent prognostic factors. In the subgroup analysis, which excluded patients with preoperative chemoradiotherapy, the severe and moderate risk groups (GNRI: <92) (hazard ratio 0.48; p = 0.0057), and T factor (≥T2) (hazard ratio; p = 0.021) were independent prognostic factors. CONCLUSIONS: GNRI is considered to be a useful prognostic factor in patients with ESCC undergoing esophagectomy.

Jejunogastric intussusception after distal gastrectomy with Roux-en-Y reconstruction: A case report.

INTRODUCTION: Jejunogastric intussusception is a rare complication after gastric operation. Intussusception after gastric operation occurs mostly at the gastrojejunal anastomosis site and Braun anastomosis site of Billroth II reconstruction, and at the Y anastomosis site of Roux-en-Y reconstruction. However, jejunogastric intussusception after distal gastrectomy with Roux-en-Y reconstruction is very rare. We report a surgical case of jejunogastric intussusception after distal gastrectomy for gastric cancer treatment. PRESENTATION OF CASE: An 82-year-old woman underwent laparoscopic distal gastrectomy for early gastric cancer treatment. Reconstruction was performed using Roux-en-Y anastomosis. Oral intake was started on postoperative day 4, however vomiting and high-grade fever occurred on postoperative day 12, after which oral intake became difficult. DISCUSSION: Anastomotic stenosis of the gastrojejunostomy was suspected, and various examinations were performed. Gastroendoscopy and computed tomography revealed an elevated lesion with ring-like folds protruding through the anastomosis site into the remnant stomach. Reoperation was performed on postoperative day 28 after a diagnosis of jejunogastric intussusception was made. It failed to reduce the intussusception, so partial resection of the gastrojejunal anastomosis was performed and Roux-en-Y reconstruction was repeated. Reconstruction was conducted after taking into consideration the recurrence of intussusception. CONCLUSION: Jejunogastric intussusceptions after distal gastrectomy is a rare complication; however, when it occurs, early diagnosis and appropriate management are necessary.

A case of separation surgery with drainage tube-less (DRESS) esophagostomy for advanced cancer with a respiratory fistula.

INTRODUCTION: An esophagorespiratory fistula (ERF) can cause severe pneumonia or a lung abscess which progresses to life-threatening sepsis. A case of a patient with esophageal cancer and an esophagopulmonary fistula (EPF) who underwent separation surgery with drainage tube-less (DRESS) esophagostomy and was promptly started on definitive chemoradiotherapy (CRT) is reported. PRESENTATION OF CASE: A 79-year-old man visited a clinic with a month-long history of dysphagia. Esophageal cancer at the middle thoracic esophagus was detected, and invasion of the left main bronchus and lower lobe of the right lung was seen on contrast-enhanced computed tomography (CT). Three weeks later, the patient was transferred to our hospital. CT showed a lung abscess in the lower lobe of the right lung that continued into the adjacent esophageal cancer. Due to the EPF, the patient underwent emergency surgery that consisted of esophageal separation surgery and double bilateral esophagostomy and enterostomy. Definitive CRT for the esophageal cancer was started from postoperative day 25. At six-month follow-up, the patient achieved relapse-free survival. DISCUSSION: Separation surgery with a DRESS esophagostomy provides good control of inflammation because of division of the respiratory tract from the alimentary tract, which allows prompt initiation of CRT. Alternatively, a DRESS esophagostomy allows patients to be free from any tube trouble. CONCLUSION: Separation surgery with a DRESS esophagostomy for an ERF is a promising method to improve patient quality of life that is less invasive, controls inflammation, and facilitates subsequent definitive CRT.

Accompanying role of hepato-biliary-pancreas surgeon in urological surgery.

INTRODUCTION: The present case reports demonstrated the accompanying surgical support from hepato-biliary-pancreas (HBP) surgeons for urological surgery to secure operative safety because HBP surgeons are well experienced in dissecting techniques for mobilization of the liver or pancreas. We experienced 9 consecutive patients who underwent nephrectomy, adrenectomy or resection of retroperitoneal tumors by urological surgeons. Cardiovascular intervention was also required in cases of long tumor thrombus into the vena cava. CASES: All patients had no severe co-existing diseases except the main tumor. Reverse T-shape incision was performed in 7 cases and thoracolaparotomy in two. Dissection and mobilization at the site of severe compression by the urinary tumors were performed in three cases. Partial liver resection was performed for testicular liver metastases in two, and right hepatectomy for right renal cancer was performed in one. Encircling the vena cava and preparation of transection for tumor thrombi were performed in three, and among these, cardiovascular intervention was necessary in two because of extension into the right atrium. During admission, all patient outcomes were uneventful without severe complications. We herein showed the representative two cases of combined surgery. DISCUSSION: and conclusion The point of this case report is the coordination between each surgeon and anesthesiologist under precise perioperative planning or management. The role of HBP surgeons is to provide information as a specialist on the operative field for urological or cardiovascular surgery to achieve operative safety.

A cytokine signal inhibitor for rheumatoid arthritis enhances cancer metastasis via depletion of NK cells in an experimental lung metastasis mouse model of colon cancer.

Current therapy for rheumatoid arthritis (RA) relies on global suppression of the immune response or specific blockade of inflammatory cytokines. However, it is unclear how immunosuppressants affect patients with cancer. Therefore, in the present study, the effect of three biological agents, tofacitinib, anti-mouse IL-6 receptor antibody (MR16-1) and etanercept, which are used for the treatment of RA diseases, on a tumor-bearing mouse model was investigated. The effect of the three agents was examined using a mouse lung-metastasis model with the murine colon 26 cancer cell line. Lymphocyte subsets and natural killer (NK) cells in peripheral blood and spleen were analyzed using fluorescence-activated cell sorting, and the number of lung surface nodules was examined. In the continuous tofacitinib administration (15 mg/kg/day) group, the number of lung surface nodules was significantly increased compared with that of the vehicle-treated group (vehicle, 1.20±0.58; tofacitinib, 35.6±10.81; P<0.01). NK cell number in the blood and spleen of tofacitinib-treated mice was decreased 10-fold, and the percentage of cluster of differentiation (CD)11+CD27- NK cells was significantly reduced. MR16-1 [8 mg/mouse; once a week; intraperitoneal (i.p.)] or etanercept (1 mg/mouse; 3 times a week; i.p.) treatment did not affect the number of NK cells or lung metastasis. In the present study, immunosuppressants that target cytokines, including tofacitinib, were demonstrated to inhibit the proliferation and differentiation of NK cells, and exhibit the potential to promote cancer metastasis using a mouse model of lung metastasis.

Significance of a soft-coagulation system with monopolar electrode for hepatectomy: A retrospective two-institution study by propensity analysis.

BACKGROUND: The VIO soft-coagulation system (VIO) with a monopolar electrode is a novel hemostatic device that provides hemostasis by superficial contact at the bleeding site without carbonization. Because heat injury remains a concern, surgical records and postoperative liver dysfunction were retrospectively evaluated in a cohort study. METHODS: Between September 2010 and March 2016, 322 patients underwent hepatectomy in which hemostatic devices were used at two institutions. Surgical results with use of VIO at one institute (VIO group) were compared with those without use of VIO at a second institute (control group), and propensity analysis was performed. RESULTS: In limited resection and segmentectomy or sectionectomy performed in the VIO group, the prevalence of liver cirrhosis was significantly higher and the operation time was significantly longer in comparison with the control group (p < 0.05). In all hepatectomies, postoperative levels of total bilirubin and aspartate or alanine transaminase tended to be increased and prothrombin activity tended to be lower in the VIO group in comparison with the control group (p < 0.05). The prevalence of hepatic failure in the VIO group was significantly higher in comparison with that in the control group (p < 0.05). In cases of segmentectomy or sectionectomy, blood loss was significantly increased in the VIO group in comparison with that in the control group (p < 0.05) Propensity score matching showed that although the surgical records and outcomes were not significantly different between the groups, postoperative liver dysfunction was significant in the VIO group in comparison with the control group (p < 0.05). CONCLUSIONS: Mild postoperative hepatic thermal injury with VIO was confirmed, and therefore, surgeons should take care when using the VIO system to make frequent wide resected cuts on the surface of the liver.

Salvage photodynamic therapy accompanied by extended lymphadenectomy for advanced esophageal carcinoma: A case report.

INTRODUCTION: Salvage surgery for locoregional failures after definitive chemoradiotherapy (dCRT) for esophageal cancer is widely practiced, but treatment options complementing it are also needed due to the high morbidity and mortality and low rate of curative resection. PRESENTATION OF CASE: A 58-year-old man with a surgical history of right upper lobectomy for lung cancer was diagnosed as having esophageal squamous cell carcinoma. Computed tomography revealed swelling of the lesser curvature lymph node, and it had invaded the stomach, the body and tail of the pancreas and the left gastric artery, splenic artery and celiac artery. The patient underwent definitive-dose radiation with chemotherapy. Complete response was attained for the primary tumor, but the metastatic lymph node infiltrating the stomach, pancreas and major vessels remained. Therefore, the Appleby operation was proposed to the patient and subsequently performed aiming at curability. However, the primary tumor recurred 38 months after surgery, so the novel modality of photodynamic therapy using talaporfin sodium and a diode laser was performed, and a complete response was attained for this lesion. The patient is alive at 50 months after the salvage Appleby operation. DISCUSSION AND CONCLUSION: Salvage lymphadenectomy for esophageal cancer may be insufficient as a curative treatment because of regrowth of the primary lesion. However, photodynamic therapy may be applicable as a curative treatment option for recurrence of the primary lesion after salvage lymphadenectomy.