Right lateral approach to the superior mesenteric artery in robotic pancreaticoduodenectomy.

Ninomiya and colleagues introduced a novel approach to the superior mesenteric artery in robotic pancreaticoduodenectomy. The right lateral approach allows repositioning of the superior mesenteric artery to the right-most surface, facilitating safer artery division and simplifying detachment around the superior mesenteric vein, potentially reducing operative time and minimizing blood loss.

Neonatal inguinal hernias containing the uterus: a case report on changes in uterine position.

A female newborn weighing 542 g and delivered at 27 weeks gestation presented with bilateral inguinal hernias while in the neonatal intensive care unit. Ultrasonography confirmed herniation of the uterus into the right inguinal hernia without signs of incarceration. Due to the absence of complications, she was discharged and scheduled for follow-up at the outpatient clinic. At 11 months of age, a subsequent ultrasonography showed only omental herniation, with no evidence of uterine prolapse. When she reached 1 year of age, a laparoscopic percutaneous extraperitoneal closure procedure was performed. During the surgery, it was observed that the uterus and fallopian tubes were located near the hernia orifice, but no clear prolapse was detected. The procedure concluded safely with successful high ligation. It has noted that in cases of uterine prolapse hernias, the uterus tends to recede as the child grows, which supports the decision to delay surgery for improved safety.

Impact of Preoperative Tumor Size on Prognosis of Resectable and Borderline Resectable Pancreatic Ductal Adenocarcinomas.

BACKGROUND: Tumor size (TS) is a well-established prognostic factor of pancreatic ductal adenocarcinoma (PDAC). However, whether a uniform treatment strategy can be applied for all resectable PDACs (R-PDACs) and borderline resectable PDACs (BR-PDACs), regardless of TS, remains unclear. This study aimed to investigate the impact of preoperative TS on surgical outcomes of patients with R-PDACs and BR-PDACs. METHODS: Chart data from three institutions were reviewed to select patients who underwent pancreatectomy for R-PDACs and BR-PDACs between January 2006 and December 2020. The patients were divided into TSsmall and TSlarge groups according to a TS cutoff value determined for each of R- and BR-PDAC using the minimum P value approach for the risk of R1 resection. RESULTS: TS of 35 mm and 24 mm was the best cutoff value in R-PDAC and BR-PDAC, respectively. The R1 rate was higher in the TSlarge than TSsmall group, in both R- (n = 35, 37% versus n = 294, 19%; P = 0.011) and BR-PDAC (n = 89, 37% versus n = 27, 15%; P = 0.030). Overall survival was significantly better in the TSsmall than TSlarge group in R-PDAC (38.2 versus 12.1 months; P < 0.001), but comparable between the two groups in BR-DPAC (21.2 versus 22.7 months; P = 0.363). Multivariate analysis revealed TS > 35 mm as an independent predictor of worse survival in patients with R-PDAC. CONCLUSION: Larger TS was associated with a higher R1 rate and is a worse prognostic factor in patients with R-PDAC.

Predicting conversion surgery in patients with locally advanced pancreatic cancer after modified FOLFIRINOX treatment.

BACKGROUND: /Objective: FOLFIRINOX therapy (FFX) for locally advanced pancreatic cancer (LAPC) is increasingly recognized as a potent neoadjuvant therapy that enables transition to conversion surgery (CS). However, predictors of CS achievement after chemotherapy are controversial. This study aimed to demonstrate the efficacy of CS after modified FFX (mFFX) in patients with LAPC and to identify and score predictors of CS. METHODS: From January 2014 to December 2018, patients with LAPC who received mFFX as a first-line treatment were screened. Patients' overall survival was compared with and without CS. Moreover, the predictors for CS were analyzed to create scores for the CS factors. RESULTS: Forty-three patients received mFFX, including 20 patients who underwent CS (CS group, 46.5%). R0 resection was achieved in 16 patients (80%). The median survival time was 39.2 months (95% confidence interval [CI] 17.3-53.8) for the CS group and 16 months (95% CI 10.5-22.6) for the non-CS group (P < 0.001; hazard ratio 0.25, 95% CI 0.12-0.54). Since an average relative dose intensity of ≥90%, tumor reduction of ≥35%, and carbohydrate antigen 19-9 reduction of ≥70% or normalization were associated with successful transition to CS in the multivariate analysis, these factors were scored (CS score, range 0-3). All of the patients in the CS group fell into the 2-3 category, compared with 2 of 23 patients in the non-CS group (P < 0.001). CONCLUSION: CS after FFX contributes to the long-term survival of patients with LAPC. The CS score could be an indicator for transition to CS.

Minimally invasive fenestration for congenital hepatic cyst in infant.

A 19-year-old woman underwent prenatal ultrasonography, which confirmed the presence of an isolated cystic mass in the upper abdominal cavity of a fetus. A female infant weighing 3085 g was delivered at 36 weeks' gestation. Ultrasonography and computed tomography examination revealed a clear unilocular cyst and occupying the right side of the abdomen. The infant's respiratory status was unstable, and she fed poorly, owing to compression by the hepatic cyst. We performed ultrasound-guided aspiration of a hepatic cyst at 15 days old, but it rapidly re-grew. Therefore, we performed laparoscopic findings and fenestration of the hepatic cyst via an umbilical arc incision and the cyst wall was excised at 43 days old. The histopathological diagnosis was mesothelial cell-derived hepatic cyst. Three years after the operation, no recurrence has been observed. Hepatic cyst fenestration by umbilical incision can be performed safely in infants and it is a cosmetically superior method.

Thoracoscopic removal with fluoroscopic radiographic guidance of thoracoamniotic shunting catheters in newborns.

Fetal thoracoamniotic shunting (TAS), which drains pleural effusion, is a treatment for severe primary fetal pleural effusion. While TAS is an effective treatment, its complications include bleeding and the catheter becoming dislodged, and also penetrating the thoracic cavity or chest wall. Catheters dislodged into the thoracic cavity in TAS can be removed by thoracoscopy. However, if there are adhesions in the thoracic cavity, finding the TAS catheter with a thoracoscope can be difficult. We used fluoroscopic radiography in addition to a thoracoscope to remove a TAS catheter in four patients. A 5-mm trocar was inserted into the thoracic cavity, and a 2.7-mm scope and 3-mm forceps were inserted into the trocar. We searched for TAS catheters using a thoracoscope and fluoroscopic radiography. If there are adhesions in the thoracic cavity and removing the TAS catheter is difficult, the combined use of a thoracoscope and fluoroscopic radiography may prove helpful.

Refractory Acute Antibody Mediated Rejection in Liver Transplant After Desensitization of Preformed Donor Specific Antibody-Validity of Bortezomib and Everolimus: A Case Report.

Here, we report a case of living donor liver transplantation (LDLT) complicated with severe acute antibody-mediated rejection (aAMR), although desensitization was performed for preformed donor-specific anti-human leukocyte antigen antibody (DSA). LDLT was performed in a 59-year-old woman with alcoholic cirrhosis with a graft from her 60-year-old husband as a living donor. She had reproductive history of 4 gravidity and parity with her husband. Preoperative serologic studies showed positive complement-dependent cytotoxic crossmatch and anti-human leukocyte antigen-A26 antibody was identified as DSA. Desensitization for preformed DSA with rituximab and plasma exchange was performed before LDLT. We decided to perform LDLT using her husband right liver as living donor graft since the DSA mean fluoro-intensity was down to negative range. The immunosuppressive regimen was comprised with steroid and tacrolimus. However, the recipient developed acute cellular rejection on day 5 after LDLT, followed by severe aAMR. Re-administration of rituximab followed by 4 courses of plasma exchange failed to treat aAMR. The DSA mean fluoro-intensity was successfully suppressed after bortezomib was administered however impaired serologic liver function test and cholestasis were remained. The liver function test and cholestasis in the graft were improved after Everolimus was administered. The recipient was discharged on postoperative day 196. In conclusion, we report a case of LDLT who developed aAMR after desensitization of preformed DSA and was successfully treated with intensive therapy with bortezomib and everolimus.

Female pediatric inguinal hernia: uterine deviation toward the hernia side.

PURPOSE: We aimed to clarify the frequency and the clinical significance of deviation of the uterus in female pediatric inguinal hernia. METHODS: We retrospectively evaluated the data of 94 female pediatric inguinal hernia cases that were treated by laparoscopic percutaneous extraperitoneal closure. We assessed for correlations between uterine deviation and age, body weight, the size of the hernia orifice, and the presence of contralateral processus vaginalis (PV) patency. RESULTS: Eighty-four of 94 cases were diagnosed with unilateral inguinal hernia. A total of 62 (73.8%) of these had uterine deviation to the hernia side (Group D); 22 (26.2%) had no deviation to the hernia side (Group N) (P < 0.001). Group D cases were significantly younger than those in Group N (P = 0.0351). There was no difference in body weight, size of the hernia orifice, or contralateral PV patency between the two groups. CONCLUSION: The incidence of uterine deviation toward the hernia side was statistically significant. It is important to recognize that female pediatric inguinal hernia repair carries an increased risk of ovarian and fallopian tube damage, because these appendages are close to the hernia orifice as a result of the uterine deviation.

The Efficacy of S-1 as Adjuvant Chemotherapy for Resected Biliary Tract Carcinoma: A Propensity Score-Matching Analysis.

Even though S-1 is a widely used chemotherapeutic agent, there is no evidence for its use in an adjuvant setting for biliary tract carcinoma (BTC). Patients who underwent surgical treatment for BTC between August 2007 and December 2018 were selected. Propensity score matching was performed between patients who received S-1 as adjuvant chemotherapy (S-1 group) and those who underwent surgical treatment alone (observation group). Of 170 eligible patients, 38 patients were selected in each group after propensity score matching. Among those in the matched cohort, both the median recurrence-free survival (RFS) and overall survival (OS) in the S-1 group were significantly longer than those in the observation group (RFS, 61.2 vs. 13.1 months, p = 0.033; OS, not available vs. 28.2 months, p = 0.003). A multivariate analysis of the OS revealed that perineural invasion and adjuvant S-1 chemotherapy were independent prognostic factors. According to a subgroup analysis of the OS, the S-1 group showed significantly better prognoses than the observation group among patients with perineural invasion (p < 0.001). S-1 adjuvant chemotherapy might improve the prognosis of BTC, especially in patients with perineural invasion.

Erratum: Ex vivo induction of antitumor DEC-205+ CD11c+ cells in a murine neuroblastoma model by co-stimulation with doxorubicin, lipopolysaccharide and interleukin-4.

[This corrects the article DOI: 10.3892/br.2015.546.].

Immune Checkpoint Inhibition Followed by Tumor Infiltration of Dendritic Cells in Murine Neuro-2a Neuroblastoma.

BACKGROUND: Most tumors responding to immunotherapy with monoclonal antibodies targeting programmed cell death protein1 (PD1) and programmed death ligand-1 (PD-L1) show surface expression of PD-L1. Neuroblastoma has been reported to show low PD-L1 surface expression. METHODS: The effect of immune checkpoint inhibitor on mouse neuroblastoma was investigated, and host immune cells were analyzed in the tumor microenvironment. Expression of co-stimulatory molecules by Neuro-2a mouse neuroblastoma cells was analyzed using flow cytometer. Neuro-2a cells were inoculated subcutaneously into A/J mice, followed by intraperitoneal injection of antibodies targeting PD-1 and PD-L1. Mice were sacrificed for the measurement of tumor weights on day 14 following tumor inoculation, and tumor-infiltrating cells were analyzed using a flow cytometer. RESULTS: Dim expression of PD-L1 was observed on the cell surface of cultured Neuro-2a cells. Growth of subcutaneous tumors was significantly suppressed, and PD-L1-expressing tumor cells were depleted by the antibody treatment. We confirmed that Neuro-2a cells opsonized by the anti-PD-L1 antibody were phagocytosed in the in vitro setting. In the treated tumor microenvironments, CD8α+ lymphocyte and CD11c+ MHC II+ cells were significantly accumulated in comparison with the control group. These CD11c+ MHC II+ cells expressed CD80, CD86, CD14, and CD40, but not CD205, PD-L1, or CTLA4. PD-1 expression was detected dimly. Immune suppressive effects of CD11b+Gr-1+ myeloid-derived suppressor cells by the administration of anti-PD-1 and PD-L1 antibodies were not observed in spleen, regional lymph nodes, or tumor microenvironment. CONCLUSIONS: Our findings raise the possibility that co-administration of anti-PD-1 and anti-PD-L1 antibodies have a synergistic effect on inhibition of tumor growth and could be an effective therapy against neuroblastoma with dim expression of PD-L1.

Usefulness of preoperative drip infusion cholangiography with computed tomography for predicting surgical difficulty during laparoscopic cholecystectomy.

BACKGROUND: Drip infusion cholangiography with computed tomography (DIC-CT) is a major preoperative modality used for patients undergoing laparoscopic cholecystectomy (LC). METHODS: This study included 218 patients for whom preoperative DIC-CT images were obtained prior to undergoing LC. The association between gallbladder (GB) opacification in DIC-CT and the operative time was assessed. RESULTS: The GB opacification on the DIC-CT images was classified as follows: Grade 0, homogeneous opacification; Grade 1, heterogeneous opacification; Grade 2, only cystic duct can be identified; and Grade 3, no opacification. Images obtained for the 218 patients showed 41 (18.8%) with Grade 0, 91 (41.7%) with Grade 1, 54 (24.8%) with Grade 2, and 32 (14.7%) with Grade 3. The operative time and intraoperative blood loss were significantly longer and larger, respectively, in cases classified as Grade 2 or 3 (GB negative) compared with cases classified as Grade 0 or 1 (GB positive). We created an LC difficulty score based on the following variables that were significant independent predictors of increased operative time: GB negativity in DIC-CT (P = .002, 2 points), GB wall thickness (P = .002, 2 points), body mass index (P = .015, 1 point), preoperative alkaline phosphatase value (P = .018, 1 point), and preoperative C-reactive protein value (P = .04, 1 point). The LC difficulty score (Grade A, score 0-2; Grade B, score 3-5; and Grade C, score 6-7) was significantly associated with a prolonged operative time. CONCLUSION: Drip infusion cholangiography with computed tomography is useful for predicting the surgical difficulty of LC.

[A Case of Locally Advanced, Pancreatic Mixed Acinar-Endocrine Carcinoma(MAEC) Resected using Superficial Femoral Vein Grafts for Portal Reconstruction].

A 46-year-old woman with epigastric pain was found to have a tumor of the pancreatic head. Computed tomography(CT) revealed a plethoric and poorly-marginated, 7 cm tumor in the pancreatic head. The superior mesenteric vein(SMV)was infiltrated from the duodenal inferior margin and a 6 cm occlusion extended to the merger with the splenic vein. Diagnostic criteria identified locally advanced pancreatic cancer(UR-P)with a limitation in portal reconstruction. Endoscopic ultrasoundguided fine needle aspiration(EUS-FNA)diagnosed mixed acinar-endocrine carcinoma(MAEC). Due to rarity, a chemotherapy protocol has not been established. Thus, the first option for treatment was resection. CT showed that the required graft was 7 cm in length, with SMV 0.5 cm in diameter at the intestinal side and 1.4 cm in diameter at the hepatic side; accordingly, the superficial femoral vein (SFV)was selected for use. Compared to the external iliac vein, the graft is slightly thinner and about 10 cm can be harvested. This graft is useful for cases that require reconstruction of the distal SMV.

[Portal Stent for Gastrointestinal Bleeding Caused by Portal Stenosis after Hepato-Biliary-Pancreatic Surgery].

It is known that gastrointestinalbl eeding occurs due to portalstenosis as a complication in the hepato-biliary-pancreatic region at later postoperative stages. Our department has treated 5 portal stent cases since 2015. The pressure difference between the hepatic side and intestinalside at the portalstenosis site decreased from 9-14(median: 10)cmH2O to 0-6 (median: 2)cmH2O in all cases before and after placement of the stent, resulting in hemostasis(observation period 4-18 months, median: 12 months). In surgery of the hepato-biliary-pancreatic regions, veins flowing into the portal vein are also incised by dissection of the hepatoduodenal ligament. Accordingly, it has been inferred that when the portal vein becomes stenotic, the collateralroutes flow into the portalvein at the hepatic portalsite in a hepatopetalmanner through the cholangiojejunal anastomosis site from the mesenteric veins of the elevated jejunum, and the submucosal weak collateral routes collapse, causing gastrointestinal bleeding. Rebleeding is highly likely in cases with only endoscopic treatment and embolization of collateralroutes. On the other hand, it is thought that portalstenting is a radicaltreatment and is thus the first option for management.

[A Case of Splenic Lymph Node Metastasis from the Distal Bile Duct Carcinoma Seven Years after a Curative Resection].

We report a case of splenic lymph node recurrence 7 years after a distal bile duct carcinoma. A 70s man underwent pylorus ring-preserving pancreaticoduodenectomy for distal bile duct carcinoma in 20XX. The pathological diagnosis was T2N0M0, Stage Ⅱ(Japanese Classification of the Biliary Tract Cancers 5th edition). Then, S-1 was administered as an adjuvant chemo- therapy 1month later and continued for 3 years. At 7 years postoperatively, the serum CEA level was elevated(CEA 77.0 ng/ mL), and FDG-PET showed high-grade accumulation in the splenic hilum lymph node, which was diagnosed as lymph node recurrence. Because it was a solitary metastasis and had a long recurrence-free period, tumor resection was not performed, and the patient opted for a nonsurgicaltreatment. No recurrence occurred to date. Recurrent resection is rarely performed for splenic lymph node metastasis.

[Conversion Surgery after Etoposide/Cisplatin(EP)Therapy for Huge Pancreatic Neuroendocrine Carcinoma - A Case Report].

Neuroendocrine carcinoma(NEC)is known as rapid tumor growth, high grade malignancy and poor prognosis. We report a case of huge pancreatic NEC successfully performed conversion surgery after EP therapy. A 70-year-old female, was presented to our hospital with appetite loss. CT scan revealed huge tumor, 15 cm in diameter, locating at the pancreas with possible involvement to liver, stomach, common hepatic artery, left gastric artery and gastroduodenal artery. Peritoneal dissemination and para-aortic lymph node metastasis were also suspected. EUS-FNA showed neuroendocrine carcinoma with almost 100%positive staining rate of Ki-67. We immediately started etoposide/cisplatin(EP)therapy. After 6 courses of EP, the tumor shrank remarkably and peritoneal disseminations were disappeared. Common hepatic artery and gastroduodenal artery became free from the tumor. However, after 7 courses of EP, CT and PET-CT revealed tumor re-growth. Also renal impairment could not afford to continue EP therapy. Therefore we decided to perform conversion surgery. In the guideline in Japan, there is no content specialized for surgical treatment for NEC. Moreover, second-line of chemotherapy for NEC has not been established. In the future, accumulation of NEC cases will contribute to develop effective multidisciplinary treatment.

[Resection for the Recurrence of Hepatocellular Carcinoma in the Inferior Vena Cava and Right Atrium under Deep Hypothermic Circulatory Arrest].

A 77-year-old man underwent extended right lobectomy of the liver for rupture of hepatocellular carcinoma. Recurrence in the inferior vena cava andright atrium was noted 30 months after surgery. We performedextirpation of this tumor thrombosis under retrograde cerebral perfusion during deep hypothermic circulatory arrest. The pericardium was cut through sternotomy, and cooling was initiated. After cardiac arrest at 20.4°C, the inferior vena cava was separated. An incision was made in the right atrium andthe tumor thrombus was extirpated. In the meantime, brain protection was maintainedby retrograde cerebral perfusion. The patient was discharged on day 12 without postoperative complications. He remains alive 6 months after surgery without recurrence. This procedure prevented pulmonary embolism due to tumor thrombosis release. It was also possible to perform the procedure with retrograde cerebral perfusion.