[Perioperative Outcome of Laparoscopic Surgery after Colonic Stent Placement for Obstructive Colorectal Cancer].

In recent years, bridge to surgery(BTS), in which surgery is performed after colorectal stenting for obstructive colorectal cancer, has gradually become popular, and laparoscopic surgery is also a treatment option. From January 2020 to December 2022, we retrospectively evaluated clinicopathological factors in 18 colorectal cancer cases who underwent radical resection after colorectal stenting. We found no difference in patient background, histopathological factors, primary anastomosis rate, stoma creation rate, operative time, postoperative complication rate and length of hospital stay between the laparoscopic surgery(L)and open surgery(O)groups. Blood loss was significantly lower in group L. In T4 patients, laparoscopic surgery after colorectal stenting can be safely performed, but conversion to open surgery may be necessary. Surgery after colorectal stenting should be performed based on preoperative accurate imaging and sufficient experience.

Giant splenic artery aneurysm rupture into the stomach that was successfully managed with emergency distal pancreatectomy.

BACKGROUND: Splenic artery aneurysms usually rupture into the free peritoneal space and rarely into the gastrointestinal tract. We report the case of a patient with a giant splenic artery aneurysm that ruptured in to the stomach with hemorrhagic shock and was successfully treated with emergency surgery. CASE PRESENTATION: A 59-year-old man presented to the emergency department with chest pain and syncope. Contrast-enhanced computed tomography showed splenic artery aneurysm with active contrast extravasation. He developed upper gastrointestinal (UGI) bleeding and hypovolemic shock. We diagnosed a splenic artery aneurysm ruptured in to the stomach, performed emergency distal splenopancreatectomy including the aneurysm and partial gastric resection, and could prevent patient death. CONCLUSIONS: This report shows that splenic artery aneurysm can cause UGI bleeding. Thus, clinicians should be alert about this condition when managing patients with UGI bleeding and/or splenic artery aneurysm.

Non-occlusive mesenteric ischemia during acute stroke management: three case reports.

BACKGROUND: There are many reports of non-occlusive mesenteric ischemia in patients on maintenance hemodialysis and following cardiac surgery. However, there are few reports of non-occlusive mesenteric ischemia in patients with acute stroke. CASE PRESENTATION: We report three cases of non-occlusive mesenteric ischemia with onset during treatment for acute stroke. All of the patients were undergoing strict blood-pressure control, and two patients developed NOMI soon after tracheostomy when enteral nutrition had been resumed. CONCLUSION: Many stroke patients are older adults with risk factors such as arteriosclerosis. Thus, during acute stroke management, there is a possibility that patients may develop non-occlusive mesenteric ischemia due to decreased intestinal blood flow secondary to strict blood-pressure control. This case report implicates early enteral nutrition as a potential etiopathogenic factor of non-occlusive mesenteric ischemia in patients with acute stroke.

[A Case of Sigmoid Colon Cancer with Retroperitoneal Fibrosis Using Intraoperative Indocyanine Green Fluorescence Angiography for Colorectal Anastomosis].

A 72-year-old man was presented with anemia and diagnosed with sigmoid colon cancer by colonoscopy. CT showed a soft tissue density around the retroperitoneum, leading to the diagnosis of retroperitoneal fibrosis. Stenosis of left ureter, inferior mesenteric artery, and left colic artery due to the soft tissues were detected. Sigmoidectomy and retroperitoneal biopsy were performed, and colorectal anastomosis was completed after confirming the intestinal blood flow by ICG fluorescence angiography. In retroperitoneal fibrosis, identifying blood vessels intraoperatively can be difficult. ICG fluorescence angiography is useful for reliable anastomosis in colorectal cancer surgery with retroperitoneal fibrosis.

Expression of annexin II and stromal tenascin C promotes epithelial to mesenchymal transition and correlates with distant metastasis in pancreatic cancer.

The interaction between cancer cells and stromal components contributes to cancer invasion and metastasis in pancreatic ductal adenocarcinoma (PDAC). The present study investigated the role of the correlation between annexin II (ANX2) and stromal tenascin C (TNC) with the progression of PDAC. The functions of the expression ANX2 and TNC were assessed in in vitro experiments using mouse and human PDAC cells, and the clinical effect was analyzed using immunohistochemistry with surgically resected PDAC tissues. The effects on epithelial to mesenchymal transition (EMT), invasion, putative cancer stemness, and anoikis resistance were examined in vitro using murine precancerous pancreatic intraepithelial neoplasia (PanIN) cells and murine and human invasive PDAC cells with ANX2 knockdown using specific small interfering RNA (siRNA)s and recombinant TNC (rTNC). ANX2 was expressed at a high level in primary PanIN cells and invasive PDAC cells, compared with the levels in liver metastatic PDAC cells. In the ANX2­knockdown cells, there were fewer cells with a morphological mesenchymal appearance in three­dimensional culture and invasion was reduced compared with that in the control cells. Morphological change into the mesenchymal phenotype and invasion were enhanced by rTNC treatment in the control PDAC cells but not in the ANX2­knockdown cells. Pancreatosphere formation assays showed that ANX2 and TNC facilitated the maintenance of stem­like characters in PDAC cells. Furthermore, anoikis assays indicated that the interaction of ANX2­TNC contributed to anoikis resistance in PDAC cells. In the immunohistochemistry analyses, the group with a high expression of ANX2 and high stromal TNC was significantly correlated with distant metastasis, and was associated with hematogenous/peritoneal recurrence and poor outcomes following surgery in resected human primary PDAC tissues. In conclusion, the results demonstrated that ANX2 and stromal TNC regulated invasion in addition to stemness and anoikis resistance, which are crucial for metastasis in the progression of PDAC. These results indicate the potential of the ANX2­TNC axis as a therapeutic target for PDAC metastasis.

Perioperative allogenic blood transfusion is a poor prognostic factor after hepatocellular carcinoma surgery: a multi-center analysis.

PURPOSE: The influence of allogenic blood transfusion on the postoperative outcomes of hepatocellular carcinoma (HCC) surgery remains controversial. This study aims to clarify the clinical impacts of perioperative allogenic blood transfusion on liver resection outcome in HCC patients. METHODS: We analyzed data collected over 5 years for 642 patients who underwent hepatectomy for HCC at one of the five university hospitals. We investigated the impact of allogenic blood transfusion on postoperative outcome after surgery in all patients and in 74 matched pairs, using a propensity score. RESULTS: Of the 642 patients, 198 (30.8%) received perioperative allogenic blood transfusion (AT group) and 444 (69.2%) did not (non-AT group). Overall survival was lower in the AT group than in the non-AT group in univariate (P < 0.001) and multivariate analyses (risk ratio 1.521, P = 0.011). After matching the different distributions using propensity scores, perioperative blood transfusion was found to be a poor prognostic factor for HCC patients. CONCLUSIONS: In this multi-center study, perioperative blood transfusion was an independent factor for poor prognosis after curative surgery for primary HCC in the patient group and in pairs matched by propensity scores.

Sex Determining Region Y Box 9 Induces Chemoresistance in Pancreatic Cancer Cells by Induction of Putative Cancer Stem Cell Characteristics and Its High Expression Predicts Poor Prognosis.

OBJECTIVES: Pancreatic cancer is a highly chemoresistant tumor and underlying mechanisms are not well understood. Sex determining region Y box 9 (Sox9) is a transcription factor playing important roles on maintenance of pluripotent cells during pancreatic organogenesis. The purpose of this study is to evaluate the roles of Sox9 in pancreatic cancer. METHODS: The Sox9 expression was evaluated by immunohistochemical analysis. Effects of Sox9 inhibition by siRNA or shRNA on chemosensitivity, sphere formation, stem cell markers expression, and in vivo tumor formation rate were examined using pancreatic cancer cell lines. RESULTS: High expression of Sox9 in pancreatic cancer tissue is correlated with poor prognosis (P = 0.011). Cells with high Sox9 expression (PANC-1, Capan-1) showed stronger chemoresistance to Gemcitabine than cells with low Sox9 expression (BxPC-3, MIA PaCa-2). The chemosensitivity in PANC-1 was recovered by suppressing Sox9 using siRNA (P < 0.05). Both sphere formation rate and the proportion of CD44CD24 cells were decreased by Sox9 inhibition. Tumor formation rate of Tet-on inducible Sox9 shRNA-transfected PANC-1 cells in KSN/Slc nude mice was decreased by induction of shRNA with doxycycline feeding (P < 0.05). CONCLUSION: Sox9 plays an important role in chemoresistance by the induction of stemness in pancreatic cancer cells.

Late-onset bile leakage after hepatic resection.

BACKGROUND: Postoperative bile leakage can be a serious complication after hepatic resection. Few studies have analyzed patients according to the time of onset of bile leakage. We analyzed differences between patients with early- and late-onset bile leakage after hepatic resection and assessed clinical characteristics and outcomes in patients with late-onset leakage. METHODS: Between 2008 and 2010, 1,009 patients underwent hepatic resection at 4 participating university hospitals and 2 community hospitals. Fifty-two patients (5.1%) with postoperative bile leakage were divided into an early-onset group (<2 weeks after surgery, n = 34) and a late-onset group (≥2 weeks after surgery, n = 18). Patient characteristics and outcomes were collected prospectively and analyzed retrospectively. RESULTS: The proportion of patients who underwent intra-abdominal placement of a drainage catheter was significantly less in the late-onset group than the early-onset group. All 18 patients in the late-onset group developed intra-abdominal infection, and 2 died of sepsis. The proportion of patients who underwent invasive treatment (abdominal paracentesis, endoscopic biliary drainage, or second hepatic resection) was significantly greater in the late-onset group than in the early-onset group. The time to resolution of bile leakage was significantly greater in the late-onset group than the early-onset group. CONCLUSION: Patients should be monitored carefully for bile leakage for several weeks after hepatic resection, because late-onset bile leakage can cause serious complications. Intra-abdominal infection should also be treated as soon as possible, because it may induce refractory bile leakage with serious complications.

Do patients with small solitary hepatocellular carcinomas without macroscopically vascular invasion require anatomic resection? Propensity score analysis.

BACKGROUND: The benefits of anatomic resection in patients with small (<5 cm), solitary hepatocellular carcinomas remain unclear. Outcomes were therefore evaluated in patients who underwent anatomic resection or nonanatomic resection of small solitary hepatocellular carcinomas. METHODS: Factors affecting overall survival and disease-free survival were investigated in 330 patients who underwent curative hepatectomy for solitary (≤5 cm) hepatocellular carcinomas without macroscopic vascular invasion. In addition, a propensity score matching model with 330 patients was constructed to overcome bias, with subgroups analyzed by tumor diameter (<3 cm and 3-5 cm). RESULTS: ICG-R15 ≥25% was confirmed as being independently associated with poorer overall survival and disease-free survival. One-to-one matching of preoperative characteristics yielded 72 pairs of patients receiving anatomic resection and nonanatomic resection, with long-term outcomes, including overall survival and disease-free survival, being similar in these 2 groups. Subgroup analysis showed that, in patients with tumors <3 cm in diameter, short-term outcomes were better in the nonanatomic resection group than in the anatomic resection group, including significantly reduced operation time (P = .02), blood loss (P = .01), blood transfusion (P < .01), complications (particularly bile leakage and abdominal abscess) (P = .04), and postoperative hospital stay (P < .01). CONCLUSION: Anatomic resection was not superior to nonanatomic resection in survival outcomes in patients with solitary small hepatocellular carcinomas without macroscopic vascular invasion. Rather, postoperative short-term outcomes were more favorable with nonanatomic resection.

Higher complication rate in hepatocellular carcinoma patients undergoing prophylactic cholecystectomy with curative hepatic resection.

AIMS: We performed a retrospective analysis to evaluate the short and long-term impact of simultaneous prophylactic cholecystectomy with hepatectomy in these patients. METHODS: We identified 642 patients who underwent curative hepatocellular carcinoma resection between 2001 and 2005 at five university hospitals. One hundred and twenty-five hepatocellular carcinoma patients who received left lateral sectionectomy or partial resection in the left lateral and Spiegel lobes were identified and followed. They were divided into two groups, 74 with and 51 without simultaneous cholecystectomy. None of these patients had gallbladder stones or polyps at preoperative diagnosis. RESULTS: Although not statistically significant, the operating time was longer and blood loss was greater in the cholecystectomy group. Patients in the cholecystectomy group had a significantly higher postoperative morbidity rate. Surgical complications according to the Clavien classification differed significantly between the two groups. Variables significantly associated with complications in the univariate and multivariate analyses were simultaneous cholecystectomy and operative blood loss ≥ 1000 ml. CONCLUSION: Simultaneous cholecystectomy of the asymptomatic gallbladder with curative resection of hepatocellular carcinoma in the left lateral section or Spiegel lobe resulted in higher postoperative complications. Consequently, the gallbladder should be preserved except in cases of gallbladder stones or polyps.

Extraperitoneal Fluid Collection due to Chronic Pancreatitis.

A 39-year-old man was referred to our hospital for the investigation of abdominal fluid collection. He was pointed out to have alcoholic chronic pancreatitis. Laboratory data showed inflammation and slightly elevated serum direct bilirubin and amylase. An abdominal computed tomography demonstrated huge fluid collection, multiple pancreatic pseudocysts and pancreatic calcification. The fluid showed a high level of amylase at 4,490 IU/l. Under the diagnosis of pancreatic ascites, endoscopic pancreatic stent insertion was attempted but was unsuccessful, so surgical treatment (Frey procedure and cystojejunostomy) was performed. During the operation, a huge amount of fluid containing bile acid (amylase at 1,474 IU/l and bilirubin at 13.5 mg/dl) was found to exist in the extraperitoneal space (over the peritoneum), but no ascites was found. His postoperative course was uneventful and he shows no recurrence of the fluid. Pancreatic ascites is thought to result from the disruption of the main pancreatic duct, the rupture of a pancreatic pseudocyst, or possibly leakage from an unknown site. In our extremely rare case, the pancreatic pseudocyst penetrated into the hepatoduodenal ligament with communication to the common bile duct, and the fluid flowed into the round ligament of the liver and next into the extraperitoneal space.

Clinicopathological features of recurrence in patients after 10-year disease-free survival following curative hepatic resection of hepatocellular carcinoma.

BACKGROUND: The present study aimed to clarify the clinicopathologic features of long-term disease-fee survival after resection of hepatocellular carcinoma (HCC). METHODS: This retrospective study identified 940 patients who underwent curative resection of HCC between 1991 and 2000 at five university hospitals. Seventy-four patients with 10 years of recurrence-free survival were identified and followed up. They were divided into two groups, 60 recurrence-free and 14 with recurrence after a 10-year recurrence-free period. RESULTS: Overall survival rates of recurrence and non-recurrence groups were 68 and 91 % at 16 years, and 34 and 91 % at 20 years (p = 0.02), respectively. There were five (36 %), and two deaths (3 %), respectively, after 10 recurrence-free years. A second resection for recurrence was performed in four patients (29 %), and mean survival was 15.3 years after the first hepatectomy. Although three patients in the non-recurrence group (5 %) developed esophageal and/or gastric varices, seven patients in the recurrence group (50 %) developed varices during 10 years (p < 0.0001). In multivariate analysis, preoperative and 10-year platelet count was identified as a favorable independent factor for maintained recurrence-free survival after a 10-year recurrence-free period following curative hepatic resection of HCC. CONCLUSIONS: Recurrence of HCC may occur even after a 10-year recurrence-free period. Long-term follow-up after resection of HCC is important, and should be life-long. Patients with higher preoperative and 10-year platelet counts are more likely to have long-term survival after resection. A low platelet count, related to the degree of liver fibrosis, is a risk factor for recurrence and survival of HCC after curative resection.

Two cases of hepatocellular carcinoma located adjacent to the Glisson's capsule treated by laparoscopic radiofrequency ablation with intraductal chilled saline perfusion through an endoscopic nasobiliary drainage tube.

Radiofrequency ablation (RFA) is a commonly used local therapy for hepatocellular carcinoma (HCC). However, for tumors located adjacent to the Glisson's capsule in the hepatic hilar region, RFA may cause bile duct injury and may be difficult to perform using the standard procedure. We describe 2 HCC cases in which RFA was performed laparoscopically under general anesthesia while cooling bile ducts to prevent bile duct injury. An endoscopic nasobiliary drainage tube was preoperatively inserted, through which chilled saline was rapidly infused during laparoscopic RFA for HCC adjacent to the Glisson's capsule in the hepatic hilar region. The patient was discharged from hospital without intraoperative or postoperative complications. Follow-up contrast-enhanced CT revealed complete tumor cauterization and no evidence of late bile duct stenosis. This procedure is performed under general anesthesia and, unlike those performed under local anesthesia, is associated with minimal stress to patients and minimal risk of bile duct injury.

[A case of unresectable gastric cancer successfully treated with combination chemotherapy of S-1 + CPT-11].

A 70-year-old female, with type III gastric cancer underwent a staging laparoscopy in September 2004. Judging from the results of endoscopy, enhanced CT and staging laparoscopy, we finally diagnosed the patient with stage IV (T3N2MOHOP1CY1), and we started a combination chemotherapy of S-1 + CPT-11 (S-1: 80 mg/m2, day 1-21/35 days, CPT-11: 80 mg/m2, day 1, 15/35 days) from October 2005 to January 2007. Enhanced CT after 2 courses of the combination chemotherapy showed partial response (PR) in the primary lesion. PR continued up to the 13 courses. The CT and gastro fiberscope finally showed complete response (CR) with Group I in biopsy. During these procedures, the grade 3 of neutropenia, grade 1 of diarrhea and grade 1 of fatigue occurred as adverse events. In January 2007, Virchow and, abdominal lymph node metastases were detected, and that we judged the metastases as progressive disease (PD). Nevertheless, the second-line of paclitaxel chemotherapy (70 mg/m2, days 1, 8,15/28 days) has started and she was being judged PD after 2 courses, she died in April 2007.

[A case of S-1 resistant multiple lung metastases after curative total gastrectomy for gastric cancer successfully treated by S-1 combined with CPT-11 as the third-line chemotherapy].

A 78-year-old female underwent a curative total gastrectomy with D2 lymphandectomy for advanced gastric cancer in March 2003. S-1 mono-therapy (80 mg/m2, day 1-28/42 days) began as the first-line chemotherapy from October 2004 when multiple lung metastases were detected by CT. Paclitaxel mono-therapy (80 mg/m2, days 1, 8, 15/28 days) began as the second-line chemotherapy from April 2005 when prior S-1 mono-therapy judged as progressive disease (PD) by CT. Paclitaxel mono-therapy judged it as partial response (PR) in June, but the final judgement was as PD in September 2005. S-1 + CPT-11 combination therapy (S-1: 80 mg/m2, day 1-21, CPT-11: 80 mg/m2, days 1, 15/35 days) began as the third-line chemotherapy from September 2005. After 10 courses, multiple lung metastases were judged as complete response (CR) in September 2006. During the third-line chemotherapy, any adverse event of grade 2 or more did not occur. After judgment of CR, the patient has been followed without chemotherapy due to patient's desire, and is still alive without any recurrence in July 2007.

[A case of advanced gastric cancer with obstructive jaundice due to liver metastases successfully treated with chemotherapy].

We report a successful case of chemotherapy for primary far-advanced gastric cancer accompanied with poor general condition related to jaundice due to hepatic metastasis. A 54-year-old man, who had been admitted to another hospital in October 2006 with a complaint of tarry stool, was referred to our hospital. The result of detailed examination revealed an advanced gastric cancer, multiple lymph node metastases and jaundice (T-Bil 3.3 mg/dL) due to multiple hepatic metastases. The performance status (PS) was level 4. In parallel with a whole body control, a combined therapy with S-1 and CPT-11 was performed from October 27 as the first-line therapy. As a consequence of the first course, the jaundice disappeared. After the second course, the patient left the hospital. However, the patient was re-admitted to hospital in January 2007 by a reason of fever and a deterioration of PS. As exacerbation of cancerous peritonitis and the primary tumor were seen, a weekly paclitaxel therapy was performed as the second-line therapy. Two courses of treatment resulted in the disappearance of ascites and a reduction of hepatic/lymph node metastasis. PS was improved to level 0 as well. After these therapies, the patient was discharged from the hospital. As of June 2007, he continuously receives chemotherapy as an outpatient.

[Neoadjuvant therapy with imatinib mesilate for gastrointestinal stromal tumor of the stomach before subsequent successful surgical resection].

A 65-year-old man is presented here with a huge mass of 13 cm in diameter in the left upper abdomen. Histopathologic assessment of endoscopic forceps biopsy revealed a c-kit positive gastrointestinal storomal tumor (GIST) of the stomach. Abdominal computed tomography (CT) showed a direct invasion to the pancreas. Imatinib mesilate was administered as neoadjuvant therapy according to the NCCN Guidelines. Imatinib mesilate therapy was stopped within 2 weeks because of adverse events such as Grade 2 of facial edema and dizziness. However, no hematological adverse event was shown. After three months of treatment (relative dose intensity was 87.5%), CT revealed a reduction in tumor diameter of 35.6% and showed no longer a direct invasion to the pancreas. The radical operation was considered feasible and partial gastrectomy was performed. The tumor was well encapsulated and radical surgery was possible without rupture. Adjuvant therapy was not performed. The patient has now been in good health without a recurrence for three months after the surgery.

[A case of an elderly patient with gastric cancer successfully treated with TS-1 considering impaired renal function caused by aging].

A 75-year-old female patient with impaired renal function caused by aging was treated with TS 1 for gastric cancer with extensive multiple liver metastases. TS-1 contains CDHP, which inhibits DPD activity and maintains a high blood concentration of 5-FU. Because CDHP is excreted from the kidney, a careful TS-1 administration is necessary for patients with impaired renal function considering an occurrence of severe adverse events. Based on the result previously reported by us about pharmacokinetic study and recommended administration dosage of TS-1 for patients with impaired renal function, we administered 50 mg/day of TS-1 for four weeks followed by two weeks rest per one course for this patient. The patient's creatinine clearance calculated by the Cockcroft-Gault method was 38 ml/min, and we reduced the administration dosage in consideration of her impaired renal function, although normal dosage of TS-1 calculated from body surface area for this patient was 100 mg/day. As this patient underwent TS-1 treatment, sizes of multiple liver metastases and the blood concentration level of CEA were gradually reduced, and the reductive rate of the former was more than 90% and the level of the latter fell to a normal range after 12 courses of TS 1 treatment. Through all the treatment courses, relative drug intensity was 100% and the performance status of this patient was kept 0 without any grade 3 or more adverse events under ambulatory treatment. A successful treatment for this patient might indicate that it was important to consider the appropriate reduction of the dosage of TS-1 administration for elderly patients with gastric cancer, because there is a reverse correlation between aging and renal function. To clarify this problem, a multicenter prospective phase II study about TS-1 reductive administration depending on the renal function for elderly patients with gastric cancer (OGSG0404) is ongoing in our clinical study group (OGSG; Osaka Gastrointestinal Chemotherapy Study Group).