Risk-Adjusted Assessment of the Learning Curve for Pure Laparoscopic Donor Hepatectomy for Adult Recipients.

BACKGROUND: Studies on pure laparoscopic donor hepatectomy (PLDH) have been reported. However, only few studies have reported on the learning curve of PLDH. In this report, we aimed to determine the learning curve of PLDH in adult patients using cumulative sum (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) analyses. METHODS: The data of donors who underwent PLDH at a single center between December 2012 and May 2022 were retrospectively reviewed. The learning curve was evaluated using the CUSUM and RA-CUSUM methods based on surgery duration. RESULTS: Forty-eight patients were finally included in the present study. The mean operation time was 393.6 ± 80.3 min. PLDH was converted to laparotomy in three cases (6.3%). According to the Clavien-Dindo classification, nine cases (18.8%) had higher-than-grade III postoperative complications and the most frequent complications were biliary complications. The CUSUM graph shows two peaks, at the 13th and 27th case. The multivariate analysis revealed that a body mass index ≥ 23 kg/m2 and intraoperative cholangiography were the only factors that were independently associated with longer operation time. Based on these results, an RA-CUSUM analysis was performed to assess the learning curve, which showed a decrease in the learning curve after 33 to 34 PLDH procedures. CONCLUSIONS: A learning curve effect was demonstrated in this study after 33 to 34 PLDH procedures. There are relatively many biliary complications, and it is necessary to further examine the method of bile duct transection.

Reconsideration of Temperature Determined by the Excited-State Population Distribution of Hydrogen Atoms Based on Tsallis Entropy and Its Statistics in Hydrogen Plasma in Non-Equilibrium State.

In non-equilibrium plasmas, the temperature cannot be uniquely determined unless the energy-distribution function is approximated as a Maxwell-Boltzmann distribution. To overcome this problem, we applied Tsallis statistics to determine the temperature with respect to the excited-state populations in non-equilibrium state hydrogen plasma, which enables the description of its entropy that obeys q-exponential population distribution in the non-equilibrium state. However, it is quite difficult to apply the q-exponential distribution because it is a self-consistent function that cannot be solved analytically. In this study, a self-consistent iterative scheme was adopted to calculate q-exponential distribution using the similar algorithm of the Hartree-Fock method. Results show that the excited-state population distribution based on Tsallis statistics well captures the non-equilibrium characteristics in the high-energy region, which is far from the equilibrium-Boltzmann distribution. The temperature was calculated using the partial derivative of entropy with respect to the mean energy based on Tsallis statistics and using the coefficient of q-exponential distribution. An analytical expression was derived and compared with Boltzmann statistics, and the distribution was discussed from the viewpoint of statistical physics.

Standardized single-incision plus one-port laparoscopic left lateral sectionectomy: a safe alternative to the conventional procedure.

PURPOSE: Laparoscopic left lateral sectionectomy (LLLS) is a feasible and safe procedure with a relatively smooth learning curve. However, single-incision LLLS requires extensive surgical experience and advanced techniques. The aim of this study is to report the standardized single-incision plus one-port LLLS (reduced port LLLS, RPLLLS) technique and evaluate its safety, feasibility, and effectiveness for junior surgeons. METHODS: Between January 2008 and November 2020, the clinical records of 49 patients who underwent LLLS, divided into the conventional LLLS (n = 37) and the RPLLLS group (n = 12), were retrospectively reviewed. The patient characteristics, pathologic results, and operative outcomes were evaluated. RESULTS: A history of previous abdominal surgery in the RPLLLS group was significantly high (56.8% vs. 91.7%, p = 0.552). Notably, junior surgeons performed 62.2% of the conventional LLLSs and 58.4% of the standardized RPLLLSs. There were no significant differences between the two groups in terms of median operative time (121.0 vs. 113.5, p = 0.387), median blood loss (13.0 vs. 8.5, p = 0.518), median length of hospital stays (7.0 vs. 7.0, p = 0.408), and morbidity rate (2.7% vs. 0%, p = 0.565), respectively. CONCLUSION: This standardized RPLLLS is a feasible and safe alternative to conventional LLLS and may become the ideal training procedure for both junior surgeons and surgeons aiming to learn more complex procedures.

Map7/7D1 and Dvl form a feedback loop that facilitates microtubule remodeling and Wnt5a signaling.

The Wnt signaling pathway can be grouped into two classes, the ß-catenin-dependent and ß-catenin-independent pathways. Wnt5a signaling through a ß-catenin-independent pathway promotes microtubule (MT) remodeling during cell-substrate adhesion, cell migration, and planar cell polarity formation. Although Wnt5a signaling and MT remodeling are known to form an interdependent regulatory loop, the underlying mechanism remains unknown. Here we show that in HeLa cells, the paralogous MT-associated proteins Map7 and Map7D1 (Map7/7D1) form an interdependent regulatory loop with Disheveled, the critical signal transducer in Wnt signaling. Map7/7D1 bind to Disheveled, direct its cortical localization, and facilitate the cortical targeting of MT plus-ends in response to Wnt5a signaling. Wnt5a signaling also promotes Map7/7D1 movement toward MT plus-ends, and depletion of the Kinesin-1 member Kif5b abolishes the Map7/7D1 dynamics and Disheveled localization. Furthermore, Disheveled stabilizes Map7/7D1. Intriguingly, Map7/7D1 and its Drosophila ortholog, Ensconsin show planar-polarized distribution in both mouse and fly epithelia, and Ensconsin influences proper localization of Drosophila Disheveled in pupal wing cells. These results suggest that the role of Map7/7D1/Ensconsin in Disheveled localization is evolutionarily conserved.

[Two Cases of Penoscrotal Strangulation].

Case 1 (42-year-old man) : The patient was examined for penoscrotal swelling that had continued for 1 month. An annular erosive skin ulcer was observed at the penoscrotal base, with distal swelling. Asking the patient about the history of his condition was difficult due to a history of mental illness. We suspected his symptoms were due to an embedded foreign object. As computed tomography indicated the presence of a subcutaneous foreign object, surgery was performed to remove it. A rubber band was found wrapped twice around the area. After releasing the strangulation, penoscrotal swelling improved. Case 2 (72-year-old man) : Penoscrotal swelling appeared after having an automobile tow hook attached to the penoscrotal base for 2 weeks. The patient was examined at the emergency room because he could not remove it on his own. A rescue squad was called, and they cut the strangulating object with an electric saw. After releasing the strangulation, penoscrotal swelling improved. Although we experienced 2 cases of penoscrotal strangulation involving strangulating objects with different characteristics, improvement was achieved in both by releasing the strangulation. The cases of penoscrotal strangulation reported in Japan with known strangulation type are reviewed.

[Influence of Stx2 Subtype on Bacteriological Identification of Outbreaks of EHEC O157: H- Infections in Saitama City].

In 2013, two outbreaks of enterohemorrhagic Escherichia coli (EHEC) occurred in Saitama city. According to reports from each of the medical institutions that detected the EHEC isolates, the isolates seemed to differ in their production of Vero Toxin (VT / Shiga Toxin: Stx) since one isolate produced only Stx1 and the other produced both Stx1 and Stx2. However, a patient survey conducted by a public health center revealed that common foodstuffs had been consumed in both outbreaks. Because, the two EHEC isolates were newly detected from two people in one patient's family, we analyzed the phenotypic and genetic relationships among four isolates in total. All the isolates were serotyped as O157: H-, and both stx1 and stx2 were detected. Subsequently, all four isolates were shown to have the same pulsed-field gel electrophoresis (PFGE) banding pattern. The findings suggested that these isolates belonged to the same strain group. Among these cases, the isolates had stx2c which is one of the stx2 subtypes. Reportedly, some cases with the Stx2 subtype can not be detected using conventional tests for toxin. In addition, Stx2 can be overlooked as a result of this limitation of Stx-production tests. Both epidemiological research by public health centers and genetic analysis by prefectural and municipal public health institutes (PHIs) are very important for clarifying possible relationships among outbreaks, as in the present cases. Moreover, collaborations and networks among medical institutions, PHIs and public health centers should be further strengthened to prevent the spread of infections.

Dishevelled, a Wnt signalling component, is involved in mitotic progression in cooperation with Plk1.

Wnt signalling is known to promote G1/S progression through the stimulation of gene expression, but whether this signalling regulates mitotic progression is not clear. Here, the function of dishevelled 2 (Dvl2), which transmits the Wnt signal, in mitosis was examined. Dvl2 localized to the spindles and spindle poles during mitosis. When cells were treated with nocodazole, Dvl2 was observed at the kinetochores (KTs). Dvl2 bound to and was phosphorylated at Thr206 by a mitotic kinase, Polo-like kinase 1 (Plk1), and this phosphorylation was required for spindle orientation and stable microtubule (MT)-KT attachment. Dvl2 was also found to be involved in the activation of a spindle assembly checkpoint (SAC) kinase, Mps1, and the recruitment of other SAC components, Bub1 and BubR1, to the KTs. However, the phosphorylation of Dvl2 by Plk1 was dispensable for SAC. Furthermore, Wnt receptors were involved in spindle orientation, but not in MT-KT attachment or SAC. These results suggested that Dvl2 is involved in mitotic progression by regulating the dynamics of MT plus-ends and the SAC in Plk1-dependent and -independent manners.

Wnt5a signaling controls cytokinesis by correctly positioning ESCRT-III at the midbody.

Wnts activate at least two signaling pathways, the ß-catenin-dependent and -independent pathways. Although the ß-catenin-dependent pathway is known to contribute to G1-S transition, involvement of the ß-catenin-independent pathway in cell cycle regulation remains unclear. Here, we show that Wnt5a signaling, which activates the ß-catenin-independent pathway, is required for cytokinesis. Dishevelled 2 (Dvl2), a mediator of Wnt signaling pathways, was localized to the midbody during cytokinesis. Beside the localization of Dvl2, Fz2, a Wnt receptor, was detected in the midbody with the endosomal sorting complex required for transport III (ESCRT-III) subunit, CHMP4B. Depletion of Wnt5a, its receptors, and Dvl increased multinucleation. The phenotype observed in Wnt5a-depleted cells was rescued by the addition of purified Wnt5a but not Wnt3a, which is a ligand for the ß-catenin-dependent pathway. Moreover, depletion of Wnt5a signaling caused loss of stabilized microtubules and mislocalization of CHMP4B at the midbody, which affected abscission. Inhibition of the stabilization of microtubules at the midbody led to the mislocalization of CHMP4B, while depletion of CHMP4B did not affect the stabilization of microtubules, suggesting that the correct localization of CHMP4B depends on microtubules. Fz2 was localized to the midbody in a Rab11-dependent manner, probably along stabilized microtubules. Fz2 formed a complex with CHMP4B upon Wnt5a stimulation and was required for proper localization of CHMP4B at the midbody, while CHMP4B was not necessary for the localization of Fz2. These results suggest that Wnt5a signaling positions ESCRT-III in the midbody properly for abscission by stabilizing midbody microtubules.

[Identification of resistance and susceptibility to cefotaxime in EHEC O121 strains isolated from an outbreak at two nurseries].

A Shiga toxin 2 producing enterohemorrhagic Escherichia coli (EHEC) O121: H19 was isolated from a 2-year-old child who attending a nursery. An EHEC O121 outbreak in two nurseries (A, B), involving a total of 17 infected persons including 12 children, was revealed through contact investigation. The symptoms of all infected persons were almost all mild, and no one developed the hemolytic uremic syndrome. The combination use of desoxycholate-hydrogen sulfide-lactose (DHL) and CHROMagar STEC as selective isolation media was employed for efficient fecal examination. Nursery A and nursery B were combined as one group after the outbreak in nursery A was confirmed. As a result, EHEC O121 infected persons were also detected in children from nursery B. The 17 strains of EHEC O121 obtained from the total population showed almost the same pulsed-gel electrophoresis (PFGE) pattern, suggesting that these strains were very closely related. However, 13 of these 17 strains obtained from nursery A were susceptible to cefotaxime, whereas the remaining 4 strains obtained from nursery B showed cefotaxime resistance. A cefotaxime resistant Escherichia coli (E. coli) O86 strain was isolated in the stool specimen from a child who had been infected with the cefotaxime resistant EHEC O121. Both the cefotaxime resistant EHEC O121 and E. coli O86 had the same drug resistant gene (bla(CTX-M-1) group). The child was the index case of these 4 later cases and had received no antibiotics therapy prior to the laboratory examination. These findings suggested the possibility that an EHEC O121 strain had acquired a drug resistant gene from E. coli O86 in the digestive tract of the child.

The interplay between Wnt signaling pathways and microtubule dynamics.

Wnt signaling pathways represent an evolutionarily highly conserved, intricate network of molecular interactions that regulates various aspects of cellular behavior, including embryonic development and tissue homeostasis. Wnt signaling pathways share the ß-catenin-dependent (canonical) and the multiple ß-catenin-independent (non-canonical) pathways. These pathways collectively orchestrate a wide range of cellular processes through distinct mechanisms of action. Both the ß-catenin-dependent and ß-catenin-independent pathways are closely intertwined with microtubule dynamics, underscoring the complex crosstalk between Wnt signaling and the cellular cytoskeleton. This interplay involves several mechanisms, including how the components of Wnt signaling can influence the stability, organization, and distribution of microtubules. The modulation of microtubule dynamics by Wnt signaling plays a crucial role in coordinating cellular behaviors and responses to external signals. In this comprehensive review, we discussed the current understanding of how Wnt signaling and microtubule dynamics intersect in various aspects of cellular behavior. This study provides insights into our understanding of these crucial cellular processes.

Radiological complete response with regorafenib for multiple lung metastases of ascending colon cancer: a case report.

BACKGROUND: Regorafenib is an oral diphenylurea multikinase inhibitor and currently approved for use following third-line therapy for metastatic colorectal cancer (CRC) patients. Only one case has previously been reported of metastatic CRC showing a complete response (CR) to regorafenib. CASE PRESENTATION: A 68-year-old Japanese man underwent laparoscopy-assisted ileocecal resection and D3 lymphadenectomy due to his ascending colon cancer. Eighteen months after surgery, a laparoscopic hepatic left lateral segmentectomy was performed due to a liver tumor, and a pathological diagnosis of colorectal liver metastasis was made. Three months after the second surgery, contrast-enhanced computed tomography (CT) revealed multiple lung metastases. The patient had undergone 18 courses of the FOLFOX + bevacizumab chemotherapy regimen as their first-line therapy and 11 courses of the FOLFIRI + ramucirumab chemotherapy regimen as their second-line therapy. As their third-line therapy, the patient was administered the regorafenib chemotherapy regimen. We evaluated the chemotherapy treatment's effect on the lung tumors by CT after 3, 7, 11, and 17 courses of the regorafenib chemotherapy regimen, finding that the lung tumors had shrunk with time; thus, each tumor was considered a partial response (PR) based on the RECIST guidelines. After 21 courses of the regorafenib chemotherapy regimen, the chemotherapy was discontinued in response to the patient's wishes. Even at 1 and 3 months after the discontinuation of the chemotherapy, CT revealed that the lung tumors had shrunk, with each considered a PR. Furthermore, 9 months after the discontinuation of the chemotherapy, CT revealed scarring of the lung tumors. This was considered a CR, rather than a PR. The patient remains disease-free 18 months after the discontinuation of chemotherapy. CONCLUSIONS: In this paper, we present the second case of radiological CR with regorafenib for multiple lung metastases of ascending colon cancer. Currently, there is no consensus on a treatment strategy for patients with radiological CR.

Atypical heat shock transcription factor HSF5 is critical for male meiotic prophase under non-stress conditions.

Meiotic prophase progression is differently regulated in males and females. In males, pachytene transition during meiotic prophase is accompanied by robust alteration in gene expression. However, how gene expression is regulated differently to ensure meiotic prophase completion in males remains elusive. Herein, we identify HSF5 as a male germ cell-specific heat shock transcription factor (HSF) for meiotic prophase progression. Genetic analyzes and single-cell RNA-sequencing demonstrate that HSF5 is essential for progression beyond the pachytene stage under non-stress conditions rather than heat stress. Chromatin binding analysis in vivo and DNA-binding assays in vitro suggest that HSF5 binds to promoters in a subset of genes associated with chromatin organization. HSF5 recognizes a DNA motif different from typical heat shock elements recognized by other canonical HSFs. This study suggests that HSF5 is an atypical HSF that is required for the gene expression program for pachytene transition during meiotic prophase in males.

Abscopal effect with fever of unknown cause during radiotherapy: Two case reports and review of the literature.

The abscopal effect is a rare phenomenon that is defined as regression of tumor lesions distant from irradiation targets. At our department, two cases with an abscopal effect with fever of unknown cause (FUC) and an inflammatory response during radiotherapy were encountered. Radiotherapy is a local treatment; therefore, it rarely causes systemic side effects during radiotherapy, and if a patient develops a fever during radiotherapy, it is frequently considered tumor fever. We experienced 2 cases of FUC during irradiation followed by abscopal effect. The obvious relationship between the abscopal effect and the fever remains to be clarified. However, FUC during radiotherapy may be a hint to the abscopal effect, considering that immune response and cytokines are closely related to the abscopal effect.

Genetic evidence for single-strand lesions initiating Nbs1-dependent homologous recombination in diversification of Ig v in chicken B lymphocytes.

Homologous recombination (HR) is initiated by DNA double-strand breaks (DSB). However, it remains unclear whether single-strand lesions also initiate HR in genomic DNA. Chicken B lymphocytes diversify their Immunoglobulin (Ig) V genes through HR (Ig gene conversion) and non-templated hypermutation. Both types of Ig V diversification are initiated by AID-dependent abasic-site formation. Abasic sites stall replication, resulting in the formation of single-stranded gaps. These gaps can be filled by error-prone DNA polymerases, resulting in hypermutation. However, it is unclear whether these single-strand gaps can also initiate Ig gene conversion without being first converted to DSBs. The Mre11-Rad50-Nbs1 (MRN) complex, which produces 3' single-strand overhangs, promotes the initiation of DSB-induced HR in yeast. We show that a DT40 line expressing only a truncated form of Nbs1 (Nbs1(p70)) exhibits defective HR-dependent DSB repair, and a significant reduction in the rate--though not the fidelity--of Ig gene conversion. Interestingly, this defective gene conversion was restored to wild type levels by overproduction of Escherichia coli SbcB, a 3' to 5' single-strand-specific exonuclease, without affecting DSB repair. Conversely, overexpression of chicken Exo1 increased the efficiency of DSB-induced gene-targeting more than 10-fold, with no effect on Ig gene conversion. These results suggest that Ig gene conversion may be initiated by single-strand gaps rather than by DSBs, and, like SbcB, the MRN complex in DT40 may convert AID-induced lesions into single-strand gaps suitable for triggering HR. In summary, Ig gene conversion and hypermutation may share a common substrate-single-stranded gaps. Genetic analysis of the two types of Ig V diversification in DT40 provides a unique opportunity to gain insight into the molecular mechanisms underlying the filling of gaps that arise as a consequence of replication blocks at abasic sites, by HR and error-prone polymerases.

[Renal tuberculosis in an isthmus of a horseshoe kidney after bacillus Calmette-Guerin therapy for bladder cancer].

A 63-year-old man with a horse shoe kidney was evaluated after an episode of asymptomatic gross hematuria. Cystoscopy revealed bladder tumor near the right ureteral orifice, and transurethral resection demonstrated high grade pT1 urothelial carcinoma. The patient was started on intravesical BCG instillation therapy at a dose of 81 mg weekly for 8 weeks without fever. 6 months later after the final BCG treatment, CT examination demonstrated a renal hypovascular tumor in an isthmus of a horseshoe kidney. We couldn't deny malignant tumor and tumorectomy was performed. Histological examination revealed epithelioid cell granulomas and no organisms were identified by Ziehl-Neelsen or Grocott-Gomori stains for acid-fast bacilli and fungi. We reported a rare case of renal tuberculosis in an isthmus of a horseshoe kidney after BCG therapy for bladder cancer that was considered due to vesicoureteral reflux.

Mobilization of multilineage-differentiating stress-enduring cells into the peripheral blood in liver surgery.

PURPOSE: This study investigated whether liver damage severity relates to the mobilization of multilineage-differentiating stress-enduring (Muse) cells, which are endogenous reparative pluripotent stem cells, into the peripheral blood (PB) and whether the degree of mobilization relates to the recovery of liver volume following human liver surgery. METHODS: Forty-seven patients who underwent liver surgery were included in the present study. PB-Muse cells were counted before surgery, on postoperative days (PODs) 3 and on POD 7. Liver volume was measured using computed tomography before and after surgery. RESULTS: The PB-Muse cell count increased after surgery. The number of PB-Muse cells before surgery was higher, but without statistical significance in the group with neoplasms than in the healthy group that included liver donors (p = 0.065). Forty-seven patients who underwent liver surgery were divided into major hepatic resection (MHR; hepatectomy of three or more segments according to the Couinaud classification, n = 22) and minor hepatic resection (mhr; hepatectomy of two segments or less according to the Couinaud classification, n = 25) groups. PB-Muse cells increased at high rates among MHR patients (p = 0.033). Except for complication cases, PB-Muse cells increased at higher rates in the group with advanced liver volume recovery (p = 0.043). The predictive impact of the rate of increase in PB-Muse cells on the recovery of liver volume was demonstrated by multivariate analysis (OR 11.0, p = 0.014). CONCLUSIONS: PB-Muse cell mobilization correlated with the volume of liver resection, suggesting that the PB-Muse cell number reflects the degree of liver injury. Given that the degree of PB-Muse cell mobilization was related to liver volume recovery, PB-Muse cells were suggested to contribute to liver regeneration, although this mechanism remains unclear.

Single-Port Laparoscopic Duodenojejunostomy Employing Semi-Kocherization for a Young Female with Superior Mesenteric Artery Syndrome.

Single-port laparoscopic duodenojejunostomy employing semi-Kocherization performed for a patient with superior mesenteric artery (SMA) syndrome is presented in this report. A 24-year-old woman missed meals due to work pressure, and her body weight decreased from 42 kg to 27 kg within 6 months. After this severe weight loss, she suffered from postprandial abdominal pain. An enhanced computed tomography revealed that the aortomesenteric angle was 11° (narrow), and the distance was short at 4.5 mm. Duodenography also revealed dilatation of the proximal duodenum. These findings led to a diagnosis of SMA syndrome, and we performed single-port laparoscopic duodenojejunostomy. We first dissected the fusion between the duodenum and transverse mesocolon, such as Kocherization, enough to mobilize the duodenum; this procedure was termed semi-Kocherization. A gauze was placed in the dissected space for a landmark from the transverse mesocolon side. We confirmed the gauze at the duodenum's lateral side, then opened the transverse mesocolon, and pulled the duodenum out. We performed side-to-side duodenojejunostomy. The postoperative course was unremarkable, and she gained 4 kg within 2 months of discharge. Semi-Kocherization is shown to be an effective technique to increase duodenal mobility for performing anastomosis, and single-port laparoscopic surgery can reduce wounds and increase cosmesis.

Map7D2 and Map7D1 facilitate microtubule stabilization through distinct mechanisms in neuronal cells.

Microtubule (MT) dynamics are modulated through the coordinated action of various MT-associated proteins (MAPs). However, the regulatory mechanisms underlying MT dynamics remain unclear. We show that the MAP7 family protein Map7D2 stabilizes MTs to control cell motility and neurite outgrowth. Map7D2 directly bound to MTs through its N-terminal half and stabilized MTs in vitro. Map7D2 localized prominently to the centrosome and partially on MTs in mouse N1-E115 neuronal cells, which expresses two of the four MAP7 family members, Map7D2 and Map7D1. Map7D2 loss decreased the resistance to the MT-destabilizing agent nocodazole without affecting acetylated/detyrosinated stable MTs, suggesting that Map7D2 stabilizes MTs via direct binding. In addition, Map7D2 loss increased the rate of random cell migration and neurite outgrowth, presumably by disturbing the balance between MT stabilization and destabilization. Map7D1 exhibited similar subcellular localization and gene knockdown phenotypes to Map7D2. However, in contrast to Map7D2, Map7D1 was required for the maintenance of acetylated stable MTs. Taken together, our data suggest that Map7D2 and Map7D1 facilitate MT stabilization through distinct mechanisms in cell motility and neurite outgrowth.

A case of pathological complete response with liposomal irinotecan + 5-FU/LV for unresectable locally advanced pancreatic cancer.

BACKGROUND: Pancreatic cancer has one of the worst prognoses of any all cancers. 5-FU/leucovorin + irinotecan + oxaliplatin (FOLFIRINOX), gemcitabine (GEM) plus nab-paclitaxel regimens have been recognized as global-standard, first-line treatments for patients with advanced pancreatic cancer. The liposomal irinotecan (nal-IRI) + 5-FU/LV regimen is now included in treatment guidelines as a recommended and approved option for use in patients with metastatic pancreatic cancer that has progressed after GEM-based therapy and who have a suitable performance status and comorbidity profile. There is no report that nal-IRI + 5-FU/LV regimen was significantly effective, and we will report it because we experienced this time. CASE PRESENTATION: A 69-year-old man presented with epigastric pain, and a contrast computed tomography (CT) revealed an enhanced mass lesion measuring 33 × 27 mm on the pancreatic body with encasement of the common hepatic artery (CHA) and the splenic vein. An endoscopic ultrasound-guided fine needle aspiration was performed and demonstrated cytology consistent with adenocarcinoma. Therefore, we diagnosed the patient with unresectable locally advanced pancreatic cancer. The patient received the GEM and S-1 regimen; however, the adverse event was relatively severe. Then, 11 cycles of nal-IRI + 5-FU/LV regimen were administered. A CT scan revealed that the tumor had shrunk to 18 × 7 mm in diameter with encasement of the CHA. The encasement of the splenic vein had disappeared, without any distant metastases. From this post-chemotherapy evaluation and intraoperative frozen section of around the celiac artery, gastroduodenal artery and pancreas stump confirmed absence of tumor cells, we performed distal pancreatectomy with celiac axis resection. A histological examination of the surgical specimen revealed no evidence of residual adenocarcinoma, consistent with a pathological complete response to treatment. CONCLUSIONS: We present the first case of a pathological complete response with nal-IRI + 5-FU/LV for unresectable, locally advanced pancreatic cancer. In the future, nal-IRI may become a key drug for pancreatic cancer treatment.

Pure Laparoscopic Left Hepatectomy for Regrowth of Mucinous Cystic Neoplasm of the Liver after Laparoscopic Deroofing.

Background: Hepatic cystic lesions are common entities, most of which are simple hepatic cysts (SHCs). Mucinous cystic neoplasm of the liver (MCN-L) is a rare tumor characterized by ovarian-like stroma and accounts for <5% of all hepatic cysts. Distinguishing between SHCs and MCN-L is challenging because of the similarity in their imaging findings. Herein, we report a rare regrowth case of MCN-L after laparoscopic deroofing, treated with pure laparoscopic left hepatectomy. Case Presentation. A 63-year-old woman with a large hepatic cystic lesion and abdominal pain was referred to our hospital for surgical treatment. Computed tomography (CT) showed cystic lesions with septations arising from macrolobulations in the left medial segment. She underwent laparoscopic deroofing based on the diagnosis of SHCs; however, the final histopathological diagnosis was MCN-L. She chose observational follow-up, and MCN-L regrowth was detected on follow-up CT 6 months after the laparoscopic deroofing. We performed pure laparoscopic left hepatectomy for complete resection of the MCN-L. She had an uneventful postoperative course and no recurrence at the 5-year follow-up after the radical resection of the MCN-L. Conclusion: MCN-L is a rare entity, and accurate diagnosis with imaging modalities is greatly challenging. Laparoscopic hepatectomy for MCN-L should be considered as a strong alternative to secure safety and curability.