Prognostic Impact of Budding Grade in Patients With Residual Liver Recurrence of Colorectal Cancer After Initial Hepatectomy.

BACKGROUND: Many patients undergoing hepatectomy for colorectal liver metastases (CRLM) experience recurrence. However, no criteria for screening candidates to undergo repeat hepatectomy (RH) for CRLM have been established. Budding, one form by which colorectal carcinoma malignancies are expressed, is a new pathologic index. This study aimed to analyze prognostic factors, including budding, and to provide criteria for screening candidates to undergo RH for recurrent CRLM. METHODS: Data of 186 consecutive patients who underwent hepatectomy for CRLM between April 2008 and December 2015 were collected. Survival was calculated using the Kaplan-Meier method. Uni- and multivariate analyses were performed to determine factors significantly affecting mortality. RESULTS: Of 186 patients, 131 experienced recurrence after hepatectomy, with 83 of the 131 patients showing recurrence in the liver, and 52 of these 83 patients undergoing primary surgery at the authors' institution and having information on budding grade. In the univariate analysis, preoperative chemotherapy, budding grade, extrahepatic metastases, and number of liver metastases at the time of recurrence were associated with overall survival (OS) for the 52 patients. In the multivariate analysis, budding grade and number of liver metastases at the time of recurrence were associated with OS. CONCLUSION: The study examined simple prognostic factors that could help to screen patients better for RH. Repeat hepatectomy improved the prognosis for patients with recurrent CRLM. The independent prognostic factors for OS were number of liver metastases at recurrence as a conventional factor and budding grade as a new pathologic factor. With budding used as an index, patients who could benefit from hepatectomy can be screened more precisely.

Stapler sizes optimized for pancreatic thickness can reduce pancreatic fistula incidence after distal pancreatectomy.

PURPOSE: The purpose of this paper was to identify the optimum-sized stapler cartridges for reducing the incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP). METHODS: The authors retrospectively analyzed 101 patients who underwent DP with a triple-row stapler to identify the clinicopathological factors that strongly influence POPF after DP. The height difference (HD) was defined as the difference between the pancreatic thickness and the height of the closed stapler. RESULTS: POPF occurred in 58 (57%) patients. A multivariate analysis identified HD and pancreatic thickness as independent risk factors for the occurrence of POPF after DP. Akaike's information criterion for identifying the risk factors was more favorable for HD (115.18) than for pancreatic thickness (118.02). The incidence of POPF was significantly lower (29%) in patients with an HD between 6 and 12 mm than in the other two groups (< 6-mm group: 100%, P = 0.008; ≥ 12-mm group: 84%, P < 0.001). CONCLUSIONS: A too-thick or too-narrow pancreas carries a risk of developing POPF after DP when using a triple-row stapler. Selecting staplers to achieve an HD of 6-12 mm may reduce the incidence of POPF following DP.

Laparoscopic fenestration for a large ruptured splenic cyst combined with an elevated serum carbohydrate antigen 19-9 level: a case report.

BACKGROUND: Non-parasitic splenic cysts are associated with elevated serum carbohydrate antigen (CA) 19-9 levels. We report a case in which a 23-year-old female exhibited a large ruptured splenic cyst and an elevated serum CA19-9 level. CASE PRESENTATION: The patient, who experienced postprandial abdominal pain and vomiting, was transferred to our hospital and was found to have a large splenic cyst during an abdominal computed tomography (CT) scan. On physical examination, her vital signs were stable, and she demonstrated rebound tenderness in the epigastric region. An abdominal CT scan revealed abdominal fluid and a low-density region (12 × 12 × 8 cm) with enhanced margins in the spleen. The patient's serum levels of CA19-9 and CA125 were elevated to 17,580 U/mL and 909 U/mL, respectively. A cytological examination of the ascitic fluid resulted in it being categorized as class II. Finally, we made a diagnosis of a ruptured splenic epidermoid cyst and performed laparoscopic splenic fenestration. The patient's postoperative course was uneventful, and she was discharged on postoperative day 5. The cystic lesion was histopathologically diagnosed as a true cyst, and the epithelial cells were positive for CA19-9. Follow-up laboratory tests performed at 4 postoperative months showed normal CA19-9 (24.6 U/L) and CA125 (26.8 U/L) levels. No recurrence of the splenic cyst was detected during the 6 months after surgery. CONCLUSION: Laparoscopic fenestration of a ruptured splenic cyst was performed to preserve the spleen, after the results of abdominal fluid cytology and MRI were negative for malignancy.

Prognostic Value of Preoperative Systemic Immunoinflammatory Measures in Patients with Esophageal Cancer.

BACKGROUND: It is reported that several systemic immunoinflammatory measures, including systemic immune-inflammatory index (SII), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio, and C-reactive protein (CRP)-to-albumin ratio (CAR), are associated with survival in patients with various types of cancer. OBJECTIVE: The aim of the present study was to clear which systemic immunoinflammatory measures had the greatest prognostic values. In addition, we examined which component had the greatest prognostic power in patients with esophageal cancer. METHODS: Preoperative systemic immunoinflammatory measures were evaluated in 143 patients undergoing esophageal resection for esophageal cancer from 2009 to 2014. Univariate and multivariate analyses were performed to determine the prognostic significance of these markers. Receiver operating characteristic (ROC) curves were plotted, and the area under the ROC curves (AUROCs) were compared to verify the accuracy of each measure in predicting overall survival (OS). RESULTS: In univariate analysis, preoperative SII, NLR, and CAR were the predictors of OS in patients who underwent esophagectomy for esophageal cancer (p < 0.05, respectively), whereas in multivariate analysis, CAR and pathological tumor depth were the significant predictors of OS (hazard ratio [HR] 1.994, p = 0.03 vs. HR 1.967, p = 0.02, respectively). According to AUROC, the CRP (0.66) and albumin levels (0.66) were more important systemic immunoinflammatory measures than neutrophil (0.58), lymphocyte (0.63), and platelet (0.56) levels. CONCLUSION: Among systemic immunoinflammatory measures, CAR was the most significant predictor of OS in patients with esophageal cancer. CRP and albumin levels were more important components of systemic immunoinflammatory measures.

Impact of angiotensin-converting enzyme 2 levels on postoperative pneumonia after esophagectomy.

BACKGROUND: Pulmonary complications after esophagectomy are often fatal. The prediction of postoperative pulmonary complications remains a challenge. Accumulating evidence demonstrates a physiological and pathological role for angiotensin-converting enzyme 2 (ACE2) in the respiratory system. The purpose of this study was to evaluate the predictive value of ACE2 levels for the development of postoperative pneumonia. METHODS: To evaluate the association between serum ACE2 levels and pneumonia after esophagectomy, we retrospectively reviewed the medical records of 80 patients who underwent thoracoscopic esophagectomy for esophageal cancer from 2009 to 2014. RESULTS: Nineteen patients (23.8%) developed pneumonia after esophagectomy. Patients with pneumonia had significantly higher levels of ACE2 from the preoperative day to postoperative day (POD) 3, white blood cell count (POD7), and C-reactive protein (POD3, POD5, and POD7) than patients without pneumonia. Patients with postoperative pneumonia had higher serum ACE2 levels on POD3 than patients without pneumonia. CONCLUSIONS: The elevation of ACE2 levels on POD3 may predict the incidence of pneumonia.

Vitamin A-coupled liposome system targeting free cholesterol accumulation in hepatic stellate cells offers a beneficial therapeutic strategy for liver fibrosis.

AIM: Liver fibrosis is a life-threatening disorder for which no approved therapy is available. Recently, we reported that mouse hepatic stellate cell (HSC) activation increased free cholesterol (FC) accumulation, partly by enhancing signaling through sterol regulatory element-binding protein 2 (SREBP2) and microRNA-33a (miR-33a), which resulted in HSC sensitization to transforming growth factor-ß (TGFß)-induced activation in a "vicious cycle" of liver fibrosis. METHODS: Human HSCs were isolated from surgical liver specimens from control patients and patients with liver fibrosis. C57BL/6 mice were treated with carbon tetrachloride for 4 weeks and concurrently given SREBP2-siRNA- or anti-miR-33a-bearing vitamin A-coupled liposomes. RESULTS: In human activated HSCs obtained from patients with liver fibrosis, FC accumulation was enhanced independently of serum cholesterol levels through increased signaling by both SREBP2 and miR-33a. This increased FC accumulation enhanced Toll-like receptor 4 (TLR4) protein levels and lowered the TGFß-pseudoreceptor Bambi (bone morphogenetic protein and activin membrane-bound inhibitor) mRNA levels in HSCs. Notably, in a mouse liver fibrosis model, reduction of FC accumulation, specifically in activated HSCs by suppression of SREBP2 or miR-33a expression using SREBP2-siRNA- or anti-miR-33a-bearing vitamin A-coupled liposomes, downregulated TLR4 signaling, increased Bambi expression, and consequently ameliorated liver fibrosis. CONCLUSIONS: Our results suggest that FC accumulation in HSCs, as an intracellular mediator promoting HSC activation, contributes to a vicious cycle of HSC activation in human and mouse liver fibrosis independent of serum cholesterol levels. Targeting FC accumulation-related molecules in HSCs through a vitamin A-coupled liposomal system represents a favorable therapeutic strategy for liver fibrosis.

The impact of postoperative adjuvant chemotherapy on the development of nonalcoholic fatty liver disease after pancreatoduodenectomy.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) after pancreatoduodenectomy (PD) is increasingly being recognized as a late postoperative complication, but the main causes have not been fully investigated. This study aimed to clarify the relationship between NAFLD after PD and postoperative adjuvant chemotherapy, focusing particularly on the adjuvant chemotherapy regimens administered. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 154 patients who underwent PD from April 2007 to December 2013, to identify the clinicopathologic factors most strongly influencing NAFLD development after PD. Moreover, the postoperative adjuvant chemotherapeutic regimen and the course after the cessation of adjuvant chemotherapy were examined in detail. RESULTS: The incidence of postoperative NAFLD was 26.6% (41/154). The incidence of NAFLD was significantly higher in the patients with than in those without adjuvant chemotherapy: 38% versus 19% (P = 0.016). Multivariate analysis identified postoperative adjuvant chemotherapy (P = 0.021) and remnant pancreatic volume (P < 0.0001) as independent risk factors. The prevalence of NAFLD after PD was higher in patients treated with the S-1 regimen than in those given either regimens such as those containing gemcitabine or no adjuvant chemotherapy. Recovery from NAFLD 1 y after the cessation of adjuvant chemotherapy was observed in 54.5% (12/22) of patients receiving this treatment. In those treated with the S-1 regimen, improvement was more frequent than in those not receiving adjuvant chemotherapy (57.1% versus 11.8%, P = 0.018). CONCLUSIONS: Considering the development of NAFLD, adjuvant chemotherapy after PD should be cared for the patients with small remnant pancreas.

In vivo evaluation of a modified linear stapling device designed to facilitate accurate pathologic examination of the surgical margin.

BACKGROUND: Microscopic involvement of the resection margin could influence the long-term outcome of patients undergoing curative surgery for gastric cancer. Linear staplers, commonly used for gastrectomies, are often equipped with three lines of staples on either side of the resection line. Although multiple lines of staples reinforce closure of the gastric or intestinal stump, they could hinder accurate histopathologic evaluation of the surgical margin of the resected specimen. METHODS: We modified a linear stapling device by removing one line (stapler E2) or two lines (stapler E1) of staples on the specimen side, and attempted to dissect a silicon film and then the stomach from a porcine model using the stapling device and examined the distances between the cutting edge and the nearest staple line. RESULTS: The distance between the cutting edge and the staple line for stapler E1 was significantly greater than the distance between the cutting edge and the nearest staple line for stapler E2 or the control device. Consequently, specimens of exemplary quality were available for pathologic examination of the surgical margin. Moreover, the lack of multiple layers of staples did not result in contamination of the abdominal cavity with gastric juice during laparoscopic procedures in the porcine model. CONCLUSIONS: Stapler E1 is safe and could be useful for the pathologic evaluation of the true surgical margin.

Acyl-CoA:cholesterol acyltransferase 1 mediates liver fibrosis by regulating free cholesterol accumulation in hepatic stellate cells.

BACKGROUND & AIMS: Acyl-coenzyme A: cholesterol acyltransferase (ACAT) catalyzes the conversion of free cholesterol (FC) to cholesterol ester, which prevents excess accumulation of FC. We recently found that FC accumulation in hepatic stellate cells (HSCs) plays a role in progression of liver fibrosis, but the effect of ACAT1 on liver fibrosis has not been clarified. In this study, we aimed to define the role of ACAT1 in the pathogenesis of liver fibrosis. METHODS: ACAT1-deficient and wild-type mice, or Toll-like receptor 4 (TLR4)(-/-)ACAT1(+/+) and TLR4(-/-)ACAT1(-/-) mice were subjected to bile duct ligation (BDL) for 3 weeks or were given carbon tetrachloride (CCl4) for 4 weeks to induce liver fibrosis. RESULTS: ACAT1 was the major isozyme in mice and human primary HSCs, and ACAT2 was the major isozyme in mouse primary hepatocytes and Kupffer cells. ACAT1 deficiency significantly exaggerated liver fibrosis in the mouse models of liver fibrosis, without affecting the degree of hepatocellular injury or liver inflammation, including hepatocyte apoptosis or Kupffer cell activation. ACAT1 deficiency significantly increased FC levels in HSCs, augmenting TLR4 protein and downregulating expression of transforming growth factor-ß (TGFß) pseudoreceptor Bambi (bone morphogenetic protein and activin membrane-bound inhibitor), leading to sensitization of HSCs to TGFß activation. Exacerbation of liver fibrosis by ACAT1 deficiency was dependent on FC accumulation-induced enhancement of TLR4 signaling. CONCLUSIONS: ACAT1 deficiency exaggerates liver fibrosis mainly through enhanced FC accumulation in HSCs. Regulation of ACAT1 activities in HSCs could be a target for treatment of liver fibrosis.

Multifocal lesions with pancreatic atrophy in IgG4-related autoimmune pancreatitis: report of a case.

We herein report a case of IgG4-related autoimmune pancreatitis (AIP). A 72-year-old male with jaundice visited our hospital complaining of epigastralgia. A blood chemistry analysis revealed elevated serum levels of total bilirubin and DUPAN-II. Computed tomography (CT) revealed irregularly shaped pancreatic masses with a stricture of the main pancreatic duct (MPD) in the head and tail that were interposed by marked atrophy with MPD dilation in the body. F-18 fluorodeoxyglucose (FDG)-positron emission tomography/CT revealed abnormally intense FDG uptake only at the masses. During surgery, another small tumor was also found in the atrophied body; therefore, a total pancreatectomy was performed under the diagnosis of multiple pancreatic cancers. The histological analysis revealed fibrosis with dense and diffuse infiltrations of lymphocytes and IgG4-positive plasma cells. The pancreatic parenchyma of the body was firmly replaced by fibrosis. AIP can lead to the formation of multiple pancreatic lesions, and thus the correct diagnosis is occasionally difficult to establish in atypical cases.

[Risk factors and prevention of surgical site infection for colorectal surgery].

Surgical site infection (SSI), the most frequent adverse event after colorectal surgery, leads to longer hospital days and increased healthcare costs. The development of SSI depends on a complex interplay between patient-related and procedure-related factors. This review refers to the several risk factors for the development of SSI and the risk factor index which were indicated by National Nosocomial Infections Surveillance. Furthermore, this review will focus on the prevention of SSI and refer to colon preparation and preventive antibiotics for colorectal surgery.

Predictive value of pleural and serum interleukin-6 levels for pneumonia and hypo-oxygenations after esophagectomy.

OBJECTIVE: Pulmonary complications after esophagectomy continue to be a significant cause of morbidity and mortality. Although several factors have been implicated to be associated with pulmonary complications after esophagectomy, the prediction of pulmonary complications remains a challenge. The purpose of this study was to evaluate the predictive value of cytokine levels in sera and pleural drainage fluid for pneumonia and hypo-oxygenations following esophagectomy. METHODS: A total of 66 patients who underwent esophagectomy for esophageal cancer were retrospectively evaluated for preoperative status, surgical procedures, and postoperative systemic response and laboratory data up to postoperative day (POD) 7. Interleukin-6 (IL-6) and IL-8 levels were also examined in patient sera and pleural drainage fluid until POD 5. RESULTS: Eighteen patients (27.3%) had pneumonia following esophagectomy. Patients with pneumonia had significantly more frequent intraoperative blood transfusions, more frequent re-intubation, longer hospital stays, and higher hospital mortality than those without pulmonary complications. Patients with pneumonia had significantly higher levels of serum and pleural IL-6 immediately after surgery and on POD 1 than those without pneumonia. Univariate and multivariate analyses revealed higher pleural IL-6 levels were associated with postoperative minimum PaO2/FiO2 ratio. CONCLUSIONS: The elevation of pleural IL-6 levels immediately after surgery and on POD 1 may predict the incidence of pneumonia and the levels of postoperative impaired oxygenation following esophagectomy.

Prognosis of Pancreatic Cancer Based on Resectability: A Single Center Experience.

Although conversion surgery has increasingly been performed for initially unresectable advanced pancreatic ductal adenocarcinoma (PDAC), the rate of conversion, including that for patients who do not undergo resection, remains unclear. Patients with PDAC who were treated between January 2013 and December 2018 were classified into three groups: resectable (R), borderline resectable (BR), and unresectable (UR). We analyzed patient outcomes, including the rate of surgical resection and survival, in each of these groups. In total, 211 patients (R, 118; BR, 22; UR, 81) were selected. Among them, 117 (99%), 18 (82%), and 15 (19%) patients in the R, BR, and UR groups, respectively, underwent surgical resection. R0 resection rates were 88, 78, and 67%, whereas median overall survival (OS) from treatment initiation were 31, 18, and 11 months (p < 0.0001) in the R, BR, and UR groups, respectively. In patients who underwent surgical resection, relapse-free survival (RFS) and OS were similar among the three groups (R vs. BR vs. UR; median RFS (months), 17 vs. 13 vs. 11, p = 0.249; median OS (months), 31 vs. 26 vs. 32, p = 0.742). Lymph node metastases and incomplete adjuvant chemotherapy were identified as independent prognostic factors for OS. Although the surgical resection rate was low, particularly in the BR and UR groups, the prognosis of patients who underwent surgical resection was similar irrespective of the initial resectability status.

Outcome of overlap anastomosis using a linear stapler after laparoscopic total and proximal gastrectomy.

BACKGROUND: Recently, novel intracorporeal esophagojejunostomy using a linear stapler after laparoscopic total gastrectomy (LTG) was reported and termed as the overlap method. In this study, we evaluated the feasibility and safety of the overlap method for esophagojejunostomy or esophagogastrostomy after LTG or laparoscopic proximal gastrectomy (LPG), respectively. METHODS: Twenty-five patients underwent anastomosis using a linear stapler during esophagojejunostomy and esophagogastrostomy after LTG and LPG, respectively. Clinicopathological data and surgical outcomes were evaluated. RESULTS: The average surgical duration for LTG was 236.8 min compared with 224.1 min for LPG. Postoperative complications were observed in four patients (16.0%); these included a wound infection, an intestinal obstruction, an afferent loop syndrome, and a reflux symptom. The average postoperative hospital stay of the patients was 12.5 days. There was no case of conversion to open surgery, anastomotic leakage or stenosis, or mortality. CONCLUSIONS: The overlap method for esophagojejunostomy or esophagogastrostomy after LTG or LPG is safe and feasible and does not require an additional minilaparotomy, which may result in less pain and favorable cosmetic outcomes.

Importance of maintaining left gastric arterial flow at Appleby operation preserving whole stomach for central pancreatic cancer.

The safety of whole stomach-preserving Appleby operation with resection of the left gastric artery (LGA) for pancreatic cancer cannot be assured. The anatomy of the celiac axis (CA) with special regard to the position of the origin of the LGA was examined. Using 3D images of the vascular architecture reconstructed from volume data of helical CT, the length of the CA and the position of the origin of the LGA from the CA were measured in 53 patients. Among 53 patients, 47 patients (89%) had classical anatomy of the CA branches. The mean length(2 standard deviation) of the CA and the distance from the root of the LGA to the bifurcation of the CA were 25.2mm (-4.9) (range 14.6-36.5) and 10.3mm (+4.5)(range 2.4-21.9), respectively. In 23 (45%) cases, the LGA arose farther than 10mm away from the bifurcation of the CA. Among six patients with anatomical variation of the arteries, two (4%) had the LGA directly arising from the aorta. Conservation of the LGA at modified Appleby operation would give complete cancer removal by en bloc resection of the nerve plexus, without risk of ischemic complications of the stomach and liver.

Primary Tumor Histology Affects Oncological Outcomes Independently of the Anatomical Extent of Disease in Colorectal Liver Metastasis.

INTRODUCTION: Growing evidence indicates the prognostic importance of the crosstalk between cancer cells and stroma through the induction of epithelial-mesenchymal transition (EMT). This study aimed to clarify the prognostic value of evaluating primary tumor histology with the anatomical extent of disease in patients with colorectal liver metastasis (CRLM). METHODS: Prognostic analyses were performed in 411 CRLM patients who underwent hepatectomy at two institutions. Tumors were graded into one of three histological categories based on integrated assessment of EMT-associated histology (HistologyEMT) in primary tumors, i.e., poorly differentiated clusters (PDCs) and desmoplastic reaction (DR). RESULTS: A prognostic grouping system for the anatomical extent of disease (N stage, liver metastasis number and size, and extrahepatic disease; Gradeanatomical) stratified patients into three groups with different five-year relapse-free survival (RFS) rates after hepatectomy: A, 31% (191 patients); B, 15% (124 patients); and C, 6% (96 patients; P < 0.0001). HistologyEMT (A, G1 PDC and mature-type DR; C, G3 PDC and immature-type DR; and B, others) identified 49, 120, and 242 patients with 46%, 5%, and 22% five-year RFS, respectively (P < 0.0001). Among prognostic factors, the Akaike information criterion was most favorable in Gradeanatomical, followed by HistologyEMT. Multivariate analysis demonstrated that these two factors independently impacted RFS; two-year RFS after hepatectomy in different patient groups had a wide range (10%-76%). CONCLUSIONS: Histological assessment of dedifferentiation and the stromal environment of primary tumors contributed to effective risk stratification of early relapse after hepatectomy, which could be useful to determine clinical management for CRLM patients.

Prognostic significance of regional lymph node metastasis according to station in ampullary carcinoma.

BACKGROUND: The TNM (Tumor, Node, Metastasis) classification of the 8th Union for International Cancer Control and the 6th Japanese classification of biliary tract cancer were made on the premise that the prognostic effect of each regional lymph node station is similar. However, some studies have reported different effects of lymph node metastasis location on post-resection prognosis. This study aimed to investigate outcome following radical resection of ampullary carcinoma according to station of lymph node metastasis. METHODS: Patients who underwent surgical resection for ampullary carcinoma between January 2007 and December 2017 at two separate Japanese institutions were included. Regional lymph nodes were subclassified as follows: Pancreatoduodenal lymph nodes (PD) and others (OT). RESULTS: Of the 101 patients analyzed, 34 had regional lymph node metastasis. OT metastasis was found in eight patients. Significant differences were found in relapse-free survival (RFS) and overall survival (OS) between the three study groups (no nodal metastasis, only PD metastasis and OT metastasis; P < .001 for both). OT metastasis was an independent prognostic factor in the multivariate analysis for RFS (hazard ratio [HR] 17.14; 95% confidence interval [CI], 6.33-43.93) and OS (HR 11.06; 95% CI, 3.7-32.99). CONCLUSION: The poor prognosis of ampullary carcinoma patients with OT metastasis suggests that regional lymph nodes should not be categorized equally into one group.

A patient with a pancreatic neuroendocrine tumor and multiple liver metastases achieved a long-term partial response to third-line streptozocin treatment.

The Japanese guideline for gastroenteropancreatic neuroendocrine tumor treatment recommends everolimus or sunitinib as first-line treatment for unresectable pancreatic neuroendocrine tumors (PNETs). Streptozocin (STZ) is recommended as an alternative. We encountered a patient with PNET who had multiple liver metastases and who showed a remarkable response to third-line STZ. The patient was a 50-year-old man with a pancreatic head tumor 32 mm in diameter. We planned to perform subtotal stomach-preserving pancreaticoduodenectomy, but abandoned resecting the pancreas during the surgery upon discovering a small liver tumor 3 mm in diameter, examination of frozen sections of which revealed a poorly differentiated adenocarcinoma. However, the final pathological examination revealed that the liver nodule was a PNET; hence, we completed the subtotal stomach-preserving pancreaticoduodenectomy 5 weeks after the first laparotomy. The patient received no adjuvant chemotherapy after surgery. Twenty-one months later, we discovered 20 scattered liver metastases via computed tomography; these were considered unresectable. Therefore, we administered everolimus for 7 months, but the patient developed interstitial pneumonia and experienced metastatic progression. Subsequent sunitinib administration for 6 months was ineffective. Finally, we chose STZ (1000 mg/m2, weekly) as a third-line treatment, which produced a partial response for 10 months. The patient remains alive 38 months after the detection of recurrence. As the order in which anti-cancer drugs should be administered to treat PNET has not been determined, additional predictors of their therapeutic efficacy should be investigated.

Restoration of Dehiscent Pancreaticojejunostomy Causing a Major Postoperative Pancreatic Fistula by Reinsertion of a Pancreatic Duct Tube Using the Rendezvous Technique.

INTRODUCTION: A postoperative clinically relevant pancreatic fistula can cause severe sequelae. We aimed to describe our minimally invasive procedure (rendezvous technique) for the treatment of a pancreatic fistula resulting from pancreaticojejunal anastomosis dehiscence involving a dislodged main pancreatic duct tube. METHODS: In our rendezvous technique, a guidewire is advanced into the jejunal lumen from the access site of the drainage tube and is caught by a snare catheter, which is used to replace the dislodged main pancreatic duct tube. Then, the guidewire is passed from the access site of the drainage tube to the site of the dislodged main pancreatic duct tube. A sheath is inserted along the route of the dislodged main pancreatic duct tube and is placed across the pancreaticojejunal anastomosis over the guidewire. Another guidewire is advanced into the main pancreatic duct via the sheath, and a new main pancreatic duct tube is inserted into the main pancreatic duct over the second wire. This technique was performed in two patients with a pancreatic fistula. RESULTS: Our rendezvous technique was successfully performed in a 73-year-old man with an intractable clinically relevant pancreatic fistula and large discharge from the drain and a 74-year-old woman with a pancreatic fistula and fluid collection between the elevated jejunum and remnant pancreas. Discharge from the drain and fluid collection decreased after the procedure. CONCLUSION: Our rendezvous technique is an effective minimally invasive approach for a pancreatic fistula resulting from pancreaticojejunal anastomosis dehiscence.

Prognostic significance of histological categorization of desmoplastic reaction in colorectal liver metastases.

Desmoplastic reaction (DR) involves the growth of fibrous or connective tissues around a tumor and has recently attracted attention as an indicator of malignant potential. Previous studies have confirmed that histological categorization of DR in the primary tumor is an independent prognostic factor in patients with colorectal liver metastases (CRLM). However, it remains unclear whether the DR status of the metastatic liver lesion (DRliver) is a useful prognostic factor. This pathological review evaluated records from 204 patients who underwent hepatectomy for CRLM at the National Defense Medical College Hospital in Japan. Each case's DRliver was classified as mature, intermediate, or immature based on the presence of keloid-like collagen and myxoid stroma in the metastatic liver lesion. This resulted in 12 cases of mature DRliver, 101 cases of intermediate DRliver, and 91 cases of immature DRliver. There was a significant correlation between the DR statuses of the primary tumor and the metastatic liver lesion (Spearman's rho = 0.3, P = 0.0001). The 5-year relapse-free survival rates after hepatectomy were 33.8% for mature/intermediate DRliver and 16.7% for immature DRliver (P = 0.0021). The 5-year overall survival rate after hepatectomy was higher in the mature/intermediate DRliver group (64.8%) than in the immature DRliver group (35.0%; P = 0.0012). The multivariate analysis confirmed that DRliver categorization could independently predict relapse-free survival and overall survival. In conclusion, DRliver categorization may be valuable for predicting prognosis after hepatectomy among patients with CRLM.