Clinical characteristics and predictive factors of postoperative intra-abdominal abscess after distal pancreatectomy.

PURPOSE: The postoperative mortality rate of distal pancreatectomy is lower than that of pancreaticoduodenectomy, although persistent complications may occur after distal pancreatectomy. Fluid collection (FC) is frequently observed after distal pancreatectomy; however, FC may occasionally progress to postoperative intra-abdominal abscess (PIAA), which requires conservative or progressive interventional treatment. This study aimed to compare the status between patients with or without PIAA, identify predictive factors for PIAA and clinically relevant postoperative pancreatic fistula, and investigate the clinical characteristics of patients with PIAA with interventional drainage. METHODS: We retrospectively reviewed data of patients who underwent distal pancreatectomy between January 2012 and December 2019 at two high-volume centers, where hepatobiliary-pancreatic surgeries were performed by expert specialist surgeons. Logistic regression analysis was performed to determine the predictive factors for PIAA. RESULTS: Overall, 242 patients were analyzed, among whom 49 (20.2%) had PIAA. The median postoperative period of PIAA formation was 9 (range: 3-49) days. Among the 49 patients with PIAA, 25 (51.0%) underwent percutaneous ultrasound, computed tomography, or endoscopic ultrasound-guided interventions for PIAA. In the univariate analysis, preoperative indices representing abdominal fat mass (i.e., body mass index, subcutaneous fat area, and visceral fat area) were identified as predictive factors for PIAA; in the multivariate analysis, C-reactive protein (CRP) level (continuous variable) on postoperative day (POD) 3 (odds ratio: 1.189, 95.0% confidence interval: 1.111 - 1.274; P < 0.001) was the only independent and significant predictive factor for PIAA. CONCLUSIONS: CRP level on POD 3 was an independent and significant predictive factor for PIAA after distal pancreatectomy.

[A Case of Thoracoscopic Subtotal Esophagectomy for Malignant Esophageal Melanoma].

The patient is a 77-year-old woman presented with a 20 mm infiltrative ulcerative lesion in the lower thoracic esophagus, and histopathological examination revealed malignant esophageal melanoma. Contrast-enhanced computed tomography (CT)revealed a 25-mm mass in the lower thoracic esophagus, which was resectable without obvious invasion of the adjacent organs, enlarged lymph nodes, and distant metastatic findings. The patient underwent video assisted esophagectomy and 2 field lymph nodes dissection. Histopathological examination revealed a primary malignant esophageal melanoma, which was diagnosed as pT1b(SM3)N2M0, pStage Ⅱ. At 2 months postoperatively, contrast-enhanced CT scan showed multiple hepatic and pulmonary metastases, and combination immune-chemotherapy of nivolumab and ipilimumab was initiated. However, the patient's general condition deteriorated rapidly, and palliative care was implemented at 4 months postoperatively. Surgery is currently the initial choice for resectable primary malignant esophageal melanoma; however, a multidisciplinary treatment strategy, including preoperative adjuvant chemotherapy, should be reconstructed.

[A Case of Advanced Gastric Cancer with Pancreatic Invasion Completely Resected after Chemotherapy].

An 80-year-old man with severe anemia was found to have a circumferential type 3 lesion with obstruction in the gastric pylorus during upper gastrointestinal endoscopy. A contrast-enhanced CT scan of the abdomen showed severe invasion of the pancreatic head, and the diagnosis was gastric cancer L, Circ, cType 3, tub2, cT4b, N(+), M0, cStage ⅣA. The patient underwent laparoscopic gastrojejunostomy for gastrointestinal transit obstruction followed by 4 courses of SOX therapy as systemic chemotherapy. After chemotherapy, the invasion to the head of the pancreas was obscured, and pyloric gastrectomy and lymph node dissection were performed. The patient was recurrence-free as of 18 months after surgery. In this case, we performed gastric jejunal bypass surgery followed by chemotherapy with oral anticancer agents to achieve the downstaging of unresectable advanced gastric cancer with pancreatic invasion and pyloric stenosis in patients with poor general condition. As a result, the patient was able to undergo distal gastrectomy, which is one of the recommended multidisciplinary treatments.

[Staging Laparoscopy in the Treatment of Advanced Gastric Cancer].

OBJECTIVE: We examined the applicability and safety of staging laparoscopy(SL)in the treatment of advanced gastric cancer. METHODS: We retrospectively reviewed the gastric cancer cases that were examined using SL between January 2015 and December 2019 at our hospital. RESULTS: Within this period, 59 gastric cancer patients underwent SL, of whom 53 were diagnosed with SL at first examination. The rare complications of SL were postoperative nausea and vomiting(1 case). In 47.5%(28/59)of patients, we observed peritoneal dissemination including positive lavage cytology. In 2 cases, peritoneal dissemination was found during curative resection despite not being detected by SL. Thus, the false negative rate of peritoneal dissemination discovery was 6.7%(2/30). Among the individuals who were diagnosed as P1 or CY1 at first, subsequent SLs were performed in 6 cases, and 5 patients were re-assigned as P0CY0, of whom 4 underwent conversion surgery. CONCLUSIONS: SL is an essential and safe examination method for defining the treatment strategy in advanced gastric cancer. However, further improvements are needed to reduce the false negative discovery rate and to advance gastric cancer treatment by increasing reliability of diagnosis.

Validation Study of Fibrinogen and Albumin Score in Esophageal Cancer Patients Who Underwent Esophagectomy: Multicenter Prospective Cohort Study.

PURPOSE: To arrange multidisciplinary treatment for esophageal cancer, a simple and accurate predictive marker for prognosis is required. The current multicenter prospective study aims to validate the prognostic significance of fibrinogen and albumin score (FA score) for esophageal cancer patients. PATIENTS AND METHODS: Patients who were planned to undergo surgical resection for esophageal cancer at four participating institutions were enrolled in this study. Patient background, clinicopathological factors, and blood concentration of plasma fibrinogen and albumin were collected. Patients with elevated fibrinogen and decreased albumin levels were allocated a score of 2; those with only one of these abnormalities were allocated a score of 1; and those with neither of these abnormalities were allocated a score of 0. Recurrence-free survival (RFS) and overall survival (OS) were evaluated as a primary endpoint. RESULTS: From four participating institutions, 133 patients were registered for the current analysis. The distribution of FA score of 0/1/2 was 84 (63%)/34 (26%)/15 (11%), respectively. In the analysis of primary endpoint, the preoperative FA score significantly classified RFS (FA score 1/2: HR 2.546, p = 0.013/6.989, p < 0.001) and OS (FA score 1/2: HR 2.756, p = 0.010/6.970, p < 0.001). We further evaluated the prognostic significance of FA score under stratification by pStage. As a result, with increasing FA score, RFS and OS were significantly worse in both pStage 0-I and II-IV groups. CONCLUSIONS: The prognostic impact of preoperative FA score was confirmed for esophageal cancer patients in the current multicenter prospective trial. FA score can be considered to predict postoperative survival and rearrange the treatment strategy before esophagectomy.

Frailty is a useful predictive marker of postoperative complications after pancreaticoduodenectomy.

BACKGROUND: Frailty results in a high risk for disability, hospitalization, and mortality. This study aimed to investigate perioperative details of frail patients who underwent pancreatectomy and whether frailty can be a predictive factor of postoperative complications, especially of clinically relevant postoperative pancreatic fistula (CR-POPF). METHODS: This retrospective study included patients who underwent pancreatectomy in our hospital between August 2016 and March 2019. The patients were divided into frail and pre-/non-frail groups. The diagnostic criteria were based on the Japanese version of the Cardiovascular Health Study. RESULTS: Of 93 patients, 11 (11.8%) and 82 (88.2%) were frail and pre-/non-frail patients, with median ages of 82 and 72 years, respectively (p = 0.041). Postoperative complications (Clavien-Dindo ≧ IIIa) were found in 8 and 32 patients (p = 0.034), CR-POPF in 3 and 13 patients (p = 0.346), and postoperative hospital stays were 21 and 17 days (p = 0.041), respectively. On multivariate analysis, frailty was an independent predictive factor (odds ratio [OR] 5.604, 95.0% confidence interval [CI] 1.002-30.734; p = 0.047) of postoperative complications (Clavien-Dindo ≧ IIIa) after pancreaticoduodenectomy. On multivariate analysis, a soft pancreas (OR 5.696, 95.0% CI 1.142-28.149; p = 0.034) was an independent and significant predictive factor of CR-POPF after pancreaticoduodenectomy. CONCLUSIONS: Frailty may be a useful predictive factor of postoperative complications in patients undergoing pancreaticoduodenectomy.

[A Case of DIC Following Mixed Acidosis during Laparoscopic Hepatectomy].

The patient was an 81-year-old man. Laparoscopic sigmoidectomy was performed for a sigmoid colon cancer(S, type 2, pT3[SS], INF a, Ly0, V0, BD1, Pn0, pPM0, pDM0, RM0, pN0, pM0, pStage Ⅲa, R0, Cur A). One year after the surgery, a blood test showed CEA as high as 68.9 ng/mL, and an abdominal enhanced computed tomography revealed a hepatic tumor showing marginal contrast in the 4th liver segment. Positron emission tomography showed an accumulation of SUVmax 19.0 at the same site, and a metastatic liver tumor was diagnosed. A laparoscopic medial hepatectomy was performed. Bleeding from the hepatectomy site increased significantly after completion. Subcutaneous emphysema spreading from the face to the trunk and thigh was observed, and blood tests revealed a pH of 7.172, PaCO2 of 71.0 mmHg, lactate of 67 mg/dL, mixed acidosis, D-dimer of 118 µg/mL, and a disseminated intravascular coagulation(DIC)syndrome was diagnosed. Following the difficulty of hemostasis, the surgery was changed to laparotomy and terminated by gauze packing. We encountered a case of acidosis exacerbated by hypercapnia that progressed to DIC during laparoscopic medial hepatectomy.

The impact of epidural catheter insertion level on pain control after esophagectomy for esophageal cancer.

BACKGROUND: Although the effectiveness of epidural anesthesia on pain control after esophagectomy has been reported, the appropriate insertion level of the epidural catheter remains unclear for adequate postoperative pain control. We investigated the relationship between the epidural catheter insertion level and postoperative pain control after esophagectomy for esophageal cancer. METHODS: We analyzed retrospectively 63 patients who underwent McKeown esophagectomy for esophageal cancer between October 2014 and November 2018. The epidural catheter was inserted at the T4-T10 level before general anesthesia induction, and epidural anesthesia was started during the operation. In the analysis, the epidural catheter insertion level was divided into three groups (over T6/T7, T7/T8, and under T8/T9) and determined. Postoperative pain was evaluated a numeric rating scale (NRS) for at least 7 postoperative days, and the first NRS after extubation was used to evaluate the impact of the epidural catheter insertion level on pain control. RESULTS: Ten patients (15.9%) failed pain control. The χ2 test and a forward stepwise logistic regression analysis revealed that only the epidural catheter insertion level affected pain control (P < 0.05). The T7/T8 insertion level significantly decreased postoperative pain after esophagectomy. In the subgroup analysis, epidural catheter insertion under T8/T9 significantly increased postoperative pain after esophagectomy when thoracoscopy/laparoscopy was assisted. No significant differences were observed in the incidence of postoperative complications among the epidural catheter insertion levels. CONCLUSIONS: The T7/T8 epidural catheter insertion level contributed to postoperative pain relief and could lead to enhanced recovery after esophagectomy for esophageal cancer.

[A Case of Giant Hematogenous Left Quadricep Muscle Metastasis of Hepatocellular Carcinoma].

The patient was a 62-year-old man with no specific medical history. Lateral segmentectomy was performed for hepatocellular carcinoma with a tumor size of approximately 14×13 cm. The histopathological diagnosis was moderately differentiated hepatocellular carcinoma: Fc(-), Fc-Inf(-), Sf(-), S0, N0, Vp2, Vv1, Va0, B0, P0, SM(-), CH. Five years after the first surgery, computed tomography(CT)revealed a left lung tumor in segment 9/10 and left lymph nodes; thus, left pneumonectomy was performed, and these tumors were identified to have metastasized from the primary tumor. Six years after the first surgery, his serum alpha-fetoprotein level was remarkably elevated from 254.9 ng/mL to 3,143.0 ng/mL for three months, and at the same time, he developed left meralgia and swelling of the left femur. Magnetic resonance imaging showed a high-density mass(30×14 cm)in the left quadriceps, and positron emission tomography-CT revealed high uptake in the left quadriceps with a maximum standardized uptake value of 12.3. A needle biopsy of the left femur tumor confirmed metastasis from the primary tumor. Radiotherapy was administered because general anesthesia can prove to be hazardous due to the patient having undergone left pneumonectomy.

A Rare Surgical Case of Giant Jejunal Artery Aneurysm in a Young Patient.

Aneurysms of the abdominal visceral arteries are infrequently encountered. Jejunal artery aneurysm (JAA) is one of the rarest visceral aneurysms, especially in young patients. Endovascular surgery tends to be an effective treatment for visceral artery aneurysms. Here, we report a case of symptomatic JAA with a peripheral dilated vessel in a young patient. However, in consideration of the patient's anatomic suitability and young age, we chose open surgical intervention with intraoperative angiography. Thus, we could resect the aneurysm and the peripheral dilated vessel, preserve the bowel, and leave no devices that could cause further complication. The choice of the most appropriate treatment should depend on aneurysm characteristics and the background of the patient.

Postoperative Delirium in Patients after Pancreaticoduodenectomy.

BACKGROUND/AIMS: Postoperative delirium (POD) is one of the most common complications after various types of surgery. The aim of this study was to investigate the incidence and risk factors for delirium after pancreaticoduodenectomy (PD). METHODS: This was a retrospective study of 146 consecutive patients who underwent PD between April 2007 and June 2015 at Saiseikai Yokohamashi Tobu Hospital. RESULTS: Twenty-nine patients (19.9%) were diagnosed with delirium. Patients who were >70 years were divided into a delirium group (n = 24) and a non-delirium group (n = 41). Multivariate analysis showed that only the Charlson Age Comorbidity Index (CACI) (OR 1.8; 95% CI 1.067-3.036; p = 0.028) was an independent risk factor of delirium for patients >70 years. The receiver operating characteristic curve revealed an optimal cutoff value of 4.5 for the CACI score in all patients (sensitivity 62.1%; specificity 82.9%; area under the curve 0.782). The higher CACI score (≥5) is significantly different from the lower CACI score (p < 0.0001) with respect to POD occurrence. CONCLUSIONS: The CACI, especially in elderly patients, was associated with the incidence of POD. Therefore, utilizing this validated and practical tool preoperatively might be useful for POD.

[Local Control of Advanced Breast Cancer with Mohs Paste and Systemic Therapy].

Unresectable locally advanced breast cancer results in a decline in patient quality of life because of the presence of bleeding, exudates, and strong odor. The clinical application of supportive care using Mohs paste for improving quality of life has become widespread. We report 2 cases of locally advanced breast cancer treated with systemic therapy and chemosurgery. Case 1 was a Japanese woman in her fifties who had a locally advanced left breast cancer. She had continuous bleeding and exudates, and received Mohs chemosurgery and endocrine therapy. One month later, the surface healed and dried up. The bleeding, exudates, and strong odor disappeared almost completely. Case 2 was a Japanese woman in her forties who had a locally advanced left breast cancer with massive exudates and oozing blood. She underwent Mohs chemosurgery 20 times, but the exudates and bleeding were not controlled. According to pathological findings, we confirmed her breast cancer to be of the triple negative subtype. After 2 courses of therapy with 5-fluorouracil, epirubicin, and cyclophosphamide, the tumor immediately decreased in diameter by 65%. The bleeding, exudates, and strong odor disappeared. Although Mohs chemosurgery is useful for local control of locally advanced breast cancer, this alone is insufficient to treat the disease. Early introduction of systemic therapy is considered essential in breast cancer treatment.

Utility of Intraductal Ultrasonography as a Diagnostic Tool in Patients with Early Distal Cholangiocarcinoma.

BACKGROUND/AIMS: It is difficult to diagnose cholangiocarcinoma in the early stages because most patients present with jaundice, which is generally thought to be the most important symptom at diagnosis. Despite improvements to surgical instruments and techniques, these rates are not quite satisfactory. Intraductal ultrasound (IDUS) is easy to handle due to the wire-guided, thin-caliber, and high-frequency probe. The purpose of the present study was to assess the efficacy of IDUS as a diagnostic tool for patients with early distal cholangiocarcinoma. METHODOLOGY: We enrolled 23 with early distal cholangiocarcinoma. The cholangiography and IDUS findings were retrospectively analyzed. The morphology of the tumors detected by IDUS was also classified including localized wall thickening, polypoid lesion, and sessile tumor. RESULTS: The morphologies on IDUS were as follows: five (21.7%) localized wall thickenings, five (21.7%) polypoid lesions, and 13 (56.5%) sessile tumors. CONCLUSIONS: Since forceps biopsy complemented by IDUS can substantially improve the diagnostic rate, pathological investigations should be performed simultaneously after detection by IDUS. We believe that noninvasive modalities should be followed by IDUS and used as a decisive approach to distinguish between benign and malignant status.

[Stereotactic Body Radiotherapy with CyberKnife®for Liver Metastases from Colorectal Cancer].

For treatment of colorectal liver metastases, liver resection is recommended for resectable cases in the clinical guidelines for colorectal cancer. On the other hand, there are currently no data supporting the efficacy of radiation therapy as a topical treatment, and this treatment can therefore not presently be recommended. With CyberKnife®, it is possible to perform stereotactic radiation therapy using a linear accelerator with high accuracy, even for lesions in the trunk area such as liver metastases. Between December 2009 and September 2014 in our hospital, we performed radiation treatment using CyberKnife® for 14 cases with 22 colorectal liver metastases. As a result, we obtained response and local control rates of 76.2%and 81.0%, respectively. Moreover, no advanced adverse events were observed. Thus, we consider that CyberKnife® treatment for colorectal liver metastases is effective as a topical treatment, with low invasiveness and high safety.

[Nanoparticle albumin-bound Paclitaxel for unresectable or recurrent gastric cancer].

The efficacy and safety of nanoparticle albumin-bound paclitaxel(nab-paclitaxel)administered every 3 weeks for unresectable or recurrent gastric cancer was evaluated retrospectively. Nab-paclitaxel was intravenously administered at 260 mg/ m² on day 1 of each 21-day course without anti-allergic premedication until disease progression or discontinuation. Nine patients received nab-paclitaxel. The overall response rate was 11.1%, and the disease control rate was 55.6%. Grade 3/4 toxicities included neutropenia(44.4%), leukopenia(33.3%), and peripheral sensory neuropathy (33.3%). It is important to manage both neutropenia and peripheral neuropathy. Although only few cases were analyzed, therapeutic effect can be obtained even with the starting dose of 180 mg/m² suggesting management of toxicities will be feasible. In view of the toxicities observed, a reduced starting dose of 180 mg/m² should be considered in the case of poor performance status patients. Nab-paclitaxel is a promising drug because of its convenience and may replace weekly paclitaxel for unresectable or recurrent gastric cancer.

[A case of gastric cancer showing response to first-line XP regimen after lymph node recurrence during the administration of S-1 as postoperative adjuvant chemotherapy].

We report on a patient who underwent total gastrectomy with D2 lymph node dissection for metastatic gastric cancer. We administered S-1 at 60 mg/m² as postoperative adjuvant chemotherapy. Six months after surgery, recurrence was detected in the para-aortic lymph node. As a first-line treatment for the recurrent cancer, the patient underwent capecitabine/CDDP therapy(capecitabine 1,800 mg/m², CDDP 60 mg/m²). A significant reduction in the recurrent lymph nodes was observed by CT after 6 months of administration, resulting in 24 months of progression-free survival. S-1/CDDP therapy is recommended as a first-line chemotherapy for recurrent gastric carcinoma in the Japanese gastric cancer treatment guidelines. Likewise, single agent S-1 administration is recommended as postoperative adjuvant chemotherapy for advanced gastric cancer patients. However, in cases of recurrence after S-1 therapy, there is insufficient evidence on the efficacy of S-1/CDDP; thus, the type of administration and time to recurrence could be considered for optimization. We identified a case of gastric cancer showing response to first-line capecitabine/CDDP therapy after lymph node recurrence following the administration of S-1 as postoperative adjuvant chemotherapy. Since capecitabine and S-1 differ in their mechanisms of action and as predictive factors for therapeutic effect, capecitabine may be an efficient option in cases of S-1 failure. The present case suggests that capecitabine/CDDP therapy may be an effective treatment for S-1 pretreated patients with advanced or metastatic gastric cancer.

[A case of metastatic rectal cancer with fulminant hepatitis caused by XELOX therapy].

We report a case of fulminant hepatitis that was caused by XELOX therapy administered for metastatic rectal cancer. A 69- year-old man with metastatic rectal cancer received 4 courses XELOX therapy. He was subsequently admitted to our hospital with general fatigue. Shenzhen flapping and altered consciousness were noticed on the fifth day of hospitalization. A liver biopsy was subsequently performed. The patient was diagnosed with liver failure due to sinusoidal obstruction syndrome caused by oxaliplatin. This case provides valuable information as there are only a few reports of fulminant hepatitis caused by oxaliplatin.

Conversion surgery for gastric remnant cancer with liver metastasis after nivolumab combination chemotherapy achieving pathological complete response: a case report and literature review.

BACKGROUND: Nivolumab combination chemotherapy has recently emerged as a potential first-line treatment for patients with unresectable or metastatic gastric cancer (GC). Further research has indicated that R0 resection by conversion surgery could be an effective treatment strategy to improve overall survival. However, there have been limited reports on the successful application of conversion surgery following combination chemotherapy achieving pathological complete response (pCR) in cases of advanced gastric remnant cancer with liver metastasis. Here, we present a case of long-term survival in a patient who underwent this treatment. CASE PRESENTATION: A 54-year-old man was initially referred to our department for treatment of stage III (cT3N1M0) gastric cancer where he underwent laparoscopic distal gastrectomy and D2 lymph node dissection. After a year of uneventful follow-up, the patient was diagnosed with a tumor in the gastric remnant combined with liver metastasis, resulting in a diagnosis of stage IV (cT3N0M1) gastric remnant cancer. Subsequently, the patient was treated with four cycles of TS-1, Oxaliplatin, and Nivolumab as the first-line regimen. Remarkably, both the remnant tumor and liver metastasis exhibited significant shrinkage, and no new lesions were found. Given this response, conversion surgery was performed to achieve complete resection of the remnant gastric cancer and liver metastasis, followed by laparoscopic remnant gastrectomy and partial hepatectomy. Pathological examination revealed the absence of residual carcinoma cells and lymph node metastases. Postoperatively, the patient was treated with adjuvant chemotherapy with S-1 for 1 year, and survived without recurrence for 18 months after conversion surgery. CONCLUSIONS: Nivolumab combination chemotherapy shows promise as a clinically beneficial treatment approach for gastric remnant cancer with liver metastasis, particularly when pCR can be achieved following conversion surgery.

Clinicopathological features of early distal cholangiocarcinoma.

BACKGROUND/AIM: The purpose of this study was to evaluate the clinicopathological features of early distal cholangiocarcinoma compared with advanced tumors. METHODOLOGY: This was a retrospective study of 45 patients who underwent resection for distal cholangiocarcinoma. There were 17 cases of early and 28 cases of advanced tumors. Data on demographic and clinical features, surgical procedures, and pathological diagnoses were collected retrospectively. RESULTS: Preoperative mean serum levels of bilirubin, alkaline phosphatase, and gamma-glutamyltransferase were statistically different between the early and advanced groups. There were no significant differences in the diameter of the common hepatic duct between groups, and there were significant differences in all tests but intraductal ultrasonography (IDUS) in tumor detection, meaning that IDUS is a very useful modality for detecting early and advanced cancer although early cancer is difficult to detect using other modalities. CONCLUSIONS: We believe that early cancer detection will generally lead to better prognosis. Further studies are needed, and efforts should continue to identify patients with suspicious findings.