Osteosarcopenia: the coexistence of sarcopenia and osteopenia is predictive of prognosis and postoperative complications after curative resection for colorectal cancer.

PURPOSE: To establish if osteosarcopenia is related to postoperative complications, prognosis, and recurrence of colorectal cancer (CRC) after curative surgery. METHODS: The clinical data of 594 patients who underwent curative resection for CRC between January, 2013 and December, 2018 were analyzed retrospectively to examine the relationship between clinicopathological data and osteosarcopenia. The following definitions were used: sarcopenia, low skeletal muscle mass index; osteopenia, low bone mineral density on computed tomography at the level of the 11th thoracic vertebra; and osteosarcopenia, sarcopenia with osteopenia. RESULTS: Osteosarcopenia was identified in 98 patients (16.5%) and found to be a significant risk factor for postoperative complications (odds ratio 2.53; p = 0.011). The 5-year overall survival (OS) and recurrence-free survival (RFS) rates of the patients with osteosarcopenia were significantly lower than those of the patients without osteosarcopenia (OS: 72.5% and 93.9%, respectively, p < 0.0001; RFS: 70.8% and 92.4%, respectively, p < 0.0001). Multivariate analysis identified osteosarcopenia as an independent prognostic factor associated with OS (hazard ratio 3.31; p < 0.0001) and RFS (hazard ratio 3.67; p < 0.0001). CONCLUSION: Osteosarcopenia may serve as a predictor of postoperative complications and prognosis after curative surgery for CRC.

Simple pelvimetry predicts the pelvic manipulation time in robot-assisted low and ultra-low anterior resection for rectal cancer.

PURPOSE: This study explored the difficulty factors in robot-assisted low and ultra-low anterior resection, focusing on simple measurements of the pelvic anatomy. METHODS: This was a retrospective analysis of the clinical data of 61 patients who underwent robot-assisted low and ultra-low anterior resection for rectal cancer between October 2018 and April 2023. The relationship between the operative time in the pelvic phase and clinicopathological data, especially pelvic anatomical parameters measured on X-ray and computed tomography (CT), was evaluated. The operative time in the pelvic phase was defined as the time between mobilization from the sacral promontory and rectal resection. RESULTS: Robot-assisted low and ultra-low anterior resections were performed in 32 and 29 patients, respectively. The median operative time in the pelvic phase was 126 (range, 31-332) min. A multiple linear regression analysis showed that a short distance from the anal verge to the lower edge of the cancer, a narrow area comprising the iliopectineal line, short anteroposterior and transverse pelvic diameters, and a small angle of the pelvic mesorectum were associated with a prolonged operative time in the pelvic phase. CONCLUSION: Simple pelvic anatomical measurements using abdominal radiography and CT may predict the pelvic manipulation time in robot-assisted surgery for rectal cancer.

Retrospective analysis of risk factors for postoperative perineal hernia after endoscopic abdominoperineal excision for rectal cancer.

BACKGROUND: In contrast to open-surgery abdominoperineal excision (APE) for rectal cancer, postoperative perineal hernia (PPH) is reported to increase after extralevator APE and endoscopic surgery. In this study, therefore, we aimed to determine the risk factors for PPH after endoscopic APE. METHODS: A total 73 patients who underwent endoscopic APE for rectal cancer were collected from January 2009 to March 2020, and the risk factors for PPH were analyzed retrospectively. RESULTS: Nineteen patients (26%) developed PPH after endoscopic APE, and the diagnosis of PPH was made at 9-393 days (median: 183 days) after initial surgery. Logistic regression analysis showed that absence of pelvic peritoneal closure alone increased the incidence of PPH significantly (odds ratio; 13.76, 95% confidence interval; 1.48-1884.84, p = 0.004). CONCLUSIONS: This preliminary study showed that pelvic peritoneal closure could prevent PPH after endoscopic APE.

Molecular Evidence for Monoclonal Skip Progression in Main Duct Intraductal Papillary Mucinous Neoplasms of the Pancreas.

OBJECTIVE: To clarify clonality of distinct multisegmental main duct (MD)-intraductal papillary mucinous neoplasms (IPMNs) using microarray analysis. BACKGROUND: IPMNs represent a pancreatic ductal cell field defect, which causes multiple occurrences of lesions. In addtion, it has been speculated that MD-IPMNs display features of monoclonal skip progression. METHODS: Total RNA was extracted from fresh-frozen tissue samples of metachronous MD-IPMNs and nonneoplastic pancreas tissue from the same pancreas from two individuals, and whole human genome microarray analysis was performed. Formalin-fixed paraffin-embedded tissue specimens from 28 distinct IPMNs were then collected from 12 patients, genomic DNA was extracted, and GNAS/KRAS mutational status was investigated. Immunohistochemical analysis was performed to validate the expression pattern of the indicated proteins. RESULTS: Microarray analysis revealed that metachronous MD-IPMNs from the same individual displayed pair-wise correlation coefficients of 0.9523 and 0.9512. In contrast, MD-IPMNs of the same histological grade from different individuals displayed coefficients of 0.8092 and 0.8211. Scatter plot analysis revealed that metachronous MD-IPMNs from the same individual displayed a closer linear relationship. Furthermore, heat map and hierarchical cluster analyses revealed that metachronous MD-IPMNs from the same individual were classified in the same branch, and the gene expression patterns were similar. The GNAS/KRAS mutational statuses of distinct MD-IPMNs were consistent with each other. Immunohistochemical assessment of five specific proteins demonstrated that the same expression pattern between two lesions was observed in 95% of the samples. CONCLUSIONS: These findings using molecular analyses indicate that MD-IPMNs might display features of monoclonal skip progression.

GNAS and KRAS mutational analyses of intraductal papillary neoplasms of the pancreas and bile duct developing in the same individual: A case report.

Intraductal papillary mucinous neoplasm (IPMN) of the pancreas and intraductal papillary neoplasm of the bile duct (IPNB) are considered as counterparts of each other, and it is suggested that these two entities have similar molecular alteration pathways. However, the occurrence of IPMN of the pancreas and IPNB in the same patient is rare. We report a surgical case of a 69-year-old woman who developed invasive IPMN of the pancreas and underwent pancreatectomy, 6 months after hepatic resection of invasive IPNB. Molecular analysis revealed GNAS/KRAS mutation in both invasive IPMN of the pancreas and IPNB. This is believed to be the first case report investigating GNAS/KRAS mutational status in both IPMN of the pancreas and IPNB developing in the same patient, and these two entities may show similar molecular alternations.

Risk factors and clinical significance of subcutaneous emphysema after robot-assisted laparoscopic rectal surgery: a single-center experience.

Subcutaneous emphysema (SE) is a complication of laparoscopic surgery, potentially resulting in severe respiratory failure. No reports to date have focused on SE during robot-assisted (RA) rectal surgery. We aimed to reveal the risk factors and clinical significance of SE after RA/laparoscopic rectal surgery. We retrospectively reviewed 221 consecutive patients who underwent RA/laparoscopic rectal surgery. The occurrence of SE was evaluated on postoperative radiographs. Laparoscopic surgery was performed in 120 patients and RA in 101. SE developed in 55 (24.9%) patients. Logistic regression analysis identified RA surgery (odds ratio [OR]: 4.89, 95% confidence interval [CI] 2.13-11.22, p < 0.001), higher age (OR: 1.06, 95% CI 1.03-1.11, p < 0.001), lower body mass index (BMI) (OR: 0.79, 95% CI 0.67-0.93, p = 0.004), thinner subcutaneous layer (OR: 0.88, 95% CI 0.79-0.98, p = 0.02), and lateral lymph node dissection (OR: 9.43, 95% CI 2.44-36.42, p < 0.001) as risk factors for SE. Maximum end-tidal CO2 was significantly higher in the SE than the non-SE cohort (p < 0.001). There was no difference in postoperative complication rate or length of hospital stay. Lower BMI (OR: 0.79, 95% CI 0.62-0.97, p = 0.02) and thinner subcutaneous layer (OR: 0.84, 95% CI 0.71-0.97, p = 0.01) were predictive factors in the RA cohort. SE occurs more frequently in RA compared with laparoscopic surgery. SE has a modest impact on short-term outcomes, but may occasionally cause severe problems. The indication of RA surgery should be considered carefully in high-risk elderly patients.

Renal Failure Without Hemodialysis Is a Risk Factor for Postoperative Complications in Colorectal Cancer Surgery.

Background/Aim: Surgical outcomes of colorectal cancer (CRC) in patients with renal failure (RF) remain to be clarified. The objective of this research was to investigate how RF impacts the surgical outcomes in patients with CRC. Patients and Methods: A retrospective analysis was performed on clinical data from 633 patients who underwent colorectal resection for CRC between January 2017 and December 2021. Outcomes of the patients with and without RF were compared. RF was defined as estimated Glomerular Filtration Rate less than 30. Results: Forty-five (7%) patients with RF were identified. RF was a significant risk factor for postoperative complications after colorectal cancer surgery (odds ratio=2.19, 95% confidence interval=1.08-4.42, p=0.0284). The patients with RF had significantly more comorbidity (p=0.016), and higher American Society of Anesthesiologists physical status (p<0.01). Hemoglobin level (p<0.01) and PNI (p<0.01) were significantly lower in those with RF. Postoperative complications were significantly higher (p=0.016), and the postoperative hospital stay was significantly longer (p<0.01) among patients with RF compared to those without RF. Patients with RF, excluding those undergoing hemodialysis, had significantly more complications compared to those without RF (p=0.004). Conclusion: Careful attention should be paid to perioperative management in RF colorectal cancer patients.

Risk Factors for Postoperative Paralytic Ileus in Advanced-age Patients after Laparoscopic Colorectal Surgery: A Retrospective Study of 124 Consecutive Patients.

Objectives: Postoperative paralytic ileus (POI) is one of the most common and troublesome complications following colorectal surgery. However, to date, the risk factors for POI remain unclear. This study aimed to identify the risk factors for POI following laparoscopic colorectal surgery in advanced-age patients. Methods: The clinical data of 124 patients aged ≥75 years who underwent curative colorectal surgery from January 2018 to December 2020 were retrospectively reviewed. The relationship between POI and clinicopathological data including sarcopenia and visceral fat obesity was then assessed. Sarcopenia was defined as a low skeletal muscle mass index; visceral obesity, visceral fat with an area ≥100 cm2 on computed tomography at the level of the third lumbar vertebra; and sarcobesity, sarcopenia with visceral obesity. Results: The rate of POI was 9% (12/124 patients), and all the affected patients improved with conservative treatment. In the univariate and multivariate analyses, sarcopenia and sarcobesity were significant predictive factors for POI. Conclusions: Sarcopenia and sarcobesity may be risk factors for POI in patients aged ≥75 years after laparoscopic colorectal surgery.

Revisiting the Prognostic Impact of Family History in Colorectal Cancer by Retrospective Propensity Score Matching.

BACKGROUND/AIM: Family history of colorectal cancer (CRC) is a known risk factor for CRC. However, its prognostic value in patients with CRC remains controversial. This study aimed to clarify the prognostic impact of a family history of CRC. PATIENTS AND METHODS: We retrospectively reviewed the database from 1978 to 2018 and enrolled 3,655 consecutive patients with CRC. We investigated the clinicopathological factors of patients with CRC with and without a family history. After propensity score matching, we performed a survival analysis of patients with CRC with and without a family history. RESULTS: Patients with CRC with a family history of CRC had a young onset (63.2 and 65.9; p<0.001), were more likely to be female (54.3% and 49.7%; p=0.042), had less symptomatic disease (76.9% and 80.8%; p=0.008), were more likely to have right-sided colon cancer (27.5% and 26.1%), and had less distant metastases (11.3% and 14.9%; p=0.023) and multiple CRCs (10.2% and 7.8%) compared with those without a family history of CRC. Prior to propensity score matching, CRC-specific survival analysis showed that a family history of CRC was a good prognostic factor (p=0.022). After propensity score matching, survival curves overlapped between the two groups. CONCLUSION: Patients with CRC with a family history of CRC had specific clinicopathological features including younger onset, female sex, proximal colon location, fewer symptoms, smaller number of distant metastases, likelihood of multiple diseases, and earlier cancer stage. Family history of CRC in patients with CRC was not a prognostic factor.

Evaluation of stress relaxation process of wood based on the eigenvalue distribution of near infrared spectra.

Wood is a highly heterogeneous composite material consisting of three major natural polymers featuring properties that can vary significantly among samples. We examined the stress relaxation of wood as a stochastic process. The eigenvalue distribution at each time was calculated from the near-infrared spectral matrix during the stress relaxation test. The eigenvalue motion was regarded as Dyson's Brownian motion. The first eigenvalue, which is equivalent to the Helmholtz free energy, gradually increased with time, indicating that the relaxation of wood exposed to change necessitates a more organised molecular configuration. The time evolutions of the Shannon entropy calculated from the probability associated with each energy eigenstate did not overlap between the inverse temperatures. Thus, the curves were smoothly shifted until continuous, thereby generating a master curve. The proposed method addresses the limitation of sample differences by assessing the behaviour of the statistical ensemble rather than that of the individual samples.

Feasibility of Prophylactic Pancreatojejunostomy in Possible High-Risk Patients for Prevention of Pancreatic Fistula during Enucleation or Limited Pancreatic Resection.

The aim of this study was to assess the feasibility of prophylactic pancreatojejunostomy after enucleation or limited pancreatic resection regarding the risk of postoperative pancreatic fistula (PF). We retrospectively reviewed the medical records of 32 patients who underwent enucleation or limited pancreatic resection and compared the clinical parameters between patients with (n = 10) and without (n = 22) prophylactic pancreatojejunostomy. Prophylactic pancreatojejunostomy was performed in patients with a possible high risk ofPF. No operation-related mortality occurred. Operation time was significantly longer (P < 0.01) and blood loss significantly greater (P < 0.01) in patients with pancreatojejunostomy. Overall complications were more frequent (P = 0.02) and postoperative hospital stay was significantly longer (P = 0.02) in patients with pancreatojejunostomy. However, other assessed factors including the prevalence of postoperative PF did not differ between groups. In conclusion, prophylactic pancreatojejunostomy is feasible, and its efficacy in preventing PF after enucleation or limited pancreatic resection in high-risk patients will require further study.

Estimation of wood stiffness and strength properties of hybrid larch by near-infrared spectroscopy.

This work was undertaken to investigate the feasibility of near-infrared (NIR) spectroscopy for estimating wood mechanical properties, i.e., modulus of elasticity (MOE) and modulus of rupture (MOR) in bending tests. Two sample sets having large and limited density variation were prepared to examine the effects of wood density on estimation of MOE and MOR by the NIR technique. Partial least squares (PLS) analysis was employed and it was found that the relationships between laboratory-measured and NIR-predicted values were good in the case of sample sets having large density variation. MOE could be estimated even when density variation in the sample set was limited. It was concluded that absorption bands due to the OH group in the semi-crystalline or crystalline regions of cellulose strongly influenced the calibrations for bending stiffness of hybrid larch. This was also suggested from the result that both alpha-cellulose content and cellulose crystallinity showed moderate positive correlation to wood stiffness.

Elevated bile amylase level without pancreaticobiliary maljunction is a risk factor for gallbladder carcinoma.

BACKGROUND: Elevated bile amylase level in patients with pancreaticobiliary maljunction (PBM) or high confluence of pancreaticobiliary ducts (HCPBD) is well known as a risk factor for gallbladder carcinoma (GBC) development. However, the effects of occult pancreaticobiliary reflux (OPR), a condition characterized by high bile amylase level in the presence of an anatomically normal pancreaticobiliary junction, on GBC development remain unclear. The aim of this study was to assess the relationship between OPR and GBC. METHODS: Clinicopathological data of 52 patients who were preoperatively diagnosed with gallbladder (GB) tumor (22 malignant, 30 benign) were retrospectively reviewed. All of the patients underwent preoperative endoscopic retrograde cholangiopancreatography to evaluate pancreaticobiliary junction morphology and bile amylase level. The relationship between the histological diagnosis of GB lesions, and pancreaticobiliary junction morphology and bile amylase level were investigated. RESULTS: Pancreaticobiliary maljunction, HCPBD, and normal pancreaticobiliary junction (NPJ) were identified in 12, nine, and 31 patients, respectively. The rates of GBC in patients with PBM, HCPBD, and NPJ were 58% (7/12), 67% (6/9), and 29% (9/31), respectively. Of the 31 patients with NPJ, 22 had OPR and nine of these had GBC. None of the patients with NPJ and normal bile amylase level had GBC. Additionally, among patients with NPJ, bile amylase level was significantly higher in patients with GBC than in patients with benign tumors. CONCLUSIONS: Occult pancreaticobiliary reflux, like PBM and HCPBD, is a risk factor for GBC development.

Clinical significance of circumportal pancreas, a rare congenital anomaly, in pancreatectomy.

BACKGROUND: Circumportal pancreas is a rare congenital pancreatic anomaly. The aim of this study was to clarify the clinical characteristics of patients with circumportal pancreases undergoing pancreatectomy. METHODS: The medical records of 508 patients who underwent pancreatectomy were retrospectively reviewed. The prevalence of circumportal pancreas and related anatomical variations were assessed. Surgical procedures and postoperative outcomes were compared in patients with and without circumportal pancreas. RESULTS: Circumportal pancreas was observed in 9 of the 508 patients (1.7%). In all nine patients, the portal vein was completely encircled by the pancreatic parenchyma above the level of the splenoportal junction, and the main pancreatic duct ran dorsal to the portal vein. The rate of variant hepatic artery did not differ significantly in patients with and without circumportal pancreas. Pancreatic fistula developed more frequently in patients with than without circumportal pancreas (44% vs. 14%, p = 0.03), but other clinical parameters did not differ significantly in these two groups. CONCLUSIONS: Despite being rare, circumportal pancreas may increase the risk of postoperative pancreatic fistula in patients undergoing pancreatectomy. However, a prospective, large-cohort study is necessary to determine the real incidence of relevant anatomical variations and the definitive clinical significance of this rare anomaly.

Expression of Bcl-2 19-kDa interacting protein 3 predicts prognosis after ampullary carcinoma resection.

BACKGROUND: An adequate management strategy for ampullary carcinoma (AC), a rare neoplasm, has yet to be determined. The aim of this study was to identify specific molecular markers allowing for the adequate management of AC. METHODS: The clinicopathological data of 41 patients who underwent curative resection of AC were reviewed retrospectively. The expression of thymidylate synthase (TS) and Bcl-2 19-kDa interacting protein 3 (BNIP3), two sensitive markers for S-1 and gemcitabine, respectively, was evaluated immunohistochemically. The relationship between the expression levels of these markers and the clinicopathological data were then investigated. RESULTS: The 5-year overall survival rate in the study population was 62%. In univariate and multivariate analyses, lymph node metastasis, neural invasion, lymphatic invasion, and the high-level BNIP3 expression were significant predictive factors for a poor postoperative prognosis. Neither TS nor BNIP3 expression were able to predict survival or the disease recurrence rate in patients who received postoperative adjuvant chemotherapy for AC. CONCLUSIONS: BNIP3 expression may serve as a prognostic marker for patients with AC, but neither TS nor BNIP3 contributes to the selection criteria for adjuvant chemotherapy for AC, at least with respect to current drug regimens.

Different Hormonal Expression Patterns Between Primary Pancreatic Neuroendocrine Tumors and Metastatic Sites.

OBJECTIVES: Pancreatic neuroendocrine tumors (PNETs) are known to have heterogeneity in terms of their ability to produce multiple hormones. The aim of this study was to evaluate the heterogeneity of PNETs from the viewpoint of hormonal expression. METHODS: The expressions of 4 representative hormones, gastrin, insulin, glucagon, and somatostatin, in both primary and metastatic lesions, were analyzed by immunohistochemical staining in 20 patients with metastatic PNETs (6 gastrinomas, 1 insulinoma, 1 glucagonoma, and 12 nonfunctioning PNETs [NF-PNETs]). Metastatic sites included lymph nodes in all 20 patients and liver metastasis in 7 patients (2 gastrinomas and 5 NF-PNETs). RESULTS: There were 6 PNETs with multiple hormone secretion (30%), and positive expression of 1 or more hormones was found in 9 of 12 patients whose primary tumors were diagnosed as NF-PNETs. The positive concordance rate of the hormonal expression pattern between primary tumors and metastatic lymph nodes and between primary tumors and hepatic metastasis were 50% and 11%, respectively. Three patients had metastatic lesions with positive hormonal expression, whereas their primary tumors were negative. CONCLUSIONS: Hormonal expressions are often different between the primary tumors and metastatic sites of PNETs.

Distinction of Invasive Carcinoma Derived From Intraductal Papillary Mucinous Neoplasms From Concomitant Ductal Adenocarcinoma of the Pancreas Using Molecular Biomarkers.

OBJECTIVES: To clarify the usefulness of molecular biomarkers for distinguishing invasive carcinoma derived from intraductal papillary mucinous neoplasms (IPMNs [Inv-IPMN]) from concomitant pancreatic ductal adenocarcinoma (PDAC). METHODS: Data from 19 patients with resected concomitant PDAC were retrospectively reviewed. KRAS/GNAS mutations and immunohistochemical (IHC) expression of p53 and p16/CDKN2A were assessed in both IPMN and distinct PDAC. As controls, KRAS/GNAS mutations and IHC labeling were assessed between invasive and noninvasive components in 1 lesion of 22 independent patients. RESULTS: KRAS/GNAS mutation status of invasive and noninvasive components in Inv-IPMN was consistent in 18 (86%) of 21 patients. Conversely, mutational patterns in IPMN and distinct PDAC in the same pancreas differed from each other in 17 (89%) of 19. There were 10 (53%) and 8 (42%) of 19 patients who showed the same p53 and p16/CDKN2A staining between concomitant PDAC and distinct IPMN. In the Inv-IPMN cohort, 19 (86%) of 22 patients showed the same IHC expression pattern between the noninvasive and invasive components. CONCLUSIONS: It may be possible to distinguish Inv-IPMN from concomitant PDAC by assessing these molecular biomarkers. More precise distinction of Inv-IPMN and concomitant PDAC will lead to adequate recognition of the natural history of IPMNs and hence optimal management.

Computed tomographic lymphography predicts the difficulty of sentinel lymph node biopsy with dye.

BACKGROUND: Sentinel lymph node biopsy (SLNB) has been a method of choice for treating breast cancer. Computed tomographic lymphography (CT-LG) provides a view of the sentinel lymph node (SLN) with the detailed lymphatic anatomy preoperatively, and the SLN is easily identified during SLNB. In this article, we examined the usefulness of CT-LG to predict the difficulty of SLNB with the dye method. METHODS: A total of 41 consecutive patients who underwent CT-LG were enrolled in this study. Each CT-LG image was reviewed by one of our co-authors. The images of lymph vessels (LVs) and SLNs were assorted into three categories: not visualized, poorly visualized, and well visualized. The time engaged in SLNB with the dye method was recorded in 30 patients. RESULTS: The time engaged in SLNB between two groups was compared: patients in whom both the SLN and LVs were well visualized (n = 16) and the remaining patients (n = 14). The former required a significantly shorter time than the latter (12.6 ± 4.1 vs. 17.6 ± 6.7 min, respectively; p = 0.025 by Mann-Whitney U test). CONCLUSIONS: Our study clearly demonstrates that the CT-LG findings of well-visualized LVs and SLNs predict the easy access to the stained LVs and SLNs. This information provides several advantages, including the fact that an easy SLNB case can be selected for a doctor with little experience in SLNB, and the volume of dye and/or length of massage can be changed for better identification of stained LVs and SLNs during SLNB.

Feasibility of near-infrared spectroscopy for on-line grading of sawn lumber.

Near-infrared (NIR) spectroscopy, coupled with multivariate analysis, has been used to evaluate the wood properties of sawn lumber of Japanese larch (Larix kaempferi), whose diffuse reflection spectra were acquired under static and moving conditions. Prediction models of the dynamic modulus of elasticity (E(fr)), the modulus of elasticity in bending tests (E(b)), the bending strength (F(b)), the wood density (DEN), and the moisture content (MC) were developed using partial least squares (PLS) analysis. For all wood properties, models obtained from data collected under the moving condition as an analogue of on-line measurement were superior to those from the static condition data. The regression coefficients for the PLS models predicting the mechanical properties in both static and moving conditions showed clear peaks at the absorption bands due to the three major polymers of wood, i.e., cellulose, hemicellulose, and lignin. NIR spectroscopy has high potential for the on-line grading of sawn lumber.