Prognostic factors based on histological categorization of desmoplastic reactions in pancreatic cancer.

BACKGROUND/PURPOSE: In colorectal cancer, the morphological categorization of fibrotic cancer stroma in the invasive frontal zone of the primary tumor is well reflected in the prognosis. Conversely, the histological characteristics of pancreatic cancer (PC) reveal fibrotic hyperplasia of stroma known as desmoplasia; however, its characterization is unknown. Therefore, this study aimed to evaluate the prognostic factors according to the histological categorization of desmoplastic reactions in PC. METHODS: We retrospectively enrolled 167 patients who underwent curative resection for PC. The desmoplastic pattern was histologically classified as mature, intermediate, or immature. Clinicopathological features were evaluated, and disease-free and overall survival (OS) were analyzed in the three groups. Prognostic factors were assessed using univariate and multivariate analyses. RESULTS: In total, 19 mature, 87 intermediate, and 61 immature desmoplastic patterns were evaluated. Jaundice decompression, white blood cell count, and platelet/lymphocyte ratio were significantly different among the groups. The mature group had a better disease-free survival (DFS) prognosis than the other two groups; however, OS did not differ between the groups. Desmoplastic patterns showed significant differences between the three groups for DFS. CONCLUSIONS: Desmoplastic patterns are a prognostic factor of DFS for PC, with mature desmoplastic reactions associated with good prognosis. Thus, they may aid in individualized therapeutic approaches in patients with PC.

Neuroendocrine carcinoma of the common bile duct associated with congenital bile duct dilatation: a case report.

BACKGROUND: Cholangiocarcinoma is frequently observed in patients with congenital bile duct dilatation (CBDD). Most cholangiocarcinomas are adenocarcinomas. Other types, especially neuroendocrine carcinomas (NECs), are rare. To the best of our knowledge, this is the third reported case of an NEC of the common bile duct associated with CBDD and the first to receive adjuvant chemotherapy for advanced disease. CASE PRESENTATION: A 29-year-old woman presented with upper abdominal pain. Preoperative imaging indicated marked dilatation of the common bile duct and a tumor in the middle portion of the common bile duct. She was suspected of having distal cholangiocarcinoma associated with CBDD and underwent pylorus-preserving pancreaticoduodenectomy. Pathological and immunohistological findings led to a final diagnosis of large-cell NEC (pT3aN1M0 pStageIIB). The postoperative course was uneventful, and she was administered cisplatin and irinotecan every 4 weeks (four cycles) as adjuvant chemotherapy. She has remained recurrence-free for 16 months. CONCLUSIONS: NEC might be a differential diagnosis in cases of cholangial tumor associated with congenital bile duct dilatation. This presentation is rare and valuable, and to establish better treatment for NEC, further reports are necessary.

Incidence of anastomotic stricture after hepaticojejunostomy with continuous sutures in patients who underwent laparoscopic pancreaticoduodenectomy.

PURPOSE: Laparoscopic hepatojejunostomy (HJ) with continuous sutures is commonly performed in laparoscopic pancreaticoduodenectomy (LPD). This study aimed to investigate the long-term surgical outcomes of HJ in LPD. METHODS: We retrospectively evaluated 103 consecutive patients who underwent pancreaticoduodenectomy via laparoscopic HJ with continuous suturing using multifilament (n = 48) or monofilament-absorbable sutures (n = 47). RESULTS: During follow-up, anastomotic stricture of HJ was identified in 8 (7.8%) patients via balloon enteroscopy-assisted cholangiography. The median time from surgery to confirmation of stricture formation was 7.6 months (range 3.6-19.4). The incidence of HJ stricture was significantly higher in patients with a thin bile duct (diameter < 6.0 mm) than in those with a thick bile duct (diameter ≥ 6.0 mm) [7/27 (25.9%) vs. 1/76 (1.3%), respectively, p < 0.01]. Similarly, it was significantly higher in the monofilament group than in the multifilament group [7/54 (13.0%) vs. 1/49 (2.0%), respectively, p = 0.04]. In the monofilament suture group, 37.5% of patients with thin bile ducts developed stricture after HJ. A multivariate analysis revealed that a thin bile duct was an independent risk factor for HJ stricture (hazard ratio: 25.3, p < 0.01). CONCLUSIONS: Stricture after laparoscopic HJ using continuous sutures frequently occurs in patients with thin bile ducts, particularly when monofilament-absorbable suture is used.

Causative bacteria associated with a clinically relevant postoperative pancreatic fistula infection after distal pancreatectomy.

PURPOSE: Clinically relevant postoperative pancreatic fistulas (CR-POPF) occurring after distal pancreatectomy often cause intra-abdominal infections. We monitored the presence of bacterial contamination in the ascitic fluid after distal pancreatectomy to clarify the bacterial origin of intra-abdominal infections associated with CR-POPF. METHODS: In 176 patients who underwent distal pancreatectomy, ascitic fluid bacterial cultures were performed on postoperative days (POD) 1-4 and when the drainage fluid became turbid. The association between postoperative ascitic bacterial contamination and CR-POPF incidence was investigated. RESULTS: CR-POPF occurred in 18 cases (10.2%). Among the patients with CR-POPF, bacterial contamination was detected in 0% on POD 1, in 38.9% on POD 4, and in 72.2% on the day (median, day 9.5) when the drainage fluid became turbid. A univariate analysis revealed a significant difference in ascitic bacterial contamination on POD 4 (p < 0.001) and amylase level on POD 3-4 (p < 0.001). A multivariate analysis revealed the amylase level and ascitic bacterial contamination on POD 4 to be independent risk factors. CONCLUSIONS: In the CR-POPF group, ascitic bacterial contamination was not observed in the early postoperative stage, but the bacterial contamination rate increased after pancreatic juice leakage occurred. Therefore, CR-POPF-related infections in distal pancreatectomy may be caused by a retrograde infection of pancreatic juice.

Relationship Between the Waiting Times for Surgery and Survival in Patients with Gastric Cancer.

BACKGROUND: Surgery for gastric cancer should be performed as soon as possible after diagnosis. However, sometimes the waiting time for surgery tends to be longer. The relation between the waiting time for surgery and survival in patients with gastric cancer remains to be fully investigated. METHODS: This retrospective, single-center cohort study evaluated patients with gastric cancer who underwent curative surgery from 2006 through 2012 at Kanagawa Cancer Center in Japan. Patients who received neoadjuvant chemotherapy were excluded. The waiting time for surgery was defined as the time between the first visit and surgery. We investigated whether the waiting time for surgery has a linear negative impact on outcomes by using a Cox regression model with clinical prognostic factors. RESULTS: In total, 801 patients were eligible. The median waiting time was 45 days (range 10-269 days). The restricted cubic spline regression curve showed that the adjusted time-specific hazard ratios of waiting times did not indicate a linear negative trend on survival between 20 and 100 days (p = 0.759). In the Cox model with a quartile of waiting times, waiting times in the 32-44-day group, 43-62-day group, and ≥63 day groups were not associated with poorer overall survival as compared with the ≤31 day group (HR: 1.01, 95% CI 0.63-1.60, p = 0.984, HR: 1.17, 95% CI 0.70-1.94, p = 0.550, HR: 1.06, 95% CI 0.60-1.88, p = 0.831, respectively). CONCLUSIONS: There was no negative relation between the waiting time for surgery (within 100 days) and survival in patients with gastric cancer.

Safe exposure of the left renal vein during laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma: anatomical variations and pitfalls.

PURPOSE: The left renal vein is technically difficult to expose during laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma despite being an important landmark for posterior dissection. We hereby propose a novel technique to safely expose the left renal vein while avoiding the associated anatomical pitfalls. METHODS: The anatomy of the left renal artery and vein was analyzed using multidetector computed tomography. We initially exposed the left renal vein on the left posterior side of the superior mesenteric artery followed by exposure toward the left kidney. We retrospectively examined the perioperative results of this technique in 33 patients who underwent laparoscopic distal pancreatectomy. RESULTS: 15.7% of the patients had an accessory left renal artery coursing cranial to the vein. In 43.1%, the left renal arterial branch ventrally traversed the vein at the renal hilum, thereby posing a risk for arterial injury. The location of the left renal vein varies cranial (17.6%) or caudal (82.4%) to the pancreas. The left renal vein was exposed without any vascular injury using this technique. The median operative time was 259 min, blood loss was 18 mL, and R0 resection rate was 97.0%. CONCLUSIONS: The initial exposure of the left renal vein should, therefore, be on the left posterior side of the superior mesenteric artery.

Approaching the superior mesenteric artery from the right side using the proximal-dorsal jejunal vein preisolation method during laparoscopic pancreaticoduodenectomy.

BACKGROUND: Although the artery-first approach is widely used in open pancreaticoduodenectomy, it is difficult to laparoscopically expose the origin of the inferior pancreaticoduodenal artery (IPDA) from the left side of the superior mesenteric artery (SMA). By contrast, damaging the inferior pancreaticoduodenal veins (IPDVs) is possible when approaching the IPDA from the right side of the SMA. To facilitate the artery-first approach in laparoscopic pancreaticoduodenectomy (LPD), we focused on the proximal-dorsal jejunal vein (PDJV) that branched from the superior mesenteric vein (SMV) dorsal side and drained the IPDVs. This study aimed to clarify the usefulness of the right SMA approach using the PDJV preisolation method. METHODS: The PDJV was first isolated, and the IPDVs were divided along the PDJV on the right side of the SMA. Then, the IPDA was divided at the root without first separating the pancreatic head from the portal vein and the SMV. Overall, 21 patients underwent this approach, and the results were retrospectively compared with those of 21 patients who underwent the artery-first approach, which was performed on the left side of the SMA. Anatomical characteristics of the PDJV were evaluated using multidetector computed tomography for the two groups. RESULTS: Operative times and resection times were significantly lower for the PDJV preisolation group than for the conventional LPD group (489.3 vs. 541.7 min, respectively; p = 0.002). During anatomical evaluation, 41 patients (97.6%) had a PDJV that drained from the SMV dorsally and was in contact with the anterior aspect of the uncinate process. The PDJV was confirmed as the first jejunal vein in 31 patients (73.8%) and as the second jejunal vein in 10 patients (23.8%). CONCLUSIONS: This approach facilitates dissection of the IPDA on the right side of the SMA, thereby reducing operative times.

[Local Resection of Gastric Tube Cancer with a Gastrointestinal Endoscope].

An 81-year-old man with esophageal cancer had undergone subtotal thoracic esophagectomy and retrosternal reconstruction using a gastric tube. He developed anemia. Gastrointestinal endoscopy was performed, which revealed a tumor in the posterior wall of the lower part of the gastric tube. Biopsy revealed well-differentiated adenocarcinoma. There was no lymph node metastasis and no distal metastasis on CT. We performed partial resection of the stomach tube because of his age and physical condition. We identified the position of the tumor by upper gastrointestinal series CT and gastrointestinal endoscopy. The tumor was located on the posterior wall of the lower part of the gastric tube and the back of the sternum lower border. Marking was performed by gastrointestinal endoscopy before operation. We simulated the operation and decided to perform laparostomy without sternotomy incision. We cut the anterior wall of the gastric tube in front of the tumor using the endoscope. We could then confirm the diagnosis of cancer, and clipped and removed the tumor from the posterior wall. The resected site was sutured with 4-0 absorbable thread. The pathological diagnosis was T1a(M)N0M0, ly0, v0, PM0, DM0, pStage ⅠA.

[A Case of Liver Metastasis 14 Years after Total Gastrectomy for Advanced Gastric Cancer].

We report a rare case of liver recurrence of gastric cancer 14 years and 3 months after curative gastrectomy. An 81-yearold man underwent total gastrectomy, D2 lymphadenectomy, Roux-en-Y reconstruction, and cholecystectomy for advanced gastric cancer in November 2002. H e was diagnosed pathologically with M, Type 5, 53×42 mm, tub2>tub1, pT4a, ly2, v2, pN1, pPM0, pDM0, M0, pStage ⅢA(JGCA 15th). Postoperative adjuvant therapy was not administered. He was followed up for 5 years after surgery without adjuvant therapy, and he did not exhibit recurrence. In February 2017, he experienced difficulties in swallowing and visited our hospital. Abdominal contrast-enhanced CT showed an 8×5 cm liver tumor in the lateral segment. Part of the tumor protruded to outside of the liver, and the tumor invaded and pushed the jejunum in the Roux limb. We performed liver biopsy and diagnosed him with liver metastasis of recurrent gastric cancer. Late relapse after gastrectomy, especially after 10 years or more, is very rare.

[A Case of Mediastinal Lymph Node Recurrence after Endoscopic Submucosal Dissection of Esophageal Cancer].

We report a case of mediastinal lymph node recurrence of esophageal cancer after endoscopic submucosal dissection (ESD). We first administered chemotherapy and then performed esophagectomy. A 78-year-old man underwent ESD for early esophageal cancer at a different hospital in January 2015. H e was diagnosed pathologically with scc, pSM1, pHM1, pVM0, ly0, v0. Additional treatment was not administered because of his age. In June 2017, chest enhanced CT showed swollen mediastinal lymph nodes. This was diagnosed as a recurrence of esophageal cancer, and he presented at our hospital. We first performed chemotherapy for that lesion, because the swollen lymph node was large and may have invaded the surrounding organs. We then performed esophagectomy.

[Stereotactic Body Radiotherapy for Liver Metastasis of Gastric Cancer].

Case 1: A 69-year-old man underwent distal gastrectomy in September 2007 for type 2 gastric cancer with liver metastasis (S5). After the operation, we administered chemotherapy. After that, we performed partial hepatectomy in July 2008. After hepatectomy, liver metastases appeared as 2 lesions in February 2009. Thus, we administered another type of chemotherapy. The effect of the chemotherapy was not favorable. Therefore, SBRT was performed for the liver metastases in December. After SBRT, he did not present with any recurrent tumors. Case 2: A 67-year-old woman underwent distal gastrectomy in March 2015. In August 2015, hepatic metastasis(S5 single shoot)was confirmed. Although chemotherapy was administered and SD was continued, it was ceased due to the patient's request. Thus, SBRT was performed in July 2016. However, from October 2016, multiple liver metastases developed and she died in January 2017.

[A Case of Neuroendocrine Carcinoma with Liver Metastasis Treated with Multimodality Therapy and Leading to Complete Response].

A 79-year-old man with cStage II A(T2N1H0P0CYXM0)advanced gastric cancer in angle. Distal gastrectomy was performed and liver metastasis was recognized during the operation. The pathological diagnosis was shown as neuroendocrine carcinoma(NEC). Chemotherapy(S-1/cisplatin[CDDP]: 1 course, etoposide/CDDP: 5 courses)was administered. After chemotherapy, liver metastasis disappeared for 9months.

[Pathological Complete Response in 3 Patients with Esophageal Cancer Treated with Neoadjuvant Chemoradiation Therapy].

Neoadjuvant chemotherapy(NAC)for esophageal cancer is standard in Japan. However, the value of neoadjuvant chemoradiation therapy(NACRT)is unknown. Thirteen patients with cStage II and III squamous cell carcinoma of the esopha- gus were treated with NACRT(CDDP 70mg/m2/day on day 1, 5-FU 70 mg/m2/day on days 1-4, radiation 30 Gy/15 Fr). We report 3 pathological CR cases and 10 non-CR cases of esophageal cancer. Between the CR and non-CR group there was no difference in the incidence of postoperative complications. No serious adverse events were observed. There were no significant differences in OS and RFS. Five cases relapsed in the non-CR group. There were no relapsed cases in the CR group.

[Efficacy of Partial Resection for Stomach Cancer in the Elderly].

We examined the effectiveness of partial gastrectomy in the elderly. Twelve patients who underwent partial gastrectomy for gastric cancer in our hospital had an average of 2.75 comorbidities before surgery. Two patients relapsed, and 2 patients died from other diseases. The depth of the gastric tumor was T2 in patients with recurrence. Partial gastrectomy should be considered carefully for advanced stage cancer. There were only small changes in weight, PS, and nutrition before and after surgery, suggesting that partial gastrectomy is effective.

[A Case of Gastric Cancer Responding to Neoadjuvant Chemotherapy Leading to Histological Change to Grade 3].

A 70-year-old man with cStage III A(cT3N2H0P0CYXM0)advanced gastric cancer in the lesser curvature with esophageal invasion and bulky lymph nodes was treated with S-1/CDDP. After 4 courses of chemotherapy, the tumor and lymph nodes were found to be reduced in a CT examination. Total gastrectomy with lymph node dissection(D2)was performed. Histopathological examination revealed no cancer cells in the stomach or lymph nodes, indicating Grade 3.

Pancreaticoduodenectomy with right-oblique posterior dissection of superior mesenteric nerve plexus is logical procedure for pancreatic cancer with extrapancreatic nerve plexus invasion.

BACKGROUND/AIMS: To achieve R0 resection, pancreaticoduodenectomy with right-side half dissection of the superior mesenteric artery nerve plexus is performed for pancreatic cancer with extrapancreatic nerve plexus invasion in many facilities. However, this cancer mainly spreads behind the superior mesenteric artery. METHODOLOGY: Forty-two patients underwent pancreaticoduodenectomy with right-oblique posterior dissection of the superior mesenteric artery nerve plexus from the 4 to 10 o'clock position for pancreatic ductal adenocarcinoma. The cancer spread was evaluated using preoperative multi-detector computed tomography and postoperative pathological examination. RESULTS: Thirty-one patients (73.8%) showed extrapancreatic nerve plexus invasion on multi-detector computed tomography. In 20 patients (47.6%), the tumor extended within 5 mm of the superior mesenteric artery, ranging between the 4-10 o'clock position in 19 (95.0%) patients. Although pathological examination revealed that the cancer infiltrated within 3 mm of the superior mesenteric artery margin in 17 (54.8%) patients with extrapancreatic nerve plexus invasion, R0 resection was achieved in 95.2% of cases. Six patients (14.3%) experienced postoperative diarrhea requiring administration of antidiarrheal agents. CONCLUSIONS: Pancreatic head cancer spreads mainly right-posterior of the superior mesenteric artery; and therefore, right-oblique posterior dissection is a logical procedure to achieve negative margin resection with complete clearance of nerve plexus involvement.

Clinical feasibility of endoscopic ultrasound-guided biliary drainage for preoperative management of malignant biliary obstruction (with videos).

BACKGROUND/PURPOSE: EUS-guided biliary drainage (EUS-BD) has recently been reported to be a useful salvage technique after ERCP fail. However, data on EUS-BD used for preoperative biliary drainage (PBD) are limited. The aim of this study was to verify the clinical feasibility of EUS-BD for PBD. METHODS: PBD was performed for malignant biliary obstruction in 318 patients at our institution between July 2014 and April 2022. Fifteen (4.7%) of these patients underwent surgical resection after preoperative EUS-BD (HGS 13; HDS 1; AGS with HGS 1) and were retrospectively analyzed. RESULTS: The stent was successfully placed in all 15 cases with a median procedure time of 15 min (technical success rate 100%). The median total bilirubin value decreased significantly from 3.7 before drainage to 0.9 after surgery (p < .001) and cholangitis was well managed (clinical success rate 100%). Surgery was performed at a median of 22 days after drainage, and there were no stent-related adverse events or recurrences of biliary obstruction. Severe surgery-related adverse events occurred in three cases, but none were associated with EUS-BD. The stent was removed during surgery in 12 cases. CONCLUSIONS: EUS-BD can be a feasible and safe alternative method of PBD for malignant biliary obstruction after ERCP fail.

Features of T1 pancreatic cancer and validation of the eighth edition AJCC staging system definition using a Korean-Japanese joint cohort and the SEER database.

BACKGROUND/PURPOSE: Little is known about the features of T1 pancreatic ductal adenocarcinoma (PDAC) and its definition in the eighth edition of the American Joint Committee on Cancer (AJCC) staging system needs validation. The aims were to analyze the clinicopathologic features of T1 PDAC and investigate the validity of its definition. METHOD: Data from 1506 patients with confirmed T1 PDAC between 2000 and 2019 were collected and analyzed. The results were validated using 3092 T1 PDAC patients from the Surveillance, Epidemiology, and End Results (SEER) database. RESULTS: The median survival duration of patients was 50 months, and the 5-year survival rate was 45.1%. R0 resection was unachievable in 10.0% of patients, the nodal metastasis rate was 40.0%, and recurrence occurred in 55.2%. The current T1 subcategorization was not feasible for PDAC, tumors with extrapancreatic extension (72.8%) had worse outcomes than those without extrapancreatic extension (median survival 107 vs. 39 months, p < .001). Extrapancreatic extension was an independent prognostic factor whereas the current T1 subcategorization was not. The results of this study were reproducible with data from the SEER database. CONCLUSION: Despite its small size, T1 PDAC displayed aggressive behavior warranting active local and systemic treatment. The subcategorization by the eighth edition of the AJCC staging system was not adequate for PDAC, and better subcategorization methods need to be explored. In addition, the role of extrapancreatic extension in the staging system should be reconsidered.

Significance of Zinc Replacement Therapy After Pancreaticoduodenectomy.

BACKGROUND/AIM: Recently, a decrease in serum zinc levels and the need for zinc preparations have been reported in the perioperative period of gastrointestinal surgery. In this study, we examined treatment outcomes among patients supplemented with zinc after pancreaticoduodenectomy (PD) and evaluated the significance of zinc replacement therapy. PATIENTS AND METHODS: From June 2020 to April 2021, 56 patients who received zinc acetate hydrate (50 mg/day) from postoperative day 3 after PD in our department were retrospectively reviewed. Patients' characteristics and preoperative as well as postoperative data, including serum zinc levels and surgical results at 1 month were reviewed. RESULTS: Preoperative zinc deficiency was present in 86.1% (46/56) of the patients. Moreover, despite zinc supplementation, 17.8% (10/56) of patients had postoperative zinc deficiency. A comparison between the low zinc level group (Zn <80 µg/dl) and the normal zinc level group (Zn ≥80 µg/dl) after surgery showed siginificant differences among patients with malignant diseases (vs. benign diseases, p=0.044), those undergoing open surgery (vs. minimally invasive surgery, p=0.036), and those with intraoperative blood loss ≥346 ml (vs. <346 ml: p=0.041) in the univariate analysis. Multivariate analysis revealed that zinc deficiency was significantly associated with open surgery [odds ratio (OR)=15.885, 95% confidence interval (CI)=1.77-142.01, p=0.013] and intraoperative blood loss (OR=9.329, 95% CI=1.50-57.74, p=0.016). CONCLUSION: In patients undergoing open PD for pancreatic cancer, zinc preparations of 50 mg may not be sufficient and further supplementation may be necessary.