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Background/aim: Obesity is a major technical limiting factor for laparoscopic surgery because abundant visceral fat is known to extend the operation time. However, special hardware is needed to assess it. We hypothesized that the depth from the peritoneum to the bifurcation of the inferior mesenteric artery (IMA) defined as 'peritoneum to IMA distance (PID)' might be a simple predictive factor for extended operation time during laparoscopic colectomy., Patients and Methods: One hundred twenty-four patients who were diagnosed with sigmoid or rectosigmoid colon cancer and underwent laparoscopic colectomy were included. The patients were divided into two groups based on the operation time (210 min). The vertical distance from the peritoneum to the bifurcation of the inferior mesenteric artery was defined as PID. The factors eliciting an operation time longer than 210 min were investigated., Results: There was significant difference in sex, BMI, cT, cN, and PID between the Early group (<210 min) and Late group (≥210 min). Less blood loss was observed in the Early group than in the Late group. Multivariate analysis showed that PID was the only independent factor that affected operation time (p<0.001)., Conclusion: PID predicts the operation time during laparoscopic colectomy for sigmoid or rectosigmoid colon cancer., Competing Interests: All Authors have no conflicts of interest to declare in relation to this study., (Copyright 2022, International Institute of Anticancer Research.)

Background: Continuing antithrombic therapy (ATT) during surgery increases the risk of bleeding. However, it is difficult to discontinue the ATT in emergency surgery. Therefore, safety of emergency laparoscopic cholecystectomy (LC) for acute cholecystitis (AC) is still unclear. We aimed to clarify the affect of ATT during emergency LC for AC., Methods: Patients with AC were classified into ATT group (n = 30) and non-ATT group (n = 120). Postoperative outcomes were compared after propensity score matching (n = 22)., Results: Higher level of c-reactive protein level and shorter activated partial thromboplastin time (APTT) was observed in ATT group than in non-ATT group after matching. No significant difference was found between other patient characteristics and perioperative results. Blood loss over 100 mL was observed in 8 patients. Multivariate analyze showed that APTT was an independent risk factor for bleeding over 100 mL (P = 0.039), while ACT and APT was not., Conclusions: Taking ATT does not affect the blood loss or complications during emergency LC for AC. Controlling intraoperative bleeding is essential for a safe postoperative outcome., (© 2022. The Author(s).)

Introduction: The closure of the appendiceal stump is a crucial part of a laparoscopic appendectomy, and an endoloop or endostapler is generally used. The endoloop can be more cost effective than the endostapler. However, reports have shown that the endoloop has a higher postoperative abdominal abscess rate than the endostapler in complicated appendicitis. At our institution, we perform a purse-string suture after ligating by endoloop to reduce postoperative abdominal abscess risk. This study aimed to clarify whether this method could reduce the incidence of postoperative abdominal abscess compared with the endostapler., Methods: Patients with acute appendicitis were classified into the purse-string suture group (n = 149) and the endostapler group (n = 82). Postoperative outcomes were compared after propensity score matching (n = 47)., Results: No significant difference was found between the two groups in terms of the patient characteristics and postoperative complications, including abdominal abscess. However, the purse-string suture group had more drain placement and a shorter hospital stay than the endostapler group (P = .04 and P = .02, respectively). In patients with complicated appendicitis, there was less drain placement and a shorter hospital stay in the purse-string suture group than in the endostapler group (P < .01 and P < .01, respectively). This might have reflected the difficulty of the operation. All postoperative abdominal abscesses occurred in complicated appendicitis cases., Conclusions: Endoloop with additional purse-string suture had a lower incidence of abscess than previous reports of using endoloop alone. Moreover, the postoperative abdominal abscess rate is similar between the two closure methods., (© 2021 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Background: Solitary fibrous tumor (SFT) is a rare mesenchymal tumor that typically arises from the pleura. Although it may appear in other organs, it rarely develops in the pancreas. We report herein a rare case of metastatic SFT of the pancreas originating from an intracranial tumor and subsequently identified as a cystic neoplasm of the pancreas., Case Presentation: A 58-year-old woman with a past medical history of brain tumor visited the hospital for further investigation of a cystic tumor in the pancreas tail. Abdominal imaging showed a heterogeneously enhancing mass that was initially suspected as a neuroendocrine neoplasm, solid pseudopapillary neoplasm, or mucinous cystic neoplasm of the pancreas. Distal pancreatectomy was performed without any intraoperative and postoperative complications. Pathological findings confirmed a diagnosis of malignant SFT of the pancreas with hyperproliferative potential. A histopathological review of her brain tumor revealed that the pancreatic tumor was derived from her brain lesion. The patient developed recurrent brain disease 4 years after the pancreatectomy, but no recurrence has been observed in the abdominal cavity., Conclusions: SFT should be considered in the differential diagnosis of untypical hypervascular pancreatic mass, particularly in patients with a history of an intrathoracic or intracranial mesenchymal tumor. Immunohistochemical analysis is crucial in detecting this tumor entity. Hyperproliferative status indicates a malignant disease and requires careful postoperative observation.

Background: This study was designed to clarify effects of postoperative adjuvant chemotherapy for high-risk Stage Ⅱ colorectal cancer., Method: The subjects were 99 patients with high-risk Stage Ⅱcolorectal cancer who underwent surgery at our department from October 2013 to March 2018. Patients were classified into adjuvant chemotherapy group and nonadjuvant chemotherapy group. Overall survival(OS)and recurrence-free survival(RFS)were analyzed between the 2 groups., Results: Thirty six patients(36.4%)underwent adjuvant chemotherapy. Adjuvant chemotherapy group were younger(p<0.010), had a better ASA-PS(p<0.010), good preoperative Hb(p<0.010), and preoperative Alb(p<0.010)compared to non-adjuvant chemotherapy group. There was no difference between the 2 groups in the high-risk factors for recurrence. Most patient had an oral medication as for adjuvant chemotherapy. There was no difference in OS and RFS between the 2 groups., Conclusion: Postoperative adjuvant chemotherapy for high-risk Stage Ⅱ colorectal cancer did not significantly improve the OS and RFS. Further study is necessary to asses the suitable regimen and patients eligible for chemotherapy.

We conducted a retrospective study to evaluate the efficacy and the problem of the neoadjuvant chemotherapy using DCF for cStage Ⅲ/Ⅳ(squamous cell)esophageal cancer. Eleven patients from January 2017 to December 2018 were enrolled into this study. The median age was 67 years old, male/female ratio was 9:2, performance status was 0 in all patients, and UICC cStage Ⅲ/Ⅳa was 7:4. Cycles of chemotherapy was 2 in 1 patients, 3 in 5 patients and additional 2 courses in 1 patient. Four patients switched to FP therapy after a course of DCF. The efficacy of chemotherapy was evaluated by the clinical response rate, average tumor reduction rate, and histological therapeutic effect rate over Grade 2 which was 63.6%, 48.3%, and 40%, respectively. Neutropenia over Grade 3 was observed in all patients and Grade 4 was observed in 6 patients. In conclusion, preoperative chemotherapy with DCF therapy is useful for the treatment of cStage Ⅲ/Ⅳ(squamous cell) esophageal cancer as long as bone marrow suppression is managed.

Background/aim: The benefits of gastrectomy for elderly gastric cancer (GC) patients remain unknown. The aim of this study was to evaluate the validity of gastrectomy., Patients and Methods: Patients who had R0 or R1 resection and diagnosed as pathological Stage I-III GC were enrolled in this study. Patients were classified according to age: Elderly group (≥80 years old), non-Elderly group (70-79 years old), Standard group (≤69 years old)., Results: As the age raised, the number of comorbidities increased and patients had a worse physical status. Operative procedure and postoperative complications of the Elderly group were similar to that of the non-Elderly group. The overall survival was similar in pathological Stages I and III between the Elderly and non-Elderly groups, while the Stage II Elderly group had shorter overall survival. Also, the Elderly group did not undergo adjuvant chemotherapy compared to other groups., Conclusion: Gastrectomy can be performed safely in elderly patients following gastrectomy, survival of elderly patients was similar to non-elderly patients. Therefore, gastrectomy is an acceptable treatment for elderly patients in good condition., (Copyright© 2019, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: The ideal neoadjuvant treatment protocol for patients with pancreatic cancer (PDAC) remains unclear. We evaluated the efficacy and safety of neoadjuvant hypofractionated chemoradiotherapy with S-1 for patients with resectable (R) and borderline resectable (BR) PDAC., Methods: Eligibility criteria included patients with R and BR PDAC, performance status 0-1, and age 20-85 years. Hypofractionated external-beam radiotherapy (30 Gy in 10 fractions) with concurrent S-1 (60 mg/m 2 ) was delivered 5 days/week for 2 weeks prior to pancreatectomy., Results: Fifty-seven patients were enrolled in this study, including 33 R and 24 BR [19 BR tumors with portal vein contact (BR-PV) and 5 BR tumors with arterial contact (BR-A)]. The total rates of protocol treatment completion and resection were 91% (50/57) and 96% (55/57), respectively. Seven patients failed to complete S-1 due to cholangitis (n = 5) or neutropenia (n = 2). The most common grade 3 toxicities [Common Terminology Criteria for Adverse Events (CTCAE) version 4.0] were anorexia (7%), nausea (5%), neutropenia (4%), and leukopenia (4%). No patient experienced grade 4 toxicity. Pathologically negative margins (R0) were achieved in 54 of 55 patients (98%) who underwent pancreatectomy. Pathological response was classified as Evans grade I in 8 patients (15%), IIa in 31 patients (56%), IIb in 14 patients (25%), III in 1 patient (2%), and IV in 1 patient (2%), and operative morbidity (Clavien-Dindo grade IIIb or less) was observed in 4 patients (8%). The 1- and 2-year overall survival (OS) rates were 91 and 83% in R patients, respectively, and 77 and 58% in BR patients, respectively (p = 0.03)., Conclusion: Neoadjuvant S-1 with concurrent hypofractionated radiotherapy is tolerable and appears promising for patients with R and BR PDAC.

We report a case of successful laparoscopic distal gastrectomy with D2 lymph node dissection preserving the common hepatic artery branched from the left gastric artery for advanced gastric cancer with an Adachi type VI (group 26) vascular anomaly. A 76-year-old female patient was admitted with a diagnosis of advanced gastric cancer at the anterior wall to the lesser curvature of the antrum (cT3N0M0 cStage IIA). Dynamic computed tomography showed the ectopia of the common hepatic artery branched from the left gastric artery. We made a diagnosis of an Adachi type VI (group 26) vascular anomaly and performed the abovementioned operation. In this anomaly pattern, scrupulous attention is required to remove the suprapancreatic lymph nodes because the portal vein is located immediately dorsal to those lymph nodes and is at increased risk for the injury in this situation. The common hepatic artery is branched from the left gastric artery, and the hepatic perfusion from the superior mesenteric artery is not present in group 26. Planning to preserve the artery will improve safety when it is possible oncologically. There were no postoperative complications, and the patient was discharged 9 days after the operation. To our knowledge, the present case is the first reported case of a laparoscopic distal gastrectomy with D2 lymph node dissection with an Adachi type VI (group 26) vascular anomaly. Preoperative diagnostic imaging is very important to prevent surgical complications because the reliable identification of vascular anomaly during an operation is very difficult.

Introduction: Laparoscopic distal gastrectomy (LDG) with D1+ lymph node dissection (LND) for early gastric cancer has been widely accepted. However, LDG with D2 LND for advanced gastric cancer remains in limited use. The aim of this retrospective study was to clarify the safety of LDG with D2 LND for gastric cancer., Methods: From January 2010 to September 2014, 296 patients underwent LDG; those who received D1+ LND (n = 230) or D2 LND (n = 66) were included in this study. The clinicopathological characteristics and short-term outcomes of both groups were investigated and compared., Results: There were no significant differences in the incidence of postoperative complications between the two groups. However, the frequency of infectious intra-abdominal complications was higher in the D2 LND group than in the D1+ LND group. Additionally, a lower risk of infectious intra-abdominal complications was seen with certified than with uncertified operators., Conclusion: The evaluation of short-term outcomes demonstrated that LDG with D2 LND is generally feasible. However, the risk of infectious intra-abdominal complications is higher with D2 LND than with D1+ LND. Also, D2 LND should be performed by trained operators., (© 2016 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and John Wiley & Sons Australia, Ltd.)

The prognosis of Stage IV b pancreatic cancer is extremely poor; the mean survival time is 2-4 months. However, new anticancer agents can improve the outcome of advanced pancreatic cancer. We present the case of a 50-year-old female patient with Stage IV b pancreatic head cancer with invasion to the superior mesenteric vein(SMV)and multiple liver metastases. The patient received S-1 as first-line chemotherapy. Three months later, a further CT scan showed reduction of the pancreatic tumor, disappearance of the liver metastases, and reduction in SMV invasion. Therefore, a subtotal stomach-preserving pancreatoduodenectomy with partial SMV resection was performed. Following surgery, the patient received S-1 chemotherapy again. However, lung metastasis appeared. Despite the initiation of gemcitabine(GEM)treatment, the patient developed metastases in other parts of the lung and the abdominal wall. She died 46 months after surgery, but it is noteworthy that the liver metastases were manageable. The combination of chemotherapy and surgery was effective in prolonging survival in this patient with Stage IV b pancreatic head cancer.

Purpose: Although splenectomy plays an important role in the management of patients with liver cirrhosis, the optimal technique, open surgery, total laparoscopic surgery or hand-assisted laparoscopic surgery (HALS), has not yet been defined. The present study evaluated the outcomes of HALS splenectomy for cirrhotic patients., Methods: A total of 28 consecutive patients with cirrhosis that underwent HALS splenectomy were enrolled into this study. The preoperative laboratory and morphometric data, intraoperative variables and postoperative outcomes were reviewed from the hospital charts., Results: The postoperative platelet count was remarkably elevated in all cases. A re-operation was required in 1 patient complicated with postoperative hemorrhage. Enhanced CT on POD 7 revealed a high incidence of portal or splenic vein thrombosis (PSVT; 22 patients, 78.6 %). PSVT was significantly associated with higher serum bilirubin, higher indocyanine green retention value at 15 min (ICG R-15), and larger splenic vein diameter., Conclusion: HALS splenectomy was a very feasible and appropriate procedure for cirrhotic patients with hypersplenism. PSVT was a frequent complication and large splenic vein diameter, high serum bilirubin, and high ICG R-15 were found to be significant risk factors for PSVT after HALS splenectomy in cirrhotic patients.

Purpose: No consistent risk factor has yet been established for the development of pancreatic fistula (PF) after distal pancreatectomy (DP) with a stapler., Methods: A total of 31 consecutive patients underwent DP with an endopath stapler between June 2006 and December 2010 using a slow parenchymal flattening technique. The risk factors for PF after DP with an endopath stapler were identified based on univariate and multivariate analyses., Results: Clinical PF developed in 7 of 31 (22 %) patients who underwent DP with a stapler. The pancreata were significantly thicker at the transection line in patients with PF (19.4 ± 1.47 mm) in comparison to patients without PF (12.6 ± 0.79 mm; p = 0.0003). A 16-mm cut-off for pancreatic thickness was established based on the receiver operating characteristic (ROC) curve; the area under the ROC curve was 0.875 (p = 0.0215). Pancreatic thickness (p = 0.0006) and blood transfusion (p = 0.028) were associated with postoperative PF in a univariate analysis. Pancreatic thickness was the only significant independent factor (odds ratio 9.99; p = 0.036) according to a multivariate analysis with a specificity of 72 %, and a sensitivity of 85 %., Conclusion: Pancreatic thickness is a significant independent risk factor for PF development after DP with an endopath stapler. The stapler technique is thus considered to be an appropriate modality in patients with a pancreatic thicknesses of <16 mm.

A partial splenectomy is a good way to prevent postsplenectomy infections by preservation of the immune role of the spleen for select patients. Although a laparoscopic total splenectomy is a safe and feasible treatment modality, the laparoscopic approach has not been generally adopted for a partial splenectomy because of technical difficulties. The hand-assisted technique provides an excellent means to explore, to retract safely, and to apply immediate hemostasis in solid organ resection. The hand-assisted laparoscopic partial splenectomy using an endopath monopolar sealer (Salient EndoSH2.0 Monopolar Sealer) was performed successfully. The segmental arteries and veins were isolated and divided using a tactile feedback. Splenic parenchyma was dissected and sealed using an endopath monopolar sealer. The surgical field was almost bloodless during the parenchymal transection and the transection time was around 15 minutes. The hand-assisted laparoscopic approach allows partial splenectomy as a safe and bloodless surgery for select patients.

Background/purpose: A consistent predictor for pancreatic fistula (PF) development in the early period after pancreatic resection is still lacking., Patients and Methods: A total of 54 consecutive patients undergoing pancreatic resection were enrolled between June 2007 and April 2010. Pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) were performed in 38 and 16 patients, respectively. For the purpose of finding an early predictor for PF development, we investigated drain amylase levels (d-Amy, IU/mL), drain output volume (d-Vol, mL/day) and drain amylase output (Amy-V, IU/day) on postoperative days (POD) 1 and 3. Amy-V was calculated as the product of d-Amy and d-Vol, and was expressed as the sum of values obtained from all drains. In addition, the ratio of d-Amy or Amy-V on POD3 to that on POD1 was calculated as the persisting ratio in each patient., Results: The overall incidence of clinical PF (International Study Group on Pancreatic Fistula Grade B and C) was 16.7%, occurring in 13.1% after PD and 25% after DP. All PF occurred in cases with a remnant pancreas of soft texture. There was no significant difference in d-Amy, d-Vol, or Amy-V on POD1 and POD3 between patients with and without clinical PF. The persisting ratio of Amy-V was significantly lower in patients without clinical PF compared to those with clinical PF (p = 0.029). Furthermore, the persisting ratio of Amy-V was significantly lower in patients with Grade A PF compared to those with Grade B PF (p = 0.03)., Conclusion: The persisting ratio of drain amylase output is a new significant predictive factor for clinical PF development., (© 2011 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background/aims: Despite recent development of therapeutic strategies for intrahepatic lesions, standard guidelines for treatment of extrahepatic metastases of hepatocellular carcinoma have not been established., Methodology: Surgical resection for intra-abdominal extrahepatic metastases of hepatocellular carcinoma was performed on 10 patients at our institution between 1992 and 2008. We retrospectively examined the clinicopathologic features and significance of a surgical approach in these patients., Results: Nine of the 10 patients received treatment for primary hepatocellular carcinoma before surgery for intra-abdominal extrahepatic metastasis. A simultaneous intrahepatic lesion was detected in half of the patients when the extrahepatic metastasis was resected. Extrahepatic recurrent organs included adrenal glands, lymph nodes, abdominal wall, stomach and diaphragm. The mean survival period after resection was 36.1 months. Two patients are still alive without further recurrence. One patient died of retroperitoneal recurrence and 7 died of intrahepatic recurrence or liver failure after resection., Conclusions: With careful case selection, considering that not all extrahepatic metastases suggest systemic spread of hepatocellular carcinoma, surgical treatment for metastatic lesions in the abdominal cavity can provide a relatively good prognosis.

Background: Preconditioning using lipopolysaccharide (LPS), a Toll-like receptor (TLR)-4 ligand, has been demonstrated to attenuate ischemia-reperfusion injury (IRI) in several organs but has not been sufficiently elucidated in the liver. We investigated the molecular mechanism of protection induced by LPS preconditioning against hepatic IRI., Methods: BALB/c mice underwent 70% hepatic ischemia for 90 min. LPS was injected intraperitoneally 20 hr before ischemia at a range of 1 to 1000 μg/kg. Hepatic injury was evaluated based on serum alanine aminotransferase levels and histopathology. Inflammatory cytokine expression, nuclear factor-κB activation, and c-Jun N-terminal kinase phosphorylation were investigated after reperfusion. Additionally, preischemic expression of negative feedback inhibitors of the TLR4 cascade was examined., Results: Only the 100 μg/kg LPS pretreatment significantly reduced serum alanine aminotransferase levels and histopathologic damage 6 hr after reperfusion; there was no difference among other LPS concentrations. In mice pretreated with LPS, intrahepatic expression of tumor necrosis factor-α and interleukin (IL)-6 as well as activation of nuclear factor-κB and c-Jun N-terminal kinase were inhibited 1 hr after reperfusion, whereas expression of IL-10, an anti-inflammatory cytokine, was induced. Suppressor of cytokine signaling (SOCS)-1, SOCS-3 and IL-1 receptor-associated kinase-M were upregulated by LPS exposure in the preischemic period., Conclusions: Hepatic LPS preconditioning elicited the upregulation of specific negative regulators in the TLR4 signaling pathway. Preischemic induction of these regulators plays an important role as immunologic preparation for the subsequent ischemia-reperfusion and produces resistance to liver injury. Preoperative modulation of the TLR4 pathway might become an alternative therapeutic strategy against hepatic IRI.

Aim: To investigate the role of (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in the diagnosis of small pancreatic cancer., Methods: This study involved 31 patients with proven invasive ductal cancer of the pancreas. The patients were divided into 3 groups according to the maximum diameter of the tumor: TS1 (maximum tumor size ≤ 2.0 cm), TS2 (> 2.0 cm and ≤ 4.0 cm) or TS3-4 (> 4.0 cm). The relationships between the TS and various diagnostic tools, including FDG-PET with dual time point evaluation, were analyzed., Results: The tumors ranged from 1.3 to 11.0 cm in diameter. Thirty of the 31 patients (97%) had a positive FDG-PET study. There were 5 patients classified as TS1, 15 as TS2 and 11 as TS3-4. The sensitivity of FDG-PET, computed tomography (CT) and magnetic resonance imaging (MRI) were 100%, 40%, 0% in TS1, 93%, 93%, 89% in TS2 and 100%, 100%, 100% in TS3-4. The sensitivity of FDG-PET was significantly higher in comparison to CT and MRI in patients with TS1 (P < 0.032). The mean standardized uptake values (SUVs) did not show a significant difference in relation to the TS (TS1: 5.8 ± 4.5, TS2: 5.7 ± 2.2, TS3-4: 8.2 ± 3.9), respectively. All the TS1 tumors (from 13 to 20 mm) showed higher SUVs in FDG-PET with dual time point evaluation in the delayed phase compared with the early phase, which suggested the lesions were malignant., Conclusion: These results indicate that FDG-PET with dual time point evaluation is a useful modality for the detection of small pancreatic cancers with a diameter of less than 20 mm.

Background: Preconditioning using lipopolysaccharide (LPS), a toll-like receptor 4 (TLR4) ligand, has been demonstrated to reduce ischaemia/reperfusion injury (IRI) in some organs, but its effect in the liver has not been elucidated. We examined the liver protective mechanism and correlated signalling pathway of LPS preconditioning in mice., Methods: BALB/c and TLR4 mutant mice underwent 90 min of 70% hepatic ischaemia. Lipopolysaccharide (100 µg/kg) was injected intraperitoneally 20 h or 30 min before ischaemia. Liver damage after reperfusion was examined using serum samples and liver specimens. To analyse the mechanism of preconditioning in detail, phosphorylation of representative signalling mediators to nuclear factor-κB (NF-κB) activation, Akt and interleukin-1 receptor-associated kinase-1 (IRAK-1), and expression of a negative feedback inhibitor, suppressor of cytokine signalling-1 (SOCS-1), were evaluated by Western blotting., Results: Pretreatment with LPS only 20 h before ischaemia elicited a preconditioning effect; however, preconditioning was absent in TLR4 mutant mice. Lipopolysaccharide significantly decreased serum alanine aminotransferase, tumour necrosis factor-α, hepatocyte necrosis and NF-κB activity after reperfusion. Phosphorylated IRAK-1 was suppressed by LPS, whereas no difference was observed in phosphorylated Akt. Pre-ischaemic LPS provided early induction of SOCS-1., Discussion: Late-phase LPS preconditioning provided liver protection against IRI through the downregulation of the TLR4 cascade derived from early induction of SOCS-1 during ischaemia/reperfusion., (© 2010 International Hepato-Pancreato-Biliary Association.)

Backgrounds/aims: The appropriate closure of the pancreatic remnant after a distal pancreatectomy remains controversial. To describe a safer and simple distal pancreatectomy using an endopath stapler, with special emphasis on the slow parenchymal flattening technique., Methodology: The slow parenchymal flattening technique (SFT) for a distal pancreatectomy using an endopath stapler (Echelon 60) was applied to avoid a destruction of pancreas capsule and parenchyma for a soft friable pancreas. In this technique, the pancreas was gently compressed with an atraumatic intestinal clamp for a few minutes prior to the stapling dissection. Then, the closure jaw of endopath stapler was closed carefully and slowly taking more than 5 minutes at the fixed speed before dissection., Results: SFT using the Echelon 60 was performed for 22 consecutive patients who required a distal pancreatectomy. Only one patient (4.5%) developed a symptomatic pancreatic fistula (ISGPF classification grade B). There were no mortalities or severe pancreatic fistula (ISGPF classification grade C) in this series., Conclusions: The SFT using the Echelon 60 can be performed easily, which enables surgeons to achieve confident pancreas stump without any tissue injury.

A 66-year-old woman underwent a total gastrectomy for advanced gastric cancer of cardia. The histological diagnosis was moderately-differentiated tubular adenocarcinoma and the pathological Stage was IV: T4 (diaphragm), N2, M0. Microscopically, there were findings of severe lymphatic and venous invasions with intravenous tumor thrombus around the splenic hilum. Immunohistochemical staining confirmed AFP production of the tumor. The risk of recurrence was considered very high and her prognosis very poor. The patient received adjuvant chemotherapy with S-1. There was no finding of recurrence in the series of postoperative follow-up examinations. Previous reports describe the prognosis of AFP producing gastric cancer as very poor. In several cases, however, aggressive treatments for AFP producing gastric cancer may result in a better prognosis. This is a long survival case of AFP producing gastric cancer successfully treated with S-1 after surgery.

We report herein two patients with acquired fatty replacement of the distal pancreas, who underwent pancreaticoduodenectomy (PD) without reconstruction of remnant pancreas. Slow-growing tumors resulted in obstructive pancreatitis of the distal pancreas and insufficient focal blood flow, resulting in marked atrophy of the pancreas and fatty replacement. Suspected disappearance and fatty replacement of the body and tail of the pancreas were noted. In this situation, the PD procedure can be achieved without the reconstruction of remnant pancreas. Interestingly, the patients did not require insulin support postoperatively.

In islet transplantation, insufficient yield is a major obstacle to one-donor/one-recipient transplant. Collagenase, which is injected via a pancreatic duct to separate islets from acini, can so easily distribute into the islet core that it may result in disruption of islets. The purpose of this study was to evaluate the superiority of reduced pressure-controlled collagenase injection (RPCI) at 80 mmHg on islet isolation to injection at 180 mmHg by examining in vivo transplant experiments besides the yield and the glucose stimulation test in a rat model. Lewis rat pancreases were distended with collagenase solution at 80 mmHg pressure as the RPCI group (group 1) and at 180 mmHg (group 2), followed by isolation. The yield in group 1 (1100 +/- 160 islets with 2750 +/- 530 IEQ) was significantly higher than that in group 2 (900 +/- 130 islets with 1570 +/- 350 IEQ, p < 0.01) due to the significant difference of the number of islets sized >150 microm in diameter, although the purity was not significantly different between the two groups. Stimulation indices in the glucose stimulation tests were 2.88 +/- 1.12 in group 1 and 1.93 +/- 0.62 in group 2 (p < 0.05). The cure rate by transplantation of 100 islets to diabetic nude mice in group 1 (8/10) was significantly higher than that in group 2 (3/10, p < 0.05). In a syngenic transplant model of 90% of islets isolated from one donor, the cure rates were 100% and 67% in groups I and 2, respectively (NS). The area under the curve on the graph of IPGTT on postoperative day 28 in group I was significantly smaller than that in group 2 (p < 0.05). In conclusion, our data show that RPCI at 80 mmHg could contribute to consistently high islet yield and in vivo function in a rat model. It was suggested that the current human protocol should be reviewed from this viewpoint.

Background/aims: We have already reported that the two-layer method (UW/PFC) reduces warm and cold ischemic injuries before islet isolation, and results in improvement of islet yield and viability. In this study, we try to evaluate the effect of the two-layer method on isolated islets., Methodology: We used male Wister rats. Isolated islets were cultured or preserved in various conditions for 24 hours. In group 1, islets were not cultured (control). In group 2, islets were cultured in RPMI at 37 degrees C. In groups 3 and 4, islets were cultured with "modified" two-layer method (RPMI/PFC) at 37 degrees C and 4 degrees C, respectively. In groups 5 and 6, islets were preserved in UW and with the two-layer method (UW/PFC), respectively at 4 degrees C. Islets in each group were evaluated in terms of function and viability in vitro., Results: Stimulation Indices were 1.3, 2.6, 3.7, 1.2, 1.4, and 2.4 in groups 1, 2, 3, 4, 5 and 6, respectively. Islets in groups 2, 3 and 6 showed clear response to glucose stimulation. Among these 3 groups, the total viability of islets assessed by FDA/PI staining was 88%, 92%, and 76% in groups 2, 3, 6, respectively., Conclusions: Although in vivo studies are mandatory, the present study is supportive that the "modified" two-layer method (RPMI/PFC), which uses oxygenated PFC and RPMI, may be superior to conventional culture method with RPMI. This method may achieve further improvement of islet viability before implantation.

Background: The shortage of cadaveric donors is a problem in islet transplantation, and recent improvements in this field have led to renewed interest in the use of nonheartbeating (NHB) donors. NHB donor pancreata that could provide a significant source for islet transplantation are associated with warm ischemic injury. We tested whether the two-layer method (TL) could improve islet yield and function from damaged pancreata after warm ischemia (WI)., Methods: Lewis rats were divided into six groups. In groups 1 to 3, rats were subjected to 0, 30, and 45 minutes of WI, respectively. Islets were isolated immediately (subgroup a) or after 3-hour preservation with TL (subgroup b). Isolated islets were assessed in terms of islet yield and in vivo function. We also assessed the pancreatic tissue ATP concentration before isolation and distended pancreata morphologically after chemical digestion by H&E staining., Results: Islet yield decreased significantly after 30 minutes of WI in group 2a, whereas TL preservation doubled this decreased yield in group 2b. Forty-five minutes of WI resulted in nearly no islet yield in both groups 3a and 3b. The success rates of transplantation in groups 1a, 1b, 2a, and 2b were 100%, 100%, 0%, and 75%, respectively. Increased tissue ATP levels and alleviation of morphological islet damage were observed in group 2b., Conclusions: These results demonstrated that pancreata damaged from 30-minute WI were restored by 3-hour TL preservation. TL may allow the selective use of NHB donors as an alternative source for islet transplantation.

Small bowel transplantation (SBT) is associated with a high incidence of infectious complications because of ischemia/reperfusion (I/R) mucosal injury concomitant with potent immunosuppression. In this study, we evaluated whether the cavitary two-layer method (cTLM) could reduce I/R injury and allow early mucosal restoration, particularly after prolonged preservation and transplantation. Canine heterotopic segmental SBT was performed immediately without preservation (group 1), after 24-h preservation in UW solution (group 2) or by the cTLM (group 3). The graft samples were taken 1 h after reperfusion and on days 1, 4 and 7. We assessed graft mucosa with detailed microscopic and electromicroscopic analyses. In Group 3, histological injury and cell apoptosis after transplantation were significantly alleviated and rapidly recovered to a similar level of group 1. The mucosal restoration was morphologically completed within 4 days. In contrast, in group 2, more pronounced mucosal injury and delayed recovery were noted. Crypt cell proliferation activity was well maintained in groups 1 and 3 throughout the experimental period. Our ultrastructural analysis suggested that mitochondrial integrity achieved by the cTLM was a basal mechanism under the prompt mucosal restoration. The cTLM could reduce I/R injury, facilitate mucosal regeneration and restore the nearly normal structure early after SBT.

Background: Although the outcome of islet transplantation has improved, there remains a major obstacle in isolating viable islets from prolonged preserved pancreas. We previously reported that the two-layer cold storage method (TLM) improved the yield and in vitro function. In this study, we performed in vivo accurate functional analyses of islets from TLM-preserved pancreas and investigated pancreatic duct cell viability, which may critically affect islet isolation., Methods: Rat islets isolated from fresh pancreas (group 1), after preservation in the University of Wisconsin (UW) solution (group 2) or by the TLM (group 3), were examined by assessing islet yields, stimulation indices, cure rates after transplantation to diabetic nude mice, and trypan blue uptake of pancreatic duct cells., Results: TLM significantly improved the islet yield compared with UW cold storage. The cure rates after transplantation were 100%, 0%, and 80% for groups 1, 2, and 3, respectively. This indicates that islet viability was well maintained even after 24 hr of TLM preservation. The percentages of nonviable duct cells were 4.1%+/-1.9%, 48.3%+/-8.0%, and 26.1%+/-21.4% in groups 1, 2, and 3, respectively, showing that the TLM was superior to UW as seen by this duct cell viability assessment., Conclusions: The TLM used for pancreas preservation before islet isolation results in excellent islet function in addition to improved islet yield comparable to freshly isolated islets. The underlying mechanism may be duct cell viability maintained during TLM preservation. Therefore the TLM is an excellent preservation technique for isolating sufficient numbers of highly viable islets.

Background: With the current shortage of donors, there is a critical need to optimally use "less-than-ideal" donors for pancreas transplantation. Objective and rapid means for assessing graft viability and suitability for transplantation are mandatory. This study examined the possibility of graft viability assessment and posttransplant outcome prediction using (31)P-nuclear magnetic resonance (NMR) spectroscopy combined with the two-layer cold-storage method (TLM)., Methods: Canine pancreas grafts were preserved with TLM for 24 hours after 0, 60, or 120 minutes of warm ischemia (groups 1, 2, or 3, respectively). After preservation, we determined intragraft phosphate metabolites noninvasively using (31)P-NMR spectroscopy. Time required for this assessment was 5 minutes. Because our previous studies demonstrated that all grafts in groups 1 and 2 were successfully transplanted (the viable group), whereas all in group 3 failed to survive (the nonviable group), the possibility of posttransplant outcome prediction was examined on the basis of the comparison between these two groups., Results: The ratios of inorganic phosphate/gamma-adenosine triphosphate (Pi/gamma-ATP) and Pi/beta-ATP reflected the extent of graft damage, and the differences were statistically significant among groups 1, 2, and 3. On the basis of analyses of receiver operator characteristic curves, the optimum cutoff levels between the viable and nonviable groups were 1.6 and 2.2 for Pi/gammaATP and Pi/betaATP, respectively. The accuracy rates of these ratios were both 83%., Conclusion: (31)P-NMR spectroscopy combined with TLM preservation could provide an objective, rapid, and possibly noninvasive means to assess pancreas graft viability and to determine suitability of damaged pancreata for organ transplantation.

Background: Ischemia and reperfusion (I/R) injury is a major determinant of early graft dysfunction and long-term graft survival in small intestinal transplantation. The cavitary two-layer method (TLM) has been reported to be superior to the University of Wisconsin cold storage method (UWM) in long-term preservation of canine small intestine. This study was designed to evaluate the protective effect of the cavitary TLM against I/R injury in canine small intestinal transplantation., Methods: Intestinal grafts harvested from beagles were allotransplanted after 24-hour preservation by UWM (group 1) or the cavitary TLM (group 2). The graft in the controls (group 3) was immediately allotransplanted without preservation. I/R injury was assessed by functional success rates, biochemical assay, graft adenosine triphosphate (ATP) and lipid peroxidation (LPO) concentrations, and histopathologic examination including TUNEL staining for apoptosis., Results: In group 1, ATP recovery was delayed after reperfusion, and most recipients died with hemorrhage of the grafts and lungs. In group 2, graft ATP concentrations recovered rapidly, and I/R injury was prevented with reduced LPO production, resulting in good outcome., Conclusions: The cavitary TLM protected intestinal grafts against I/R injury evidenced by maintenance of graft ATP levels and reduction of LPO production compared with UWM in canine small intestinal transplantation.

Background: The purpose of this study is to examine the possibility of a long-term preservation of the ischemically damaged intestine by the cavitary two-layer method (TLM) in canine small intestinal transplantation., Methods: The grafts were allotransplanted without preservation immediately (group 1) or after 30 minutes of warm ischemia (group 2). The ischemically damaged grafts were also allotransplanted after cold preservation for 24 hours in University of Wisconsin (UW) solution (group 3) or the cavitary TLM (group 4). Seven-day survivals, tissue adenosine triphosphate (ATP) concentrations, absorption tests, and histopathology were examined., Results: seven-day survivals in groups 1, 2, 3, and 4 were 8 of 8, 6 of 8, 0 of 8, and 6 of 8, respectively. In group 4, significant recovery of ATP tissue level was seen after preservation compared with group 3, and absorption function and regeneration of the graft mucosa recovered at day 14., Conclusions: Ischemically damaged canine small intestine could be preserved for 24 hours by the cavitary TLM.

Background: Apoptosis in isolated islets has been implicated in primary nonfunction or early graft failure after islet transplantation. Recently, pancreas preservation by the 2-layer method (TLM) before islet isolation has been proved to improve the islet yield, quality, and transplant results not only in experimental models, but also in clinical settings. We examined the influence of TLM on apoptosis of isolated islets., Method: Rat islets freshly isolated and after pancreas preservation by TLM or conventional cold storage in University of Wisconsin solution (UW) were examined and compared. Islet apoptosis was assessed by TUNEL and annexin V assays. The apoptosis pathways involved were investigated by measurement of caspase 3, 8, and 9 activities and by immunoblotting for total and phosphorylated c-Jun NH2-terminal kinase (JNK) and p38., Results: Islet apoptosis in the UW group was significantly increased compared with the fresh and TLM groups. Both caspase 3 and 9 activities in the UW group were higher than in the fresh and TLM groups with an approximate increase of 2- to 3-fold. On the other hand, there was no significant difference in caspase 8 activity among these 3 groups. JNKs were strongly activated both in the TLM and UW groups; although they were not activated in the fresh group, p38 was activated to almost the same levels in these 3 groups., Conclusions: Pancreas preservation by TLM before islet isolation protects isolated islets against apoptosis mainly through the mitochondrial pathway. Pancreas storage before islet isolation even with TLM triggers activation of JNKs in isolated islets.