Search

Background: Despite a strong association between nutritional indices and disease prognosis, evidence regarding the evaluation of nutritional indices after preoperative treatment for pancreatic ductal adenocarcinoma (PDAC) is insufficient. We evaluated the clinical significance of the prognostic nutritional index (PNI) in patients with resectable (R‐) and borderline resectable (BR‐) PDAC who received neoadjuvant chemoradiotherapy (NACRT) followed by pancreatic resection. Methods: We assessed 153 patients with R‐ and BR‐PDAC who underwent NACRT followed by curative resection between 2009 and 2022. We evaluated the association between preoperative PNI after NACRT and short‐ and long‐term outcomes. Results: The median preoperative PNI value after NACRT was 42.1, and the optimal cutoff value from the time‐dependent receiver operating characteristic curve was 38.6. The low PNI group (PNI < 38.6, n = 44) exhibited significantly worse inflammatory parameters, surgical outcomes, and prognoses than the high PNI group (PNI ≥ 38.6, n = 109). Multivariate analysis identified preoperative PNI ≤ 38.6 (hazard ratio [HR]: 2.32, 95% confidence interval [CI]: 1.00–5.38, p =.049), blood loss ≥1642 mL (HR: 3.05, 95% CI: 1.65–5.64, p <.001), node positive pathology (HR: 2.10, 95% CI: 1.32–3.34, p =.002), and lack of postoperative adjuvant chemotherapy (HR: 3.55, 95% CI: 2.05–6.15, p <.001) as significant predictors of overall survival. Conclusions: For patients with R‐ and BR‐PDAC receiving preoperative treatment, it is imperative to closely monitor their nutritional status when determining the optimal surgical procedure timing. [ABSTRACT FROM AUTHOR]

Background: Clinically relevant postoperative pancreatic fistula (CR‐POPF) after pancreatic resection can lead to severe postoperative complications. POPF is defined based on postoperative day (POD) 3 drainage fluid amylase level. POPF correlates with inflammatory parameters as well as drainage fluid bacterial infection. However, a standardized model based on these factors for predicting CR‐POPF remains elusive. We aimed to identify inflammatory parameter‐ and drainage fluid culture‐related risk factors for CR‐POPF on POD 3 after pancreatoduodenectomy (PD) and distal pancreatectomy (DP). Methods: Data from 351 patients who underwent PD or DP between 2013 and 2022 at a single institution were retrospectively analyzed. Risk factors for CR‐POPF were investigated using multivariate analyses, and a prediction model combining the risk factors for CR‐POPF was developed. Results: Of the 351 patients, 254 and 97 underwent PD and DP, respectively. Multivariate analyses revealed that drainage fluid amylase level ≥722 IU/L, culture positivity, as well as neutrophil count ≥5473/mm3 on POD 3 were independent risk factors for CR‐POPF in PD group. Similarly, drainage fluid, amylase level ≥500 IU/L, and culture positivity on POD 3 as well as pancreatic thickness ≥11.1 mm were independent risk factors in the DP group. The model for predicting CR‐POPF achieved the maximum overall accuracy rate when the number of risk factors was ≥2 in both the PD and DP groups. Conclusions: Inflammatory parameters on POD 3 significantly influence the risk of CR‐POPF onset after pancreatectomy. The combined models based on these values can accurately predict the risk of CR‐POPF after pancreatectomy. [ABSTRACT FROM AUTHOR]

Background: The efficacy of neoadjuvant chemoradiotherapy (NACRT) followed by pancreatoduodenectomy (PD) in elderly patients with pancreatic ductal adenocarcinoma (PDAC) remains unclear. Methods: This retrospective analysis of prospectively collected data examined the effect of NACRT followed by PD in elderly patients with PDAC. A total of 112 patients with resectable (R-) and borderline resectable (BR-) PDAC, who were planned for PD and received NACRT between 2009 and 2022, were assessed. Changes induced by NACRT, surgical outcomes, nutritional status, renal and endocrine functions, and prognosis were compared between elderly (≥75 years, n = 43) and non-elderly (<75 years, n = 69) patients over two years following PD. Results: Completion and adverse event rates during NACRT, nutritional status, renal function, endocrine function over two years postoperatively, and prognosis did not significantly differ between the two groups. Low prognostic index after NACRT and the absence of postoperative adjuvant chemotherapy may be adverse prognostic indicators for elderly patients undergoing NACRT for R- and BR-PDAC. Conclusions: Despite a higher incidence of postoperative complications, NACRT followed by PD can be safely performed in elderly patients, resulting in a prognosis similar to that in non-elderly patients. [ABSTRACT FROM AUTHOR]

Several studies have recently reported the rare occurrence of internal herniation of the small bowel after laparoscopic colorectal surgery. Most cases of internal herniation after laparoscopic colorectal surgery occur due to a mesenteric defect. However, there have been no reports on the indications for closing mesenteric defects to prevent the development of an internal hernia. This study reports a case of an internal hernia of the proximal jejunum near the ligament of Treitz in a patient who underwent laparoscopic sigmoidectomy with splenic flexural mobilization and high ligation of the inferior mesenteric vein. Assessing the risk for internal herniation before completing the initial surgery is crucial. Additionally, mesenteric defect closure should be performed to prevent the development of internal hernias among patients with a potential risk. [ABSTRACT FROM AUTHOR]

Purpose: KRAS, P16, TP53, and SMAD4/DPC4 mutations are common in pancreatic ductal adenocarcinoma (PDAC). The study aimed to evaluate the association between gene mutations in pre‐treatment endoscopic ultrasound‐guided fine needle aspiration (EUS‐FNA) samples and clinical outcomes of patients with PDAC. Methods: There were 43 patients with resectable (R) PDAC and 41 patients with borderline resectable (BR) PDAC. CDKN2A/p16, TP53, and SMAD4/DPC4 were evaluated through immunohistochemistry (IHC) of pretreatment EUS‐FNA (n = 84) and resected specimens (n = 71). All patients received neoadjuvant therapy. Results: IHC of EUS‐FNA specimens revealed p16 loss in 61 (73%), abnormal p53 in 61 (73%), and Smad4 loss in 38 (45%) patients. Abnormal p53 was associated with a lower resection rate (p =.017). Abnormal p53 and Smad4 loss were associated with recurrence within 6 months post‐pancreatectomy (p =.03, p =.03, respectively). Univariate Cox regression analysis was conducted to reveal that abnormal p53 (p =.07), p16 loss and abnormal p53 (p =.04), and Smad4 and p16 loss (p =.03) were associated with poor prognosis. Conclusions: Pre‐treatment abnormal labeling of p53 in EUS‐FNA specimen was associated with a lower resection rate and an early recurrence in R or BR PDAC cases. [ABSTRACT FROM AUTHOR]

Background and Aim: To evaluate the efficacy and safety of a grasping-type knife, called Clutch Cutter (CC), for colorectal endoscopic submucosal dissection (C-ESD). Methods: This was a randomized prospective study. Patients who underwent C-ESD for colorectal neoplasms >20 mm and <50 mm in size were enrolled, dividing into two groups: ESD using needle type of dual knife alone (D-group) and circumferential incision using dual knife followed by submucosal dissection using CC (CC-group). The primary outcome was the self-completion rate. The secondary outcomes were intraoperative complication rate, procedure time, and en bloc resection rate. Results: A total of 45 patients were allocated to the D-group and 43 to the CC-group were allocated. The self-completion rate was higher in the CC-group (87% [39/45] vs. 98% [42/43]). All of the six patients with an incomplete procedure in the D-group were completely resected with CC use. The intraoperative complication rate was not significant in either group (D vs. CC: 2% vs. 0%). The mean procedure time was significantly shorter in the D-group than that in the CC-group (62.0 vs. 81.1 min; p = 0.0036). The en bloc resection rate was 100% in the D-group and 98% in the CC-group. Conclusions: While dual knife use is superior to CC in terms of time efficiency, the use of CC may be a safe and efficacious option for achieving complete C-ESD. [ABSTRACT FROM AUTHOR]

The investigation of the thermal properties of liquid 1-butanol polymer created during a plasma-induced reaction showed some hydrogen to be electrically trapped as quasi-stable ions around negatively polarized OH and/or C=O bonds in the polymer which contributes to both electrical conductivity and the desorption of hydrogen.

Three-dimensional (3-D) microstages driven by electrostatic comb actuators that provide continuous motion along three axes (x, y, and z) were designed and fabricated. Each 3-D microstage consisted of sets of traveling tables, suspension systems, and comb actuators. To convert lateral displacement of the comb actuators to vertical motion, one suspension system incorporated leaf springs inclined to a substrate. To efficiently construct the inclined leaf springs, we devised a fabrication technique that uses deep reactive ion etching. Three-dimensional microstages were then fabricated in a 20-[micro]m-thick device layer on a silicon-on-insulator wafer. The maximum vertical (z) displacement of this 3-D microstage was 2.6 [micro]m, and the maximum lateral displacement (x and y) was more than 6 [micro]m in each direction, achieved by using support suspensions to suppress the interference between the comb actuators. A 3-D microstage was then installed in a commercial atomic force microscope, and a 3-D image of a grating was successfully measured without hysteresis using this 3-D microstage as the scanning device. [1602]

Background: Pancreatic trauma is reportedly associated with high morbidity and mortality. Main pancreatic duct (MPD) injury is critical for treatment. Methods: As a study project of the Japanese Society for Abdominal Emergency Medicine (JSAEM), we collected the data of 163 patients with pancreatic trauma who were diagnosed and treated at JSAEM board‐certified hospitals from 2006 to 2016. Clinical backgrounds, diagnostic approaches, management strategies, and outcomes were evaluated. Results: Sixty‐four patients (39%) were diagnosed as having pancreatic trauma with MPD injury that resulted in 3% mortality. Blunt trauma and isolated pancreatic injury were independent factors predicting MPD injury. Nine of 11 patients with MPD injury who were initially treated nonoperatively had serious clinical sequelae and five (45%) required surgery as a secondary treatment. Among all cases, the detectability of MPD injury of endoscopic retrograde pancreatography (ERP) was superior to that of other imaging modalities (CT or MRI), with higher sensitivity and specificity (sensitivity = 0.96; specificity = 1.0). Conclusions: Acceptable outcomes were observed in pancreatic trauma patients with MPD injury. Nonoperative management should be carefully selected for MPD injury. ERP is recommended to be performed in patients with suspected MPD injury and stable hemodynamics. [ABSTRACT FROM AUTHOR]

Although stapler dissection and closure is commonly used for laparoscopic distal pancreatectomy (LDP), it is risky in patients with thick pancreatic parenchyma or titanium allergy. We performed laparoscopic pancreatic parenchymal dissection with cavitron ultrasonic surgical aspirator (CUSA) successfully in a patient with titanium allergy. Slinging the pancreas with nylon tape delineates the surgical plane. Pancreatic parenchyma was transected by CUSA in an almost bloodless field. Pancreatic duct branches and vessels were adequately exposed and dissected with a vessel sealing system. The main pancreatic duct was closed with Hem-O-lock. CUSA is an alternative to stapler dissection during LDP in select patients. [ABSTRACT FROM AUTHOR]

Highlights • This is the first case of brachial plexus injury during thoracoscopic esophagectomy in the prone position. • This paralysis is due to excessive abduction and external rotation associated with the intraoperative position. • To avoid intraoperative brachial plexus injury in the prone position, thoughtful orientation of the head and right arm in a less loaded position is important. Abstract Introduction During prone esophagectomy, placement of a port in the third intercostal space for upper mediastinal dissection requires adequate axillary expansion. To facilitate this, the right arm is elevated cranially and simultaneously turned outward. Brachial plexus paralysis associated with esophagectomy in the prone position has not been documented. Presentation of case A 58-year-old man diagnosed with middle intrathoracic esophageal cancer was referred to our department. Thoracoscopic esophagectomy in the prone position was performed following neoadjuvant chemotherapy. After surgery, he complained of difficulty moving his right arm. Physical examination revealed perceptual dysfunction and movement disorder in the territory of cervical spinal nerve 6. Magnetic resonance imaging indicated the injury in the right posterior cord of the brachial plexus at the costoclavicular space. Therefore, we diagnosed the patient with right brachial plexus injury caused by the intraoperative position. The postoperative course was uneventful other than the brachial plexus paralysis, and he was discharged on postoperative day 23. He underwent continuous rehabilitation as an outpatient, and the right brachial plexus paralysis had completely disappeared by 2 months after surgery. Discussion This is the first case of brachial plexus injury during thoracoscopic esophagectomy in the prone position. In prone esophagectomy, managing the patient's position, especially the head and arm positions, is so important to avoid brachial plexus injury due to intraoperative positioning. Conclusion The clinicians should consider managing the patient's position with anatomical familiarity to avoid brachial plexus injury due to intraoperative positioning. [ABSTRACT FROM AUTHOR]

Background. Hepatectomy, an important treatment modality for liver malignancies, has high perioperative morbidity and mortality rates. Safe, comprehensive criteria for selecting patients for hepatectomy are needed. Since June 2011, we have used a cut-off value of ≧ 0.05 for future liver remnant plasma clearance rate of indocyanine green as a criterion for hepatectomy. The aim of this study was to verify the validity of this criterion. Methods. From June 2011 to December 2015, 212 hepatectomies were performed in Tenri Yorozu Hospital. Of these 212 patients, 107 who underwent preoperative computed tomography imaging volumetry, indocyanine green clearance test, and hepatectomy (excluding partial resection or enucleation) were retrospectively analyzed. Results. There was no postoperative mortality. Posthepatectomy liver failure occurred in 59 patients (55.1%) (International Study Group of Liver Surgery Grade A: 43 cases (40.2%), Grade B: 16 cases (15.0%), and Grade C: no cases). Operative morbidity greater than Clavien-Dindo Grade 3 occurred in 23 patients (21.5%). A low future liver remnant plasma clearance rate of indocyanine green was a good predictor for Grade B cases (area under curve = 0.804; 95% confidence interval, 0.712–0.895). Conclusion. Liver remnant plasma clearance rate of indocyanine green is a valid criterion for hepatectomy. [ABSTRACT FROM AUTHOR]

Recent studies have reported that immune checkpoint inhibitors are effective against various defective mismatch repair (dMMR)/microsatellite instability-high (MSI-H) cancers. A limited number of reports are available on the frequency of dMMR/MSI-H carcinoma in biliary tract cancer (BTC), describing its clinicopathological characteristics and prognosis. The latter carcinoma is also associated with Lynch syndrome (LS). The present study was performed to investigate the frequency of patients with dMMR/MSI-H in BTC and the clinical characteristics of BTC with dMMR/MSI-H in a single institution in Japan. A total of 116 patients with BTC who underwent curative surgical resection at Kagawa University Hospital between January 2008 and December 2017 were included. The protein expression levels of the mismatch repair (MMR) genes [mutL homolog 1 (MLH1), mismatch repair endonuclease PMS2 (PMS2), MutS homolog (MSH)2 and MSH6] were assessed by immunohistochemistry (IHC) using formalin-fixed paraffin-embedded tissue specimens. Subsequently, MSI testing was performed on patients who exhibited loss of MMR protein expression. Loss of expression of one or more proteins was detected in five cases (4.3%). Loss of MLH1/PMS2 expression was observed in one case of intrahepatic cholangiocarcinoma, whereas loss of PMS2 expression was noted in one case of perihilar cholangiocarcinoma. Loss of MSH2/MSH6 and MSH6 expression was noted in two cases of distal cholangiocarcinoma and loss of PMS2 expression in one case of ampullary carcinoma. Out of the five patients, two demonstrated MSI-H. Microsatellite stability was observed in two cases and for one case, no data were available. Two MSI-H cases were patients with loss of expression of MLH1/PMS2 and MSH2/MSH6. None of the five patients exhibited a past medical history or family history of suspected LS. The frequency of dMMR in BTC was ~5%, which was similar to that reported by similar studies performed in other countries. In the present study, IHC appeared to be more useful than MSI testing for detecting MMR abnormalities with regards to the detection rate. Furthermore, there may only be a limited number of patients with BTCs who are likely to benefit from the therapeutic effects of treatment with immune checkpoint inhibitors. [ABSTRACT FROM AUTHOR]

A microlateral force sensor (MLFS) was developed and evaluated using atomic force microscopy (AFM). The sensor was attached to a sensing table supported by a suspension system. The lateral motion of the sensing table was activated by a comb actuator. The driving voltage to the comb actuator was controlled to maintain a constant position of the sensing table by detecting the tunneling current at a detector, which consisted of two electrodes where the bias voltage was applied. An AFM was used to apply a lateral force to the sensing table of the sensor. When the probe of a cantilever was pressed against the sensing table and a raster scanning was conducted, the driving voltage of the comb actuator changed to compensate the friction force between the probe and sensing table. AFM measurements of an asperity array on the sensing table were conducted, and a lateral force microscopy image (LFM) was obtained from the change in driving voltage. The image by MLFS was very similar to the LFM image that was conventionally obtained from torsion of the cantilever. The LFM image strongly correlated with the gradient image calculated from the AFM topographic image. The force sensitivity of the MLFS was determined by comparing the LFM image obtained by using the MLFS with the tangential force derived from the gradient of the AFM image. [ABSTRACT FROM AUTHOR]