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Background: The use of the hinotori™ Surgical System (hinotori) in distal pancreatectomy (DP) is new compared to the da Vinci™ Surgical System (DVSS). The hinotori is equipped with mechanisms distinct from those of DVSS, and comprehensive reports detailing the surgical techniques and outcomes associated with hinotori in DP (hinotori-DP) are lacking. This study aimed to compare the outcomes of DP using the hinotori and DVSS (Xi system), focusing on differences in settings and techniques between the two methods., Methods: This study retrospectively investigated consecutive patients who underwent robotic DP from April 2010 (the introduction of robotic DP at our institute) to July 2024. The analysis excluded patients who underwent spleen-preserving procedures or procedures performed using robotic platform other than hinotori or daVinci Xi. The hinotori-DP cases were compared with those performed using DVSS (DVSS-DP). The techniques used in hinotori-DP were examined in more detail., Results: A total of 75 robotic DP cases (11 with hinotori and 64 with DVSS) were analyzed in this study. Different port configurations and techniques, including a lesser curvature approach, were used in the hinotori-DP compared to DVSS-DP. The operation time was relatively shorter in the hinotori-DP group (299 vs. 366 min, p = 0.095), and the postoperative complication rates were comparable (pancreatic fistula: 27 % vs. 30 %, p = 0.871; Clavien-Dindo Grade ≥3a complications: 18 % vs. 19 %, p = 0.964) between the two groups., Conclusion: The hinotori-DP can be safely performed by focusing on the unique characteristics of the hinotori surgical system., Competing Interests: Competing interests Payment or activities from a third party for any aspect of the submitted work: Nothing to disclose., (Copyright © 2025. Published by Elsevier Ltd.)

Background: Postoperative pancreatic fistula (POPF) is one of the potentially serious complications after gastrectomy for gastric cancer (GC). Drain amylase level is a predictor of POPF in open and laparoscopic gastrectomy, but no study has focused on minimally invasive surgery (MIS), including robotic gastrectomy (RG). This study assesses the effect of drain amylase levels for POPF in MIS and develop a prediction model in the MIS era., Methods: This single-institutional retrospective study, conducted from January 2011 to December 2021, included 1,353 who underwent standard MIS for GC. We placed a drain in all patients undergoing MIS gastrectomy and measured the drain amylase level on the first postoperative day (D1Amy). The predictive accuracy of D1Amy for POPF was assessed. Additionally, the entire cohort was randomly categorized into the training (1,048 patients) and validation sets (305 patients) to establish the nomogram., Results: Of the 1353 patients, 530 underwent a robotic approach. POPF and intraabdominal infectious complications of Clavien-Dindo classification grade ≥ II were observed in 80 (5.9%) and 145 (10.7%) patients, respectively. Median D1Amy was 812 U/L. The receiver operating characteristic analysis of D1Amy for POPF revealed an area under the curve (AUC) of 0.888. Multivariate analysis revealed age, tumor location, splenectomy, and D1Amy as significant risk factors for POPF. The AUC of the nomogram was 0.8960, validated with AUC of 0.9259., Conclusions: We revealed the utility of D1Amy in predicting POPF in MIS gastrectomy. Furthermore, the nomogram, incorporating D1Amy and other clinical factors, was additionally used as a predictive model for POPF., Competing Interests: Declarations. Disclosures: Seiji Inoue, Masaya Nakauchi, Susumu Shibasaki, Yusuke Watanabe, Yusuke Umeki, Kazumitsu Suzuki, Akiko Serizawa, Shingo Akimoto, Tsuyoshi Tanaka, Kazuki Inaba, Ichiro Uyama, and Koichi Suda have no commercial associations or financial involvement that might be construed as a conflict of interest in connection with the submitted article. Ichiro Uyama has received lecture fees from Intuitive Surgical, Inc., outside of the submitted work. Ichiro Uyama has been funded by Medicaroid, Inc. in relation to the Collaborative Laboratory for Research and Development in Advanced Surgical Technology, Fujita Health University. Koichi Suda has been funded by Sysmex, Co. in relation to the Collaborative Laboratory for Research and Development in Advanced Surgical Intelligence, Fujita Health University, outside of the submitted work. K.S. received research expenses from Sysmex, Co. and Medtronic, Inc., unrelated to the present study., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Hepatocyte mitochondrial morphology and gene expression were compared between biliary atresia (BA), infantile cholestasis (IC), and normal liver (NL) as prognostic indicators., Methods: Specimens of liver at portoenterostomy (PE) for BA, from intrahepatic bile duct paucity patients for IC, and from choledochal cyst or hepatoblastoma patients for NL were collected prospectively (P) beginning in 2021 (P-BA = 11, P-IC = 9, P-NL = 7) and retrospectively (R) from paraffin-embedded tissue going back to 1981 (R-BA = 25, R-IC = 9, R-NL = 4). The P-cohort had transmission electron microscopy (TEM) to image mitochondria, immunoblotting for heat shock protein 60 (HSP60), and quantitative PCR (qPCR) for HSP60 and mitochondrial functional genes. Both cohorts had immunofluorescence for HSP60 quantified as a ratio to albumin-positive hepatocytes (ALB) with HSP60/ALB<1.0 as a cutoff limit using ImageJ., Results: HSP60 was significantly lower in BA/IC than NL on qPCR (BA: p < 0.01, IC: p < 0.05) and lower in BA than IC/NL on immunoblotting (p < 0.05). HSP60/ALB was significantly lower in BA than NL/IC (p < 0.001). Despite BA subjects being matched for types of BA and ages at PE, HSP60/ALB did not correlate with jaundice clearance (JC; T-Bil<1.2 mg/dL) but was significantly higher in native liver survivors (NLS) after PE compared with liver transplant (LTx) cases (p < 0.05) and significantly lower in LTx cases achieving JC than NLS achieving JC (p < 0.05). TEM showed BA had significantly more mitochondrial inclusion bodies (p < 0.05) and significantly larger cristae (p < 0.01) than IC/NL. qPCR in BA showed significant repression of mitochondrial functional genes for mRNA stabilization and energy facilitation., Conclusion: HSP60/ALB correlates with NLS after PE for BA., Level of Evidence: II., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Advanced gastric cancer with gastric outlet obstruction (GOO) causes malnutrition and medication adherence issues, leading to a poor prognosis. We developed a novel multimodal, less invasive treatment approach for gastric cancer patients with symptomatic GOO: laparoscopic stomach-partitioning gastrojejunostomy (LSPGJ) combined with neoadjuvant chemotherapy (NAC), followed by minimally invasive gastrectomy with reuse of gastrojejunostomy. This study is a retrospective analysis of the safety and feasibility of our treatment strategy., Methods: In this single-institution retrospective study, we enrolled 54 patients (NAC group, n = 26; upfront gastrectomy group, n = 28) who achieved R0 resection through a minimally invasive approach between 2007 and 2020 and evaluated their short- and long-term outcomes., Results: After LSPGJ, the Gastric Outlet Obstruction Scoring System score significantly improved (p < 0.001). The median relative dose intensity of NAC was 88.2%. Regarding short-term outcomes, there were no differences in postoperative complications, length of postsurgical hospital stay, and adjuvant chemotherapy administration. Although overall survival and relapse-free survival showed trends toward improvement in the NAC group, these differences were not statistically significant. The cumulative incidence curve for recurrence in the NAC group was significantly lower than that of the upfront gastrectomy group (p = 0.041). Recurrence and hematogenous metastasis were significantly lower in the NAC group (p = 0.031 and 0.041, respectively) than in the upfront gastrectomy group. A forest plot revealed that NAC yielded favorable outcomes, particularly for patients with a body mass index (BMI) < 18.5 kg/m 2 , cT4, or cN1., Conclusions: LSPGJ combined with NAC followed by minimally invasive gastrectomy was a safe and feasible treatment strategy for patients with advanced gastric cancer with symptomatic GOO. This procedure may contribute to the early recovery of oral intake and help maintain NAC dose intensity, potentially improving prognosis, particularly for patients with low BMI and advanced-stage disease., Competing Interests: Declarations. Disclosures: Tsuyoshi Tanaka, Koichi Suda, Masaya Nakauchi, Masahiro Fujita, Kazumitsu Suzuki, Yusuke Umeki, Akiko Serizawa, Shingo Akimoto, Yusuke Watanabe, Susumu Shibasaki, Hiroshi Matsuoka, Kazuki Inaba, and Ichiro Uyama do not have conflicts of interest or financial relationships to disclose regarding the present study. Ichiro Uyama received funding from Medicaroid, Inc. related to the Collaborative Laboratory for Research and Development in Advanced Surgical Technology, Fujita Health University. Ichiro Uyama also received advisory fees from Intuitive Surgical, Inc. and Asahi Intecc Co., Ltd., as well as lecture fees from Intuitive Surgical, Inc., Medicaroid Inc., and Medtronic Japan Co., Ltd., all of which were unrelated to the submitted work. Koichi Suda received funding from Sysmex, Co. related to the Collaborative Laboratory for Research and Development in Advanced Surgical Intelligence, Fujita Health University. Koichi Suda also received funding for research expenses from Sysmex, Co. and Medtronic, Inc., which were unrelated to the present study., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Colorectal cancer (CRC) is well characterized in terms of genetic mutations and the mechanisms by which they contribute to carcinogenesis. Mutations in APC, TP53, and KRAS are common in CRC, indicating key roles for these genes in tumor development and progression. However, for certain tumors with low frequencies of these mutations that are defined by tumor location and molecular phenotypes, a carcinogenic mechanism dependent on BRAF mutations has been proposed. We here analyzed targeted sequence data linked to clinical information for CRC, focusing on tumors with a high tumor mutation burden (TMB) in order to identify the characteristics of associated mutations, their relations to clinical features, and the mechanisms of carcinogenesis in tumors lacking the major driver oncogenes. Analysis of overall mutation frequencies confirmed that APC, TP53, and KRAS mutations were the most prevalent in our cohort. Compared with other tumors, TMB-high tumors were more frequent on the right side of the colon, had lower KRAS and higher BRAF mutation frequencies as well as a higher microsatellite instability (MSI) score, and showed a greater contribution of a mutational signature associated with MSI. Ranking of variant allele frequencies to identify genes that play a role early in carcinogenesis suggested that mutations in genes related to the DNA damage response (such as ATM and POLE) and to MSI (such as MSH2 and MSH6) may precede BRAF mutations associated with activation of the serrated pathway in TMB-high tumors. Our results thus indicate that TMB-high tumors suggest that mutations of genes related to mismatch repair and the DNA damage response may contribute to activation of the serrated pathway in CRC., (© 2025 The Author(s). Cancer Science published by John Wiley & Sons Australia, Ltd on behalf of Japanese Cancer Association.)

Purpose: The effect of the Rho-kinase inhibitor ripasudil on the retinal optic nerve fiber layer (RNFL) remains unclear. We aimed to determine this effect in patients with primary open-angle glaucoma (POAG) using optical coherence tomography (OCT) measurements and linear mixed analysis. Methods: This study prospectively included outpatients from a single center with POAG without a history of vitreoretinal or glaucoma surgery from December 2014 to June 2020, in whom the circumpapillary RNFL thickness (cpRNFLT) was measured more than three times before and after ripasudil initiation, without additional medication or surgery during the period. Measurements were performed using OCT in the follow-up mode. The cpRNFLT change rates were compared before and after treatment using linear mixed models with adjustments for intraocular pressure (IOP) changes. Results: Thirty eyes of 20 patients (12 males and eight females) were included. Upon ripasudil prescription, the average cpRNFLT was 60.2 ± 2.1 μm. The average IOP was 15.1 ± 0.5 and 13.5 ± 0.5 mmHg, respectively, before and after treatment initiation, with a difference of -1.6 ± 0.3 mmHg. Analysis of 343 cpRNFLT measurements using linear mixed models revealed that the cpRNFLT change rate was -0.91 ± 0.15 and -0.40 ± 0.14 μm/year, respectively, before and after treatment onset, with an increase of 0.51 ± 0.21 μm/year. After adjusting for IOP changes, the improvement in cpRNFLT change rate was 0.33 ± 0.23 μm/year, albeit not statistically significant. Conclusion: The cpRNFLT change rate significantly increased after ripasudil administration, whereas the contribution of the IOP decline was not significant., Competing Interests: K.S., K.S., T.A., H.O.I., M.M., and A.T. received lecture fees from Kowa Pharmaceutical. K.S. received a consultation fee from Kowa Pharmaceutical. All other authors declare no conflicts of interest., (Copyright © 2025 Katsumasa Sakurai et al. Journal of Ophthalmology published by John Wiley & Sons Ltd.)

Background and Aims: EUS-guided peripancreatic fluid drainage (EUS-PFD) with on-demand endoscopic necrosectomy, increasingly used to manage walled-off necrosis (WON), is associated with substantial morbidity and mortality. This multicenter study aimed to externally validate recently developed quadrant (an abdominal quadrant distribution), necrosis, and infection (QNI) criteria for risk stratification in this setting., Methods: Of 423 patients with pancreatic fluid collections treated in a large multi-institutional cohort between 2010 and 2020, a total of 212 with available preprocedural CT images were included. Clinical outcomes between high- and low-risk groups defined according to QNI criteria were compared., Results: The clinical success rate did not differ significantly between the QNI-high and QNI-low groups (74.4% vs 83.5%, respectively; P = .12). Time to clinical success was longer in the QNI-high group compared with the QNI-low group (median, 68 vs 46 days; P = .0016). Compared with the QNI-low group, the QNI-high group was associated with higher rates of percutaneous interventions, direct endoscopic necrosectomy, mortality, and adverse events. The QNI-high group was independently associated with time to clinical success (hazard ratio, .64; 95% confidence interval, .46-.87; P = .005) in multivariable Cox proportional hazards regression analysis and with the risk of grade III or higher adverse events (odds ratio, 2.93; 95% confidence interval, 1.04-8.20; P = .04) in multivariable logistic regression analysis., Conclusions: The QNI criteria effectively stratified time to clinical success and the risk of adverse outcomes for patients receiving EUS-PFD of WON. Further investigations could elucidate appropriate management strategies based on QNI-based risk stratification., Competing Interests: Disclosure The following authors disclosed financial relationships: H. Isayama: research funding from Boston Scientific Japan, Fujifilm, and Piolax Medical Devices; honoraria from Boston Scientific Japan, Concept Medical, Create Medic, Fujifilm, Gadelius Medical, Hitachi Medical, Japan Lifeline, Kaneka, Kawasumi Laboratories, Olympus Medical, Piolax Medical Devices, Sumitomo Bakelite, UMIDAS, and Zeon Medical; and contributions from Boston Scientific Japan, Gadelius Medical, Japan Lifeline, and Zeon Medical. Y. Nakai: research funding from Boston Scientific Japan, Century Medical, Fujifilm, Gadelius Medical, HOYA Pentax Medical, Hitachi Medical, Kaneka, and Medico’s Hirata; and honoraria from Boston Scientific Japan, Fujifilm, Gadelius Medical, Hitachi Medical, J-MIT, Medico’s Hirata, and Olympus Medical. All other authors disclosed no financial relationships. This work was supported by a grant from the Japanese Foundation for Research and Promotion of Endoscopy (Research Grant B/#1015, to T.S.) and JSPS KAKENHI (Grants-in-Aid for Scientific Research; grant no. 21K07913, to H.S.). The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript., (Copyright © 2025 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Aim: Malnutrition is reportedly associated with the development of delirium. As dental health is essential for nutritional intake, tooth loss may be a risk factor for the development of delirium. This study aimed to investigate the relationship between postoperative delirium and the number of remaining teeth in patients undergoing gastrointestinal surgery., Methods: This retrospective study included 453 consecutive patients aged ≥65 years who underwent programmed gastrointestinal cancer surgery under general anesthesia at the Department of Surgery, Fujita Health University Hospital, between January 2022 and December 2022. Background factors were prepared between the participants with and without dental intervention. In the dental intervention group, associations between background and surgical factors and the presence of postoperative delirium were explored. Factors with significant associations with postoperative delirium in the univariate analysis were subjected to logistic regression analysis to determine their association with the number of remaining teeth., Results: Overall, 189 participants underwent postoperative management. They had a significantly lower Prognostic Nutritional Index and higher cognitive decline than the 264 patients who underwent no dental intervention during this period. However, no significant difference was observed in the incidence of postoperative delirium between the two groups. In the dental intervention group, logistic regression analyses revealed that postoperative complications and the number of remaining teeth were significantly associated with postoperative delirium development., Conclusion: The results revealed that a decrease in the number of remaining teeth is associated with postoperative delirium. The cause of this is not clear, but it is thought to be related to brain fragility. Geriatr Gerontol Int 2025; 25: 90-95., (© 2024 Japan Geriatrics Society.)

Background: In the field of abdominal surgery, including colorectal cancer surgery, robotic surgery has become widespread, and the introduction of new robotic platforms is increasing. As a result, the incidence of subcutaneous emphysema (SE) as a postoperative complication has increased; however, the causes, grade, and perioperative course of SE have not been definitively examined. Therefore, we aimed to evaluate potential risk factors of SE after robotic colorectal cancer surgery., Methods: Between November 2022 and March 2024, 244 consecutive patients who underwent robotic colorectal cancer surgery using the da Vinci Xi (n = 190) or the hinotori™ platform (n = 54) were retrospectively analyzed. Risk factors associated with postoperative SE were assessed by multivariate analysis using logistic regression models. Moreover, the grade of SE and its perioperative course were investigated based on the two robotic platforms., Results: Postoperative SE was observed in 95 patients (38.9%). Nine patients (3.7%) had severe SE. The risk factors for SE were female sex, older age (≥ 80 years), and maximum intraabdominal pressure (max IAP) with CO 2 insufflation > 10 mmHg (odds ratio [95% confidence interval]: 1.981 [1.105-3.552], p = 0.022; 2.765 [1.310-5.835], p = 0.008; and 13.249 [1.227-143.020], p = 0.033, respectively). Additionally, the incidence of SE when using the hinotori™ platform was significantly lower than when using the da Vinci Xi platform (0.302 [0.135-0.667], p = 0.004)., Conclusions: Max IAP with CO 2  > 10 mmHg was associated with SE during robotic colorectal cancer surgery. Compared with the use of da Vinci Xi, the use of hinotori™ was associated with fewer incidences of postoperative SE, especially in females and older patients (≥ 80 years)., Competing Interests: Declarations. Disclosures: Tsutomu Kumamoto, Koki Otsuka, Junichiro Hiro, Hiroko Taniguchi, Yeongcheol Cheong, Yusuke Omura, Gaku Inaguma, Yosuke Kobayashi, Megumu Kamisima, Kazuki Tsujimura, Yuko Chikaishi, Koji Masumori, Ichiro Uyama, and Koichi Suda declare that they have no conflict of interest in connection with the submitted article. Ichiro Uyama has received lecture fees from Intuitive Surgical, Inc., and Medtronic, Inc., outside of the submitted work. Ichiro Uyama has been funded by Medicaroid, Inc., in relation to the Collaborative Laboratory for Research and Development in Advanced Surgical Technology, Fujita Health University. Koichi Suda has been funded by Sysmex, Co., in relation to the Collaborative Laboratory for Research and Development in Advanced Surgical Intelligence, Fujita Health University, outside of the submitted work. K.S. received research expenses from Sysmex, Co. and Medtronic Japan Co., Ltd., unrelated to the present study., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: To investigate whether Leukotriene B4 receptor 2 (BLT-2), an upstream regulator of tight junction protein (TJP) Claudin-4, and TJPs could be etiologic factors in Hirschsprung-associated enterocolitis (HAEC) after pull-through (PT) for Hirschsprung disease (HD)., Methods: Normoganglionic colon (HD-N) and aganglionic rectum (HD-A) specimens from rectal/rectosigmoid (R/RS) or descending/transverse (D/T) HD were assessed using quantitative polymerase chain reaction (qPCR) for Occludin, TJP-1, TJP-2, Junctional adhesion molecule (JAM)-1, JAM-2, Claudin-1, Claudin-3, Claudin-4, and BLT-2 and immunoblotting for Claudin-4 using fresh specimens obtained intraoperatively (2021-2024; n = 17; R/RS = 15 and D/T = 2). Claudin-4 immunohistochemistry was also evaluated quantitatively using preserved (n = 29; R/RS = 20 and D/T = 9; 2009-2021) and fresh HD specimens for comparison with anorectal malformation patients having colostomy closure as controls (n = 42) and between HD-A versus HD-N, R/RS versus D/T, and HAEC (+) versus HAEC (-). Technically inadequate or transitional zone PT were excluded., Results: Subjects were 123 PT cases. Mean ages at PT/colostomy closure (years) were R/RS: 2.7 ± 2.9, D/T: 1.6 ± 2.2, and controls: 1.4 ± 0.7. Postoperative HAEC occurred 18 times in 14 PT cases (grade I = 5, grade II = 13). Post-PT HAEC was significantly more frequent in D/T (50.0% versus 6.4%; p < 0.001); Claudin-4 was significantly lower in HD-N from post-PT HAEC cases, especially D/T (p < 0.05) on immunohistochemistry. Claudin-4 was significantly lower in HD-N/HD-A compared with controls on immunoblotting (p < 0.05) and immunohistochemistry (p < 0.001). qPCR showed TJP-1, TJP-2, JAM-1, JAM-2, Claudin-4, and BLT-2 were significantly lower in HD-N/HD-A compared with controls., Conclusions: Lower Claudin-4 and BLT2 in post-PT HAEC HD-N (especially D/T) suggests generalized epithelial barrier derangement with possible etiologic implications for HAEC., Level of Evidence: Ⅱ., Competing Interests: Conflicts of interest The authors declare they have no conflicts of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: While Epidermal growth factor receptor (EGFR) mutation-positive lung adenocarcinoma (LUAD) has favorable outcomes with targeted therapy, early-stage prognosis remains influenced by pathological factors and central nervous system (CNS) recurrence. The study aimed to clarify prognostic factors in pathological stage (pStage) I EGFR mutation-positive LUAD., Methods: Between 2015 and 2018, 2,191 pStage I LUAD cases with known EGFR status (excluding EGFR testing after recurrence) who received anatomical resection were included from multiple institutions in Japan. Univariate and multivariate analyses of disease-free survival (DFS) and overall survival (OS) were performed., Results: 1,073 (49.0%) cases harbored EGFR mutations, including 419 (19.1%) with 19del and 529 (24.1%) with L858R. In cases with major EGFR mutation (n = 948), multivariate analysis showed that the absence of noninvasive area (NIA) (hazard ratio [HR]: 1.778, 95% confidence interval [CI]: 1.174-2.692, P = .0065), pStage (IA2 vs. IA1, HR: 2.079, 95% CI: 1.129-3.827, P = .0345; IA3 vs. IA1, HR: 4.009, 95% CI: 2.088-7.696, P = .0001; IB vs. IA1, HR: 5.280, 95% CI: 2.871-9.709, P < .0001), and presence of lymphatic invasion (HR: 1.855, 95% CI: 1.103-3.119, P = .0197) were independent predictors of shorter DFS, and only advanced pStage was an independent predictor of CNS recurrence (relative risk for pStage IA3 or more: 9.729, P < .0001)., Conclusion: In EGFR mutation-positive pStage I LUAD, those without NIA, with higher pStage and lymphatic invasion were independent predictive factors for DFS, and pStage ≥ IA3 was an independent predictor of CNS recurrence., Competing Interests: Disclosure All the authors declare no conflicts of interest in association with this study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: In Japan, the hinotori™ surgical robot system (Medicaroid Corporation, Kobe, Japan) was approved for gastrointestinal surgeries in October 2022. This report details our initial experience performing liver resection using the hinotori™ system. Methods: Ten patients, who were assessed as cases that would benefit from the robot-assisted procedure, underwent liver resections using the hinotori™ system at Fujita Health University, Okazaki Medical Center, between August 2023 and October 2024. The backgrounds (patient, tumor, and liver function conditions, along with types of liver resections and previous surgical procedures) and short-term outcomes (operation time, blood loss, postoperative complications, open conversion, length of hospital stay, and mortality) of the cases were evaluated. Results: Eight cases of partial liver resection, one extended left medial sectionectomy, and one left hemi-hepatectomy were performed. Six cases of hepatocellular carcinomas, three cases of liver metastases, and one case of hepatolithiasis were included. There were seven male and three female patients with a median age of 70 years. Three physical status class III and seven class II patients were included. The median body mass index was 24. Five patients had previous upper abdominal surgical histories and five patients had liver cirrhosis. The median operation time was 419.5 min, and the median intraoperative blood loss was 276 mL. An open conversion in one hepatocellular carcinoma case was carried out due to bleeding from collateral vessels in the round ligament. The median length of hospital stay was 7.5 days. A grade IIIa complication (delayed bile leakage) was developed in one case. All patients with tumors underwent R0 resection. There were no cases of mortality. Conclusions: Liver resection using the hinotori™ system was feasibly performed. This study reports the first global use of the hinotori™ system for liver resection.

Background/purpose: Gut microbiota status after pancreaticoduodenectomy (PD) is unclear, and postoperative fatty liver is an important complication after PD. This study evaluated the relationship between postoperative fatty liver and gut microbiota after PD., Methods: Fecal samples were collected from patients who had undergone PD and remained stable after 6 months of follow-up. A comprehensive bacterial analysis using 16S rRNA gene amplicon sequencing was performed. The results were compared with those of 85 healthy volunteers. The association between perioperative factors, gut microbiota, and development of fatty liver was investigated., Results: Twenty-four patients after PD, including 10 in the fatty liver (FL) group and 14 in the normal liver (NL) group were investigated. The β-diversity of the gut microbiota was significantly different between the healthy volunteers and patients after PD, with more Escherichia coli and Streptococcus gallolyticus and less Bifidobacterium catenulatum and Faecalibacterium prausnitzii in the patients with PD. Lactobacillus gasseri was significantly less abundant in the FL group than in the healthy volunteers, although this change was not observed in the NL group., Conclusions: The gut microbiota of patients after PD was in dysbiosis at postoperative ≥6 months. Development of fatty liver might be associated with significant differences in gut microbiota., Competing Interests: Declaration of competing interest Tadashi Fujii, Hideaki Takahashi, Yoshiki Hirooka, and Takumi Tochio are members of BIOSIS Lab. Co., Ltd. The other authors have no conflicts of interest regarding this paper. This study was supported by the Fujita Health University Faculty Research Grant., (Copyright © 2024 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background/objectives: To investigate whether the corrective effect differs between upward and downward transpositions or between exotropia and esotropia in vertical transposition accompanied by horizontal rectus muscle recession-resection., Subjects/methods: This prospective study investigated 41 patients with concomitant exotropia or esotropia with small-angle vertical deviation who underwent unilateral vertical transposition accompanied by horizontal rectus muscle recession-resection and were followed up for 1 year postoperatively. We analysed the vertical deviation corrective effect, defined as the corrective amount per displacement distance (°/tendon width [TW]). We compared the corrective effects between upward and downward transpositions and between exotropia and esotropia. Additionally, we investigated the correlation between the corrective effect and the studied parameters., Results: The 1-year vertical corrective effect was 5.2 ± 4.6° (9.0 ± 8.1 prism dioptres [Δ])/TW. The 1-year vertical corrective effect of upward transposition (7.9 ± 4.0° [13.8 ± 7.0Δ]/TW) was higher than that of the downward transposition (3.9 ± 4.4° [6.8 ± 7.7Δ]/TW, P = 0.009). In contrast, upward and downward transposition did not differ between exotropia and esotropia (P = 0.62). Multivariate analyses revealed that the 1-year vertical corrective effect correlated with the vertical transposition direction (upward or downward) and preoperative vertical deviation but did not correlate with the disease type (exotropia or esotropia). The 1-year motor success (vertical deviation ≤ 5Δ) rate was 89%., Conclusion: The vertical corrective effect of vertical transposition accompanied by horizontal rectus muscle recession-resection is greater in upward transposition than in downward transposition; however, it does not differ between exotropia and esotropia., Competing Interests: Competing interests: All authors attest that they meet the current ICMJE criteria for authorship., (© 2024. The Author(s).)

Objective: The risk factors for residual liver recurrence after resection of colorectal cancer liver metastases were analyzed separately for synchronous and metachronous metastases., Methods: This retrospective study included 236 patients (139 with synchronous and 97 with metachronous lesions) who underwent initial surgery for colorectal cancer liver metastases from April 2010 to December 2021 at the Fujita Health University Hospital. We performed univariate and multivariate analyses of risk factors for recurrence based on clinical background., Results: Univariate analysis of synchronous liver metastases identified three risk factors: positive lymph nodes (p = 0.018, HR = 2.067), ≥3 liver metastases (p < 0.001, HR = 2.382), and use of adjuvant chemotherapy (p = 0.013, HR = 0.560). Multivariate analysis identified the same three factors. For metachronous liver metastases, univariate and multivariate analysis identified ≥3 liver metastases as a risk factor (p = 0.002, HR = 2.988); however, use of adjuvant chemotherapy after hepatic resection was not associated with a lower risk of recurrence for metachronous lesions. Inverse probability of treatment weighting analysis of patients with these lesions with or without adjuvant chemotherapy after primary resection showed that patients with metachronous liver metastases who did not receive this treatment had fewer recurrences when adjuvant therapy was administered after subsequent liver resection, although the difference was not significant. Patients who received adjuvant chemotherapy after hepatic resection had less recurrence but less benefit from this treatment., Conclusion: Risk factors for liver recurrence after resection of synchronous liver metastases were positive lymph nodes, ≥3 liver metastases, and no postoperative adjuvant chemotherapy. Adjuvant chemotherapy is recommended after hepatic resection of synchronous liver metastases., Competing Interests: Declaration of competing interest The authors declare that they have no conflicts of interest., (Copyright © 2024 Asian Surgical Association and Taiwan Society of Coloproctology. Published by Elsevier B.V. All rights reserved.)

Background: Telesurgery has been made increasingly possible with the advancements in robotic surgical platforms and network connectivity. However, long-distance transnational complex robotic surgeries such as gastrectomy have yet to be attempted., Methods: Multiple transnational network connections by Science Innovation Network (SINET), Japan Gigabit Network (JGN), and Arterial Research and Education Network in Asia-Pacific (ARENA-PAC) were established and tested by multiple surgeons in a dry box model. Surgeons' perceptions of the different networks were recorded. Three robotic radical D2 gastrectomies in live porcine models were performed at a hospital in Toyoake, Japan, by a surgical team in a hospital in Singapore ~5000 km away, using the hinotori Surgical Robot System (Medicaroid Corporation)., Results: The live porcine robotic gastrectomies were all completed in under 205 min with no intraoperative complications. From the different networks that were tested, the differences in latency ranged from 107 to 132 ms and did not translate to any significant differences in surgeon timings and perceptions., Conclusions: Transnational telesurgical radical D2 gastrectomy is feasible in a porcine model. There is no appreciable difference between surgeon performance and perception with network latencies of 107-132 ms. Long-range telesurgery as clinical practice may become possible in the future., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background and Aims: EUS-guided transmural drainage with on-demand endoscopic necrosectomy (EN) is increasingly used to manage walled-off necrosis (WON). It has not been fully elucidated how EN and its timing are correlated with treatment outcomes compared with the drainage-based approach., Methods: Within a multi-institutional cohort of 423 patients with pancreatic fluid collections, including 227 patients with WON, 153 patients were identified who received the step-up treatment after the initial EUS-guided drainage of symptomatic WON; this included 102 EN patients and 51 non-EN (drainage) patients. Using the competing-risks multivariable proportional hazards regression model with adjustment for potential confounders, we calculated subdistribution hazard ratios (SHRs) for clinical treatment success (WON resolution) according to use of EN and its timing., Results: Compared with drainage alone, the EN-based treatment was associated with a shorter time to clinical success with a multivariable SHR of 1.66 (95% confidence interval, 1.12-2.46). Despite a higher risk of procedure-related bleeding in the EN group, there were no differences in the rates of severe adverse events (7.8% vs 5.9% in the EN and non-EN groups, respectively) or mortality (6.9% vs 9.8%). In the EN-treated patients, the timing of EN was not statistically significantly associated with the time to clinical success (P trend  = .34)., Conclusions: Among patients receiving EUS-guided treatment of symptomatic WON, the use of EN in addition to drainage procedures was associated with earlier disease resolution. Further research is desired to determine the optimal timing of initiating EN considering a risk-benefit balance and cost-effectiveness., Competing Interests: Disclosure The following authors disclosed financial relationships: Dr Isayama received support from Boston Scientific Japan, FUJIFILM Corporation, Piolax Medical Devices, Century Medical, Gadelius Medical, FUJIFULM Healthcare, Japan Lifeline Co.,Ltd and ZEON MEDICAL INC. Paid speaker for Boston Scientific Japan, FUJIFILM Corporation, Piolax Medical Devices, Century Medical, CREATE MEDIC, Gadelius Medical, FUJIFULM Healthcare, Japan Lifeline Co., KANEKA MEDIX CORP, Kawasumi Laboratories, Olympus Medical, Sumitomo Bakelite Co., Ltd. and ZEON MEDICAL INC. Consulting for Kawasumi Laboratories. Y. Nakai: research funding and consulting for Boston Scientific Japan, Fujifilm, Gadelius Medical, Hitachi Medical, and Medico’s Hirata; research funding from Century Medical, HOYA Pentax Medical, and Kaneka; and consulting for Olympus Medical and J-MIT. All other authors disclosed no financial relationships. This work was supported by grants from the Japanese Foundation for Research and Promotion of Endoscopy (to Drs. Saito and Nakai). Dr Hamada was supported by the Japan Society for the Promotion of Science KAKENHI grants (JP19K08362 and JP22H02841) and grants from Takeda Science Foundation and Daiichi Sankyo Company. The funders had no role in the study design, data collection and analysis, decision to publish, or manuscript preparation., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Introduction: Molecular residual disease detected by circulating tumor DNA (ctDNA) has been reported to be predictive of patients' outcomes in various types of cancers after curative intent treatment. Nevertheless, additional detailed information regarding the association of longitudinal ctDNA detection with long-term follow-up in lung cancer is needed. Here, we report on a cohort of patients with NSCLC who underwent definitive surgery and ctDNA analysis in the pre-operative, adjuvant, and surveillance settings., Method: Plasma samples were collected from 46 patients with clinical stage II-III NSCLC before surgery (n = 46), after surgery (n = 45), and every six months until two years thereafter (n = 78). A clinically validated, personalized, tumor-informed 16-plex polymerase chain reaction-next-generation sequencing assay was used for the detection and quantification of ctDNA in retrospectively analyzed plasma samples., Results: Circulating tumor DNA was detected in the first postoperative (within 51 days after surgery) plasma samples in 13% (6/45) of patients (landmark analysis). All of them had disease recurrence within a median of 9.1 months. These patients had shorter recurrence-free and overall survivals than those without detectable ctDNA at a landmark time point ( p < 0.01) and in multivariate analyses ( p < 0.03). Longitudinally (considering all postoperative follow-up time points), ctDNA was detected in 13 patients, all of whom experienced disease recurrence (positive predictive value = 100%). Three patients who had central nervous system-only metastases did not have detectable ctDNA., Conclusions: The presence of ctDNA post-surgery or during surveillance identifies patients with NSCLC at high risk of recurrence. Serial testing is important to detect disease recurrence earlier (lead-time: 3.2 months)., Competing Interests: Dr. Ohara has received honoraria from AstraZeneca. Dr. Suda has received research funding from AstraZeneca and Guardant, and has received honoraria from Chugai Pharmaceuticals, Amgen, Daiichi-Sankyo, Taiho, Boehringer Ingelheim, and AstraZeneca. Dr. Hamada has received honoraria from AstraZeneca, Chugai Pharmaceuticals, and Bristol-Myers Squibb. Dr. Tsutani has received research funding from AstraZeneca, and Chugai Pharmaceuticals and has received honoraria from AstraZeneca, Bristol Myers Squibb, Chugai Pharmaceuticals, Merck Sharp & Dohme, Ono Pharmaceuticals, and Roche; and has been on the advisory board of AstraZeneca, Chugai Pharmaceuticals, and Ono Pharmaceuticals. Dr. Mitsudomi has received research funding from AstraZeneca, Ono Pharmaceuticals, Merck Sharp & Dohme, Brigde Bio, Boehringer Ingelheim, Pfizer, Taiho and Chugai Pharmaceuticals; has received honoraria from AstraZeneca, Chugai Pharmaceuticals, Bristol-Myers Squibb, Merck Sharp & Dohme, Boehringer Ingelheim, Taiho, Eli-Lilly, Novartis, Pfizer, Amgen, Takeda, Bristol Meyers Squibb and Ono Pharmaceuticals; has been on the advisory board of Taiho; and has been on the consulting fees of AstraZeneca, Ono, Bristol Meyers Squibb, Regeneron and Novartis. Dr. Kalashnikova, Dr. Sudhaman, Dr. Cheung, Dr. Krainock, Mr. Sethi, Mr. Feeney, and Dr. Liu are employees at Natera, Inc. with stock or option to own stock. Dr. Liu also received grants (funding to Mayo Clinic) from Eisai, Exact Sciences, Genentech, Genomic Health, GRAIL, Menarini Silicon Biosystems, Merck, Novartis, Seattle Genetics, and Tesaro; travel support from AstraZeneca, Genomic Health, and Ionis; and Ad hoc advisory board meetings (all funds to Mayo Clinic): AstraZeneca, Celgene, Roche and /Genentech, Genomic Health, GRAIL, Ionis, Merck, Pfizer, Seattle Genetics, Syndax. The remaining authors declare no conflict of interest., (© 2024 The Authors.)

This study investigated the effectiveness of acoustic separation for platelet analysis in patients with non-small-cell lung cancer (NSCLC), comparing it with traditional centrifugation methods. In total, 10 patients with NSCLC and 10 healthy volunteers provided peripheral blood samples, which were processed using either acoustic separation or centrifugation to isolate platelets. The study included whole transcriptome analysis of platelets, peripheral blood mononuclear cells, and tumor tissue samples, employing hierarchical clustering and Gene Ontology analysis to explore gene expression differences. Acoustic separation proved more efficient than centrifugation in terms of platelet yield, recovery rate, and RNA yield. Gene expression profiles of platelets from patients with NSCLC showed distinct patterns compared with healthy volunteers, indicating tumor-influenced alterations. Gene Ontology analysis revealed enrichment in pathways associated with platelet activation and the tumor microenvironment. This finding indicates the potential of acoustic isolation in platelet separation and its relevance in understanding the unique gene expression profile of platelets in patients with NSCLC. The findings of this study suggested that platelets from cancer patients separated by acoustic techniques exhibited tumor-specific alterations and provided new insights into the diagnosis of cancer in platelet analysis systems in clinical practice., (© 2024 The Author(s). Cancer Science published by John Wiley & Sons Australia, Ltd on behalf of Japanese Cancer Association.)

Background: Superior outcomes have been obtained for neoadjuvant treatment with immune checkpoint inhibitors (ICI) plus chemotherapy over neoadjuvant chemotherapy alone, especially in patients with high programmed cell death ligand 1 (PD-L1) expression. However, it is not always possible to obtain sufficient tumor specimens for biomarker testing before surgery. In this study, we explored clinical factors that can predict high PD-L1 expression., Methods: We retrospectively enrolled 340 lung cancer patients who received pulmonary resection between 2014 and 2023 and who had PD-L1 expression data. Chi-squared tests and logistic regression analyses were used to identify clinical factors associated with high PD-L1 status., Results: Univariable and multivariable analyses revealed that smoking, high maximum standardized uptake value (SUVmax) of 18F-fluorodeoxyglucose positron emission computed tomography (18F-FDG PET/CT), and high plasma fibrinogen are independent predictors of high PD-L1 expression. A predictive score for high PD-L1 expression (ranging from 0 to 3) was developed based on these parameters. Notably, only 5% of patients with a score of 0 exhibited high PD-L1 expression, whereas this proportion increased to 53% for patients with a score of 3., Conclusion: These results showed that plasma fibrinogen, smoking history, and SUVmax are predictors of high PD-L1 expression, providing a basis for identifying patients expected to benefit from neoadjuvant ICI treatment., (© 2024 The Author(s). Thoracic Cancer published by John Wiley & Sons Australia, Ltd.)

Background: Posthepatectomy liver failure (PHLF) remains a severe complication after liver resection. This retrospective study investigated the correlation of three hepatic functional tests and whether 99mTc-galactosyl human serum albumin (99mTc-GSA) scintigraphy and modified albumin-bilirubin (ALBI) score are useful for predicting PHLF., Methods: This retrospective cohort study included 413 consecutive patients undergoing hepatectomies between January 2017 and December 2020. To evaluate preoperative hepatic functional reserve, modified ALBI grade, indocyanine green clearance (ICG-R15), and 99mTc-GSA scintigraphy (LHL15) were examined before scheduled hepatectomy. Based on a retrospective chart review, multivariable logistic regression analysis adjusted for confounding factors was performed to confirm that mALBI, ICG-R15, and LHL15 are independent risk factors for PHLF., Results: ICG-R15 and LHL15 were moderately correlated (r =  - 0.61) but this correlation weakened when ICG-R15 was about ≥ 20. Weak correlations were observed between LHL15 and ALBI score (r =  - 0.269) and ALBI score and ICG-R15 (r = 0.339). Of 413 patients, 66 (19%) developed PHLF (20 grade A, 44 grade B, 2 grade C). Multivariable logistic regression analyses, major hepatectomy (P < 0.001), mALBI grade (P = 0.01), ICG-R15 (P < 0.001), and Esophagogastric varices (P = 0.007) were significant independent risk factors for PHLF. Subgroup analysis showed that ICG-R15 < 19, major hepatectomy, and mALBI grade and ICG-R15 ≥ 19, major hepatectomy, LHL15, and Esophagogastric varices were significant independent risk factors for PHLF (P = 0.033, 0.017, 0.02, 0.02, and 0.001, respectively)., Conclusion: LHL15, the assessment of Esophagogastric varices, and mALBI grade are complementary to ICG-R15 for predicting PHLF risk., (© 2024. The Author(s).)

Schwannomas consist of both high-cellularity regions (Antoni A area) and hypocellular regions (Antoni B area) in histopathological findings. Neurofibromas characteristically consist of CD34 positive spindle cells with thin, wavy, nuclei and wavy collagen bands. Previous reports have described segments of schwannomas with neurofibroma features as hybrid tumors, although hybrid tumors were diagnosed based on partial CD34 positivity in many previous reports. On the other hand, the Antoni B area of some schwannomas was reported to be positive for CD34. Therefore, the definition of a hybrid tumor has not been clear. The objective of this study was to determine whether only CD34 positive findings in schwannomas could be used to define a hybrid tumor. In the analysis of our patient with schwannomatosis caused by a novel LZTR1 germline mutation, part of the tumor had CD34 positive hypocellular regions. These regions contained no thin, wavy, nuclei, indicating an Antoni B area. Laser microdissection was used to investigate the genetic background and differences in molecular mechanisms between CD34 positive and CD34 negative regions. All mutations identified in CD34 positive regions were also found in CD34 negative regions. Our data could not clear the genetic background of Antoni B which was CD34 positive area. We then reviewed the pathologies of 66 sporadic schwannomas. Histopathological examinations of all schwannomas revealed the absence of thin, wavy, nuclei and wavy collagen bands, and no hybrid tumors were found in any of the cases. Ten of 66 patients were randomly selected for CD34 immunostaining and positivity was found in all cases. Our data suggest that it is difficult to distinguish schwannomas by staining for CD34 alone, as Antoni B areas can also be positive for CD34. Therefore, CD34 staining alone should not be used to diagnose hybrid tumors in patients with schwannomas., (© 2024 Japanese Dermatological Association.)

Purpose: To assess the impact of genetic risk estimation for primary open-angle glaucoma (POAG) in Japanese individuals., Design: Cross-sectional analysis., Participants: Genetic risk scores (GRSs) were constructed based on a genome-wide association study (GWAS) of POAG in Japanese people. A total of 3625 Japanese individuals, including 1191 patients and 2434 controls (Japanese Tohoku), were used for the model selection. We also evaluated the discriminative accuracy of constructed GRSs in a dataset comprising 1034 patients and 1147 controls (the Japan Glaucoma Society Omics Group [JGS-OG] and the Genomic Research Committee of the Japanese Ophthalmological Society [GRC-JOS]) and 1900 participants from a population-based study (Hisayama Study)., Methods: We evaluated 2 types of GRSs: polygenic risk scores using the pruning and thresholding procedure and a GRS using variants associated with POAG in the GWAS of the International Glaucoma Genetics Consortium (IGGC). We selected the model with the highest areas under the receiver operating characteristic curve (AUC). In the population-based study, we evaluated the correlations between GRS and ocular measurements., Main Outcome Measure: Proportion of patients with POAG after stratification according to the GRS., Results: We found that a GRS using 98 variants, which showed genome-wide significance in the IGGC, showed the best discriminative accuracy (AUC, 0.65). In the Japanese Tohoku, the proportion of patients with POAG in the top 10% individuals was significantly higher than that in the lowest 10% (odds ratio [OR], 6.15; 95% confidence interval [CI], 4.35-8.71). In the JGS-OG and GRC-JOS, we confirmed similar impact of POAG GRS (AUC, 0.64; OR [top vs. bottom decile], 5.81; 95% CI, 3.79-9.01). In the population-based study, POAG prevalence was significantly higher in the top 20% individuals of the GRS compared with the bottom 20% (9.2% vs. 5.0%). However, the discriminative accuracy was low (AUC, 0.56). The POAG GRS was correlated positively with intraocular pressure (r = 0.08: P = 4.0 × 10 -4 ) and vertical cup-to-disc ratio (r = 0.11; P = 4.0 × 10 -6 )., Conclusions: The GRS showed moderate discriminative accuracy for POAG in the Japanese population. However, risk stratification in the general population showed relatively weak discriminative performance., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To evaluate the use of delay alternating with nutation for tailored excitation-prepared T1-weighted turbo spin echo (DANTE T1-SPACE) imaging for diagnosing optic neuritis and to analyze its correlation with clinical findings before and after treatment., Patients and Methods: Patients diagnosed with optic neuritis or non-arteritic anterior ischemic optic neuropathy (NA-AION) were evaluated at the Ophthalmology Department of Kyoto University Hospital. All patients underwent magnetic resonance (MR) studies before treatment initiation and ophthalmic examinations before and after treatment. Three ophthalmologists independently reviewed the MR scans for abnormalities. The magnetic resonance imaging (MRI) assessments included post-contrast DANTE T1-SPACE, post-contrast volumetric interpolated breath-hold examination (VIBE), and short T1 inversion recovery (STIR) scans. The presence of abnormalities in each sequence was determined., Results: Of 36 eyes from 30 patients, 21 eyes from 17 patients were diagnosed with optic neuritis, and 15 eyes from 13 patients were diagnosed with NA-AION. DANTE T1-SPACE sequences showed better sensitivity for detecting optic neuritis than STIR sequences (100% vs 67%, p = 0.009). VIBE images did not confirm enhancement of lesions in some cases with optic neuritis. No differences were observed among the sequences for NA-AION. Lesion length evaluated by DANTE T1-SPACE sequences was associated with circumpapillary retinal nerve fiber layer thickness at the initial visit, eye pain, and the time interval from symptom onset to MRI scan., Conclusion: Contrast-enhanced DANTE T1-SPACE was better than other sequences of MRI for diagnosing optic neuritis., Competing Interests: Dr Manabu Miyata reports grants and/or personal fees from Alcon Japan, Santen Pharmaceutical, Chugai Pharmaceutical, Bayer Yakuhin, Senju Pharmaceutical, and Kowa Pharmaceutical, outside the submitted work. Dr Kimitoshi Kimura reports honoraria from Biogen Inc., Mitsubishi Tanabe Pharma Corporation, Chugai Pharmaceutical Co., Ltd., Novartis Pharma, argenx SE, Daiichi Sankyo Co., Ltd., and UCB Japan Co. Ltd., outside the submitted work. John Grinstead and Sinyeob Ahn reports personal fees from Siemens Healthineers during the conduct of the study., (© 2024 Shimada et al.)

Purpose: Angiopoietin-1 (Ang1) mitigates inflammation as a proangiogenic growth factor. Action of Ang1 on lipopolysaccharide (LPS)-induced endotoxemic inflammation was investigated in endothelin receptor-B null Hirschsprung's disease mice (KO)., Methods: LPS or saline was injected intraperitoneally in KO (KO-LPS; n = 9, KO-sal; n = 5) and wild-type (WT) (WT-LPS; n = 6, WT-sal; n = 6) pups obtained within 24 h of birth. Normoganglionic terminal ileum harvested 6 h after LPS was used for RNA extraction and histology. IL-1β, SELE, VEGFA, Ang1, Angiopoietin-2 (Ang2), and TIE2 expression analyzed by quantitative polymerase chain reaction (qPCR), vascular permeability assessed by the Miles assay, severity of inflammation, and immunofluorescence for phospho-TIE2 and VE-cadherin were used to assess endothelial cell contact integrity and compared with KO pups pretreated with intraperitoneal Ang1 [Ang1(KO-LPS); n = 5] or saline [sal(KO-LPS); n = 6] 2 h before LPS., Results: KO-LPS pups showed significantly increased inflammation (p < 0.05) and expression of IL-1β, SELE, VEGFA, and Ang2 (p = 0.019, 0.003, 0.008 and < 0.0001, respectively); expression of Ang1 and TIE2 remained unchanged when compared with KO-saline. In Ang1(KO-LPS) ileum, changes seen in sal(KO-LPS) were eliminated and phospho-TIE2 and VE-cadherin fluorescence increased., Conclusion: Ang1 successfully attenuated LPS-induced normoganglionic intestinal inflammation, downregulated pro-inflammatory genes, and improved vascular barrier integrity in KO pups., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Bilateral pedicle fractures of the lumbar spine are uncommon and are typically associated with strenuous activities, traumatic events, or previous spinal surgery. This study reported a case of bilateral pedicle fracture in a patient with a long history of osteoporosis treatment with bisphosphonate and included a histological evaluation of the bone., Case Presentation: An 82-year-old woman with no history of trauma presented to our hospital with back pain that had worsened over the previous month. Computed tomography and magnetic resonance imaging revealed bilateral pedicle fractures of the third lumbar vertebra. She had osteoporosis and had been taking bisphosphonates for 9 years. The patient underwent posterior lumbar fusion, and her symptoms improved. Bone biopsy results from the spinous process revealed few osteoblasts and an absence of osteoclasts, indicating low bone turnover., Conclusions: Long-term use of bisphosphonates may contribute to the development of atypical bilateral pedicle fractures in patients with osteoporosis., (© 2024. International Osteoporosis Foundation and Bone Health and Osteoporosis Foundation.)

Background: Doublesex and mab-3 related transcription factor (DMRT) 1, commonly found in all vertebrates, regulates the transcription of genes involved in the masculinization and maintenance of gonadal somatic cells and/or germline cell development. DMRT1 has a DNA-binding domain called the DM domain and a transcription regulatory region. Unlike the former, there is little knowledge about the latter transcription regulatory region. This study aimed to identify the transcription activation regions of DMRT1 from four species: humans and mice (mammals), leopard geckos (reptiles), and medaka (teleost fish), adding perspectives on evolutionary conservation and diversity., Methods and Results: For each species, several expression plasmids of deletion mutants were constructed, and the resultant plasmid and a DMRT1-driven luciferase reporter were co-transfected into cultured cells to measure transactivation ability. The key point of this analysis is that the transactivation ability was normalized by quantifying the expression levels of DMRT1 variants using the HiBiT tag. As a result, two to three transactivation regions were suggested to exist in the C-terminal region of the DM domain in all four species. Among seven regions in DMRT1, the fourth region from the N-terminus contributed to transactivation common to the four species, and the sixth and seventh regions on the C-terminal side differed depending on the species., Conclusions: These findings indicated that the regions involved in the transactivation ability of DMRT1 could subtly change during evolution, indicating diversity in transactivation domains., (© 2024. The Author(s).)

Background: This study aimed to investigate the laparoscopic gastrectomy (LG) performance of non-Endoscopic Surgical Skill Qualification System (ESSQS)-qualified surgeons under the ESSQS-qualified surgeon guidance and compare oncological outcomes of gastric cancer to LG performed by the ESSQS-qualified surgeons., Methods: This study enrolled 1,030 patients diagnosed with both clinical and pathological stage ≤ III gastric cancer and undergoing LG from January 2009 to June 2019. ESSQS-qualified surgeons served as the operator or the instructive assistant in all LG procedures involving them. A propensity score-matched analysis was used to retrospectively compare the long-term outcomes between the ESSQS-qualified and non-ESSQS-qualified surgeons., Results: Each group included 315 pairs after propensity score matching. The 3-year recurrence-free survival rates were 84.4% and 81.7% in the non-ESSQS and ESSQS groups, respectively. The difference was 2.7% (95% confidence interval: - 3.20%-8.44%, P < 0.001), and the non-ESSQS group statistically demonstrated noninferiority as the lower 95% confidence limit was greater than the prespecified margin of -10%, indicating the achieved primary endpoint. No significant differences in 5-year recurrence-free survival (non-ESSQS: 78.5% vs. ESSQS: 77.4%, P = 0.627) and 5-year overall survival (non-ESSQS: 80.9% vs. ESSQS: 79.3%, P = 0.475) were found between the two groups. The oncological outcomes stratified according to the presence of pathological stage I, II, and III disease did not significantly differ between the two groups., Conclusions: LG performed by non-ESSQS-qualified surgeons achieved comparable oncological outcomes to the ESSQS-qualified surgeons, as long as ESSQS-qualified surgeons provided intraoperative instructions, in a high-volume center., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Subtotal colectomy is often performed on patients with synchronous colorectal cancer. However, compared with colorectal anastomosis, ileorectal anastomosis with subtotal colectomy is more likely to result in bowel dysfunction. The Deloyers procedure is useful in preserving bowel function in a patient with synchronous colorectal cancer. An 87-year-old man presented with bloody stool. Colonoscopy showed masses in the cecum, transverse colon, rectosigmoid, and rectum above the peritoneal reflection. Computed tomography scan revealed no evidence of regional lymph node swelling and distant metastasis. Therefore, robot-assisted low anterior resection, laparoscopic extended left hemicolectomy, laparoscopic cecal resection, and diverting ileostomy were performed. The patient was discharged from the hospital without complications. There was no recurrence, and the patient did not have complaints such as urgency, fecal incontinence, and excretory dysfunction. Hence, minimally invasive coloproctectomy using the Deloyers procedure can be safe and useful in preserving postoperative bowel function in elderly patients., (© 2024 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Objectives: The appropriate holistic management is mandatory for successful endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs). However, comorbidity status has not been fully examined in relation to clinical outcomes of this treatment., Methods: Using a multi-institutional cohort of 406 patients receiving EUS-guided treatment of PFCs in 2010-2020, we examined the associations of Charlson Comorbidity Index (CCI) with in-hospital mortality and other clinical outcomes. Multivariable logistic regression analysis was conducted with adjustment for potential confounders. The findings were validated using a Japanese nationwide inpatient database including 4053 patients treated at 486 hospitals in 2010-2020., Results: In the clinical multi-institutional cohort, CCI was positively associated with the risk of in-hospital mortality (P trend  < 0.001). Compared to patients with CCI = 0, patients with CCI of 1-2, 3-5, and ≥6 had adjusted odds ratios (95% confidence intervals) of 0.76 (0.22-2.54), 5.39 (1.74-16.7), and 8.77 (2.36-32.6), respectively. In the nationwide validation cohort, a similar positive association was observed; the corresponding odds ratios (95% confidence interval) were 1.21 (0.90-1.64), 1.52 (0.92-2.49), and 4.84 (2.63-8.88), respectively (P trend  < 0.001). The association of higher CCI with longer length of stay was observed in the nationwide cohort (P trend  < 0.001), but not in the clinical cohort (P trend  = 0.18). CCI was not associated with the risk of procedure-related adverse events., Conclusions: Higher levels of CCI were associated with a higher risk of in-hospital mortality among patients receiving EUS-guided treatment of PFCs, suggesting the potential of CCI in stratifying the periprocedural mortality risk., Trial Registration: The research based on the clinical data from the WONDERFULcohort was registered with UMIN-CTR (registration number UMIN000044130)., (© 2024 The Author(s). Digestive Endoscopy published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Background: Nonresectable gastric cancer develops rapidly; thus, monitoring disease progression especially in patients receiving nivolumab as late-line therapy is important. Biomarkers may facilitate the evaluation of nivolumab treatment response. Herein, we assessed the utility of serum-based inflammatory indicators for evaluating tumor response to nivolumab., Methods: This multicenter retrospective cohort study included 111 patients treated with nivolumab monotherapy for nonresectable advanced or recurrent gastric cancer from October 2017 to October 2021. We measured changes in the C-reactive protein (CRP)-to-albumin ratio (CAR), platelet-to-lymphocyte ratio (PLR), and neutrophil-to-lymphocyte ratio (NLR) in serum from baseline to after the fourth administration of nivolumab. Furthermore, we calculated the area under the receiver operating characteristic curves (AUC ROCs) for CAR, PLR, and NLR to identify the optimal cutoff values for treatment response. We also investigated the relationship between clinicopathologic factors and disease control (complete response, partial response, and stable disease) using the chi-squared test., Results: The overall response rate (complete and partial response) was 11.7%, and the disease control rate was 44.1%. The median overall survival (OS) was 14.0 (95% CI 10.7‒19.2) months, and the median progression-free survival (PFS) was 4.1 (95% CI 3.0‒5.9) months. The AUC ROCs for CAR, PLR, and NLR before nivolumab monotherapy for patients with progressive disease (PD) were 0.574 (95% CI, 0.461‒0.687), 0.528 (95% CI, 0.418‒0.637), and 0.511 (95% CI, 0.401‒0.620), respectively. The values for changes in CAR, PLR, and NLR were 0.766 (95% CI, 0.666‒0.865), 0.707 (95% CI, 0.607‒0.807), and 0.660 (95% CI 0.556‒0.765), respectively. The cutoff values for the treatment response were 3.0, 1.3, and 1.4 for CAR, PLR, and NLR, respectively. The PFS and OS were significantly longer when the treatment response values for changes in CAR, PLR, and NLR were below these cutoff values (CAR: OS, p < 0.0001 and PFS, p < 0.0001; PLR: OS, p = 0.0289 and PFS, p = 0.0302; and NLR: OS, p = 0.0077 and PFS, p = 0.0044)., Conclusions: Measurement of the changes in CAR, PLR, and NLR could provide a simple, prompt, noninvasive method to evaluate response to nivolumab monotherapy., Trial Registration: This study is registered with number K2023006., (© 2024. The Author(s).)

In certain tetraploid species resulting from interspecific hybridization, one parent's subgenome is known to selectively undergo DNA loss. The molecular mechanisms behind this remain unclear. In our study, we compared the genomes of a standard diploid species with two allotetraploid species from the Xenopus genus, both possessing L (longer) and S (shorter) homoeologous subgenomes. We observed substantial gene losses and intergenic DNA deletions in both the S and L subgenomes of the tetraploid species. Gene losses were around 1,000 to 3,000 for L and 4,000 to 6,000 for S, with especially prominent losses in the S subgenome. Many of these losses likely occurred shortly after interspecific hybridization in both L/S subgenomes. We also deduced frequent large inversions in the S subgenome. Upon reassessing transposon dynamics using updated genome databases, we reaffirmed heightened DNA transposon activity during the hybridization, as previously reported. We next investigated whether S subgenome-biased DNA loss could be correlated with the activation of DNA transposons following hybridization. Notably, distinct patterns were observed in the dynamics of DNA transposons between the L and S subgenomes. Several DNA transposon subfamilies correlated positively with DNA deletions in the S subgenome and negatively in the L subgenome. Based on these results, we propose a model that, upon and after hybridization between two related diploid Xenopus species, the mixture of their genomes resulted in the derepression of DNA transposons, especially in the S subgenome, leading to selective DNA loss in the S subgenome., (© The Author(s) 2024. Published by Oxford University Press on behalf of Society for Molecular Biology and Evolution.)

Govetto's staging system (stages 1-4) for epiretinal membrane (ERM) based on optical coherence tomography images is a useful predictor of monocular visual function; however, an association between Govetto's stage and binocular vision has not been reported. This study aimed to investigate the factors associated with Govetto's stage among the monocular and binocular parameters. This retrospective study included consecutive patients with treatment-naïve eyes with unilateral ERM without pseudo-hole. We investigated Govetto's stage, degrees of aniseikonia and metamorphopsia, foveal avascular zone area, central retinal and choroidal thickness, vertical ocular deviation, stereopsis, and binocular single vision (BSV). We compared the parameters between the BSV-present and BSV-absent groups and investigated correlations between Govetto's stage and the monocular and binocular parameters. Twenty-eight eyes of 28 patients were examined (age, 66.6 ± 10.2 years). In multivariate correlation analyses, Govetto's stage correlated with BSV (P = 0.04, β = - 0.36) and central retinal thickness (P < 0.001, β = 0.74). Of the eyes, 18 were assigned to the BSV-present group and 10 to the BSV-absent group. Govetto's stage was significantly more advanced in the BSV-absent group than in the BSV-present group (3.2 ± 0.8 vs 2.5 ± 0.7, P = 0.03). Of the 28 patients, 11 (39%) showed small-angle vertical deviations (1-12Δ). In conclusion, our findings showed that Govetto's stage correlated with binocular vision in patients with monocular ERM. Govetto's staging is a useful parameter for predicting not only monocular but also binocular vision., (© 2024. The Author(s).)

Background: Prior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. Community care is available to Veterans when care is not available through the VA, nearby, or in a timely manner., Objective: To examine differences in Veterans' experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016 to 2021., Design: Observational analyses of Veterans' ratings of community care experiences by self-reported race and ethnicity. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors., Participants: Respondents to the 2016-2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey., Measures: Care ratings in nine domains., Key Results: The sample of 231,869 respondents included 24,306 Black Veterans (mean [SD] age 56.5 [12.9] years, 77.5% male) and 16,490 Hispanic Veterans (mean [SD] age 54.6 [15.9] years, 85.3% male). In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in five of nine domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from - 0.04 to - 0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Care ratings improved from 2016 to 2021, but differences between racial and ethnic groups persisted., Conclusions: This study identified small but persistent racial and ethnic differences in Veterans' experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in five domains and, respectively, higher ratings in three and two domains. Interventions to improve Black and Hispanic Veterans' patient experience could advance equity in VA community care., (© 2024. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Purpose: To evaluate the agreement between 24-2 visual field (VF) test results obtained using the gaze analyzing perimeter (GAP; Findex) and the Humphrey field analyzer (HFA; Carl Zeiss Meditec)., Design: Cross-sectional study., Participants: Patients underwent HFA 24-2 for suspected or confirmed VF loss and were treated at the Kyoto University Hospital between December 2022 and July 2023., Methods: Patients underwent consecutive VF tests on the same eye using HFA and GAP 24-2 tests. Bland-Altman analysis was used to compare GAP and HFA results. Examination points where the sensitivity measured using GAP was ≥ 10 dB higher than that measured using HFA were re-evaluated by referring back to the original gaze data; 2 ophthalmologists assessed whether the gaze moved linearly toward the new test target., Main Outcome Measures: Mean deviation (MD) and elapsed time on an individual basis and sensitivity on an examination point basis., Results: Forty-seven eyes of 47 patients were analyzed. The correlation coefficient of the MD using HFA and GAP was 0.811 (95% confidence interval [CI]: 0.683-0.891). Bland-Altman analysis showed good agreement between HFA and GAP tests. The mean difference (95% limits of agreement) in MD between HFA and GAP results was -0.63 dB (-5.81 to 4.54 dB). Although no statistically significant differences were observed in the elapsed time (P = 0.99), measurements completed within 200 seconds were observed only in the GAP group (11 cases, 23.4%), who had significantly better HFA MD value than others (P = 0.001). On an examination point basis for sensitivity, the correlation coefficient between HFA and GAP was 0.691 (95% limits of agreement, 0.670-0.711). Original gaze data assessment revealed that the gaze moved linearly toward the new test target for 70.2% of the examination points with a sensitivity discrepancy., Conclusions: The results indicate that the GAP provides VF assessment outcomes comparable to those of the HFA. The GAP exhibited advantages in terms of testing time, particularly in patients with minimal VF impairment. Furthermore, the GAP records all eye movements, enabling the objective determination of VF abnormalities based on gaze patterns and facilitating easy posthoc verification., Financial Disclosure(s): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article., (Copyright © 2024 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: The advantages of robot-assisted minimally invasive esophagectomy (RA-MIE) over conventional minimally invasive esophagectomy (C-MIE) are unknown. This nationwide large-scale study aimed to compare surgical outcomes between RA-MIE and C-MIE using rigorous propensity score methods, including detailed covariates and relevant outcomes., Methods: This Japanese nationwide retrospective cohort study included RA-MIE or C-MIE for esophageal malignant tumors performed between October 2018 and December 2019 and registered in the Japanese National Clinical Database. The primary outcome measure was postoperative complications classified as Clavien-Dindo Grade IIIa or higher. Propensity score matching was performed to create a balanced covariate distribution between the two groups., Results: After propensity score matching, 1092 patients were selected. The RA-MIE group had a significantly longer operation time and greater blood loss than the C-MIE group (565 vs. 477 min and 120 vs. 90 mL). Furthermore, the R0 resection rate was lower in the RA-MIE group than in the C-MIE group (95.1% vs. 97.8%). The RA-MIE and C-MIE groups had no differences regarding overall complications ≥ Grade IIIa (22.0% vs. 20.3%, p  = 0.52), 30-day mortality rates (0.4% vs. 0.5%), and operative mortality rates (0.7% vs. 0.7%). Deep SSI was less frequent (2.7% vs. 6.0%) and pulmonary embolism was more frequent (2.4% vs. 0.5%) in the RA-MIE group than in the C-MIE group., Conclusions: In the initial phase of implementation, RA-MIE and C-MIE demonstrated comparable morbidity rates when performed by skilled board-certified endoscopic surgeons., Competing Interests: K.O. received lecture fees from Intuitive Surgical, Intuitive Surgical, Inc., outside the submitted work. H.K. reports receiving consultation fees from EPS Corporation and speaker fees from Chugai Pharmaceutical Co., Ltd. H.K. and H.M. are affiliated with the Department of Healthcare Quality Assessment at the University of Tokyo, which is a social collaboration department supported by grants from NCD, Johnson & Johnson K.K., Nipro Corporation, and Intuitive Surgical Sàrl. K.S. was funded by Sysmex, Co., in relation to the Collaborative Laboratory for Research and Development in Advanced Surgical Intelligence, Fujita Health University. S.T. received lecture fees from Intuitive Surgical, Inc., Covidien Japan Inc., Ethicon Inc., and Olympus Corporation. T.T. and I.U. were also funded by Medicaroid, Inc., in relation to the Collaborative Laboratory for Research and Development in Advanced Surgical Technology, Fujita Health University. K.S. received advisory fees from Medicaroid, Inc., outside the submitted work. I.U. reports holding stocks in Intuitive Surgical, Inc. Y.K. reports grants from Chugai Pharmaceutical Co., Ltd., grants from Taiho Pharmaceutical Co., Ltd, grants from Yakult Honsha Co. Ltd., grants from Asahi Kasei Pharma Corporation, grants from Otsuka Pharmaceutical Co., Ltd., grants from Takeda Pharmaceutical Co., Ltd., grants from Ono Pharmaceutical CO., Ltd., grants from Tsumura & CO., grants from Kyouwa Hakkou Kirin Co., Ltd., grants from EA Pharma Co., Ltd., grants from Medicon INC., grants from Kaken Pharmaceutical co. Ltd., grants from Eisai Co., Ltd., grants from Otsuka Pharmaceutical Factory Inc., grants from Teijin Pharma Limited., grants from Nihon Pharmaceutical Co., Ltd., grants from Nippon Covidien Inc., personal fees from Asahi Kasei Pharma Corporation, personal fees from AstraZeneca K.K., personal fees from Ethicon Inc., personal fees from Ono Pharmaceutical CO., Ltd., personal fees from Otsuka Pharmaceutical Factory, Inc., personal fees from Olympus Corporation, personal fees from Nippon Covidien Inc., personal fees from Shionogi & Co., Ltd., personal fees from Taiho Pharmaceutical Co., Ltd, personal fees from Chugai Pharmaceutical Co., Ltd., personal fees from Bristol‐Myers Squibb K.K., personal fees from MSD K.K., personal fees from Smith & Nephew KK, personal fees from Kaken Pharmaceutical Co., Ltd., personal fees from Miyarisan Pharmaceutical Co., LTD., and personal fees from ASKA Pharmaceutical Co., Ltd. outside the submitted work. I.U. received lecture fees from Intuitive Surgical, Inc., outside the submitted work. Y.K., M.I., and Y.K. are editorial board members of Annals of Gastroenterological Surgery. The remaining authors have no commercial association with or financial involvement that might pose a conflict of interest in connection with the submitted article., (© 2024 The Author(s). Annals of Gastroenterological Surgery published by John Wiley & Sons Australia, Ltd on behalf of The Japanese Society of Gastroenterological Surgery.)

Rhabdomyolysis can lead to acute kidney injury (AKI), primarily due to myoglobin-induced tubular damage. We present a case of slowly progressive rhabdomyolysis following SARS-CoV-2 infection in a 28-year-old male who was monitored through serial serum creatine kinase (CK) and myoglobin levels. Despite prominent CK elevations, the patient did not develop AKI, probably due to disproportionately mild serum myoglobin elevation with distinctive cyclic spikes. This case underscores the informative value of frequent monitoring of both CK and myoglobin to assess muscle damage severity and AKI risk in rhabdomyolysis, particularly with viral infections like COVID-19 that can cause delayed-onset muscle injury., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Okubo et al.)

Background: Adenosquamous carcinoma of the pancreas (ASCP) accounts for only 1-4% of all pancreatic exocrine cancers and has a particularly poor prognosis. The efficacy of chemotherapy for ASCP remains unknown because of the small number of cases, and few studies have evaluated conversion-intended chemotherapy., Case Presentation: A 76-year-old woman was referred to our hospital because of epigastric pain and nausea. A preoperative contrast-enhanced multidetector row computed tomography (MDCT) scan revealed a 17 × 17 mm low-density tumor with an ill-defined margin at the arterial phase in the pancreatic head. The tumor involved the common hepatic artery, left hepatic artery bifurcated from the common hepatic artery, and gastroduodenal artery, and was in contact with the portal vein. Fluorodeoxyglucose-positron emission tomography (FDG-PET) showed an uptake in the pancreatic head but no evidence of distant metastasis. The tumor was diagnosed as an adenocarcinoma of the pancreatic head and staged unresectable because the common and left hepatic arteries were involved. Hence, the patient underwent seven courses of conversion-intended chemotherapy using gemcitabine and nab-paclitaxel for pancreatic ductal adenocarcinoma over 7 months. After chemotherapy, the tumor shrank to 10 × 10 mm on contrast-enhanced MDCT. Consequently, the boundary between the tumor and major vessels of the common and left hepatic arteries and the portal vein became clear, and the involvement of the arteries with the tumor was evaluated to be released. The contact of the tumor to the portal vein also reduced to less than half the circumference of the portal vein. FDG-PET showed decreased accumulation in the tumor. Hence, the tumor was judged resectable, and pancreaticoduodenectomy was performed. The tumor and major blood vessels were easily dissected and R0 resection was achieved. The patient experienced no major complications and was discharged on postoperative day 28. The tumor was revealed as ASCP via pathological examination. The patient is alive and recurrence-free seven months after surgery. This is the first report of successful R0 resection for an initially unresectable ASCP following conversion-intended chemotherapy using gemcitabine and nab-paclitaxel regimen., Conclusions: Conversion-intended chemotherapy using gemcitabine and nab-paclitaxel regimen may be effective for ASCP., (© 2024. The Author(s).)