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Introduction: Third-line chemotherapy has been suggested to improve survival in patients with gastric cancer. This study aimed to identify factors associated with the induction of third-line chemotherapy for advanced gastric cancer, focusing on patient eligibility for clinical trial. Methods: We retrospectively analyzed 335 patients treated for unresectable or recurrent gastric cancer between April 2009 and May 2020. The patients were grouped into those that met the key eligibility criteria for clinical trial (136 patients, 40.6%) and those that did not (199 patients, 59.4%) before receiving first-line chemotherapy. Results: The overall survival (OS) was 16.8 months (95% CI: 14.0–19.6) and 9.3 months (95% CI: 7.8–11.0) in the eligible and ineligible group, respectively. Multivariate analyses to identify the risk factors associated with the induction of third-line chemotherapy revealed ineligibility of clinical trial (OR 1.95; 95% CI: 1.15–3.31), number of metastatic sites (OR 1.99; 95% CI: 1.23–3.22), low albumin concentration (OR 2.24; 95% CI: 1.14–4.38), and a lack of complete or partial response to first-line treatment (OR 1.85; 95% CI: 1.05–3.26). Indeed, in responders to first-line treatment for ineligible patients, the median OS was 17.7 months (95% CI: 10.6–27.9), respectively. Conclusions: Treatment outcomes were different for those eligible for clinical trials and those who were not. However, this study suggested that patients who responded to first-line treatment have more favorable prognosis when treated with salvage chemotherapy, even if they were deemed ineligible for clinical trials.

MicroRNAs (miRNAs) are abnormally expressed and involved in the pathogenesis of various carcinomas. The present study aimed to identify novel miRNA genes associated with the pathogenesis and prognosis of oesophageal squamous cell carcinoma (ESCC).The miRNA profiling of 873 genes was performed using surgically resected oesophageal tissues from 35 patients with ESCC to identify candidate miRNAs. To examine the biological activities of candidate miRNAs, their proliferative, invasive, and migratory abilities were evaluated in ESCC cells subjected to miRNA mimic-mediated over-expression. The miRNA expression levels of the selected candidate miRNAs were analysed in the resected oesophageal tissues of 76 patients with ESCC from the two cohorts and correlated with the clinicopathological parameters.Among the four candidate miRNAs identified by miRNA profiling, miR-877-3p was selected for subsequent analyses. In vitro analyses showed that the over-expression of miR-877-3p significantly suppressed the proliferation, invasion, and migration of ESCC cell lines compared with those of control cells. In the analyses of clinical specimens, the expression of miR-877-3p was down-regulated in ESCC tissues compared with that in adjacent normal oesophageal tissues. The down-regulation of miR-877-3p expression in ESCC tissues was significantly associated with advanced local progression and lymphatic involvement. The miR-877-3p down-regulation was also significantly associated with poor disease-free and disease-specific survival.miR-877-3p acts as a tumour suppressor gene in ESCC cells, and its down-regulation in ESCC tissues is associated with a poor prognosis. Thus, miR-877-3p may serve as a novel prognostic marker and promising therapeutic target.

Anastomotic leakage (AL) after esophagectomy is one of the major complications after esophagectomy. The aim of this study was to evaluate anastomotic procedure to reduce AL after esophagectomy with retrosternal gastric pull up. A total of 157 consecutive patients underwent thoracoscopic esophagectomy followed by retrosternal reconstruction with gastric tube in our hospital between January 2008 and December 2021. The anastomotic procedure was revised at January 2016. After cervical esophagogastric anastomosis using circular stapler, gastric tube was pulled down to linearize and place the anastomotic site below the suprasternal notch (SN). The sternum tracheal distance (STD) and the level of esophagogastric anastomosis (LEA) were measured using CT image. In comparison between the former (-December 2015, 65 cases) and later (January 2016-, 92 cases) group, AL was significantly reduced from 11/65 (16.9%) to 0/92 (0%) cases (p , p = 0.02) and LEA (0>, p Surgical procedure which avoids excessive compression on the gastric tube at the thoracic inlet may take an important role in reduction of AL.

BACKGROUND Distal pancreatectomy with en bloc celiac artery resection (DP-CAR) is a curative surgical method for locally advanced pancreatic body cancer; however, arterial reconstruction remains controversial in this procedure. This report presents the case of a 47-year-old man with advanced distal pancreatic carcinoma and initial partial response to chemotherapy who required celiac axis reconstruction of the common hepatic artery and left gastric artery. CASE REPORT A 47-year-old man had loss of appetite. He had a 40-mm hypovascular tumor extending from the pancreatic body to the tail, invading around the celiac artery, common hepatic artery, left gastric artery, and splenic artery. We initiated chemotherapy concurrent with chemo-radiotherapy with S-1 administration. After chemo-radiotherapy, computed tomography (CT) showed tumor shrinkage, indicating partial response, but soft tissue CT density surrounding the celiac axis arteries persisted. We conducted conversion surgery. When the common hepatic artery was clamped during surgery, the intrahepatic arterial blood flow reduced; thus, we reconstructed the middle hepatic artery to the common hepatic artery. The left gastric artery was also reconstructed using the second jejunal artery to prevent ischemic gastropathy. Histopathologic examination showed no tumor cells in the specimen; thus, R0 resection was achieved. CONCLUSIONS Arterial reconstruction can be an option for R0 resection in DP-CAR when hepatic arterial blood flow is reduced due to an intraoperative common hepatic artery clamping test.

Background Local duodenectomy and primary closure is a simple option for some nonampullary duodenal neoplasms. Minimizing the resection area while ensuring curability is necessary for safe primary duodenal closure. However, it is often difficult to determine the appropriate resection line from the serosal side. We developed clip-guided local duodenectomy to easily determine the resection range and perform local duodenectomy safely, then performed a retrospective observational study to confirm the safety of clip-guided local duodenectomy. Methods The procedure is as follows: placing endoscopic metal clips at four points on the margin around the tumor within 3 days before surgery, identifying the tumor extent with the clips under X-ray imaging during surgery, making an incision to the duodenum just outside of the clips visualized by X-ray imaging, full-thickness resection of the duodenum with the clips as guides of tumor demarcation, and transversely closure by Gambee suture. We evaluated clinicopathological data and surgical outcomes of patients who underwent clip-guided local duodenectomy at two surgical centers between January 2010 and May 2020. Results Eighteen patients were included. The pathological diagnosis was adenoma (11 cases), adenocarcinoma (6 cases), and GIST (1 case). The mean ± SD tumor size was 18 ± 6 mm, and the tumor was mainly located in the second portion of the duodenum (66%). In all cases, the duodenal defect was closed with primary sutures. The mean operation time and blood loss were 191 min and 79 mL, respectively. The morbidity was 22%, and all complications were Clavien–Dindo grade II. No anastomotic leakage or stenosis was observed. In the 6 adenocarcinoma patients, all were diagnosed with pT1a, and postoperative recurrence was not observed. The 1-year overall and recurrence free survival rate was 100%. Conclusions Clip-guided local duodenectomy is a safe and useful surgical option for minimally local resection of nonampullary duodenal neoplasms such as duodenal adenoma, GIST, and early adenocarcinoma.

Anastomotic leakage (AL) is one of the major complications of gastro-esophageal anastomosis after esophagectomy, which causes short-term morbidity and mortality, as well as poor long-term survival. The aim of this study was to investigate factors which were associated with AL after esophagectomy in order to determine the optimal surgical technique to reduce AL. Methods A total of 128 patients with thoracic esophageal cancer underwent subtotal esophagectomy followed by retrosternal reconstruction with gastric conduit with cervical anastomosis using circular staple in our institute from January 2008 and January 2020. The relationship between AL and surgical procedures as well as clinicopathological characteristics of the patients were retrospectively investigated. In addition, we divided the patients into 65 cases in former period (December 2015) and 63 cases in later period (January 2016-) to compare the incidence of AL. Results AL was observed in 12 cases (9.4%) of the 128 patients. The incidence of AL decreased from 16.9% (11/65) in former period to 1.6% (1/63) in later period (p = 0.004). In comparison between the cases with and without AL (12 cases vs 116cases), statistically significant difference was seen in BMI (average ± SD, 24.2 ± 4.7 vs 21.6 ± 3.1; p = 0.02), anastomotic site (posterior wall/greater curvature, 11/1 vs 54/62; p = 0.004), and level of anastomosis (above/below superior border of manubrium of sternum, 12/0 vs 33/83; p Conclusion Surgical procedure which avoid excessive pressure on the gastric tube from the surrounding structures, such as sternum, may take an important role in reduction of AL after esophagectomy. However, multiple factors, such as nutritional status and obesity, also influence risk of anastomotic leakage.

Pneumonia is the second-most common complication in postoperative patients and is associated with significant morbidity and high costs of care. We aimed to determine the risk factors for pneumonia after general and digestive surgery. The medical records of 1,016 patients who underwent general and digestive surgery between January 2016 and March 2019 in our hospital were reviewed. Of the 1,016 patients, 67 (6.6%) developed postoperative pneumonia. The multivariate analysis showed that significant predictors of postoperative pneumonia were a poor Eastern Cooperative Oncology Group performance status (ECOG-PS), low forced vital capacity and low forced expiratory volume in one second in the spirometry test, malnutrition (low serum albumin levels and low controlling nutritional status scores and prognostic nutritional index [PNI] values), esophagectomy, upper gastrointestinal surgery, and nonlaparoscopic surgery. Of these factors, the combination of PNI and ECOG-PS clearly stratified patients into low-, intermediate-, and high-risk groups with respect to developing postoperative pneumonia (area under the curve: 0.709). Although postoperative pneumonia is associated with many clinical variables, active medical intervention for the prevention of pneumonia in patients with multiple risk factors can improve the postoperative course. In particular, perioperative nutritional care may prevent postoperative pneumonia in patients with malnutrition and a poor PS.

Our previous experimental study of perforated peritonitis in rats proved that peritoneal lavage with strong acid electrolyzed water (SAEW) has no adverse effects, reduces the bacteria count in the ascitic fluid more effectively than saline, and increases the survival rate significantly. Thus, we conducted a randomized controlled study, applying SAEW in the treatment of perforated appendicitis in children. Forty-four patients, aged 3–14 years, were randomly divided into two groups: Group S (n = 20), in which the peritoneal cavity was lavaged with 100 ml/kg saline and the wound was washed out with 200 ml saline; and Group E (n = 24), in which the peritoneal cavity was lavaged with 100 ml/kg SAEW and the wound was washed out with 200 ml SAEW. No adverse effect of SAEW was observed in Group E. There was no difference in the bacterial evanescence ratio of ascitic fluid after lavage between Groups S and E (11.1 and 15.8 %, respectively). A residual abscess developed in one patient from each group (5.0 and 4.2 %, respectively). The incidence of surgical site infection (SSI) was significantly lower in Group E than in Group S (0 and 20 %, respectively; P

Background Mediastinoscopic esophagectomy is a minimally invasive surgery for thoracic esophageal cancer avoiding one-lung ventilation or transthoracic procedure. Methods We performed for the first time in the literature, salvage esophagectomy with combination of mediastinoscopic cervical approach and laparoscopic/mediastinoscopic transhiatal approach for recurrent thoracic esophageal squamous cell carcinoma (ESCC) after definitive chemoradiotherapy (dCRT) in a patient who had previously undergone a left pneumonectomy for primary lung cancer. Results A 66-year-old man was diagnosed as local recurrence of lower ESCC (cT3N0M0 cStage II) at 9 years after dCRT. His medical history included left-sided pneumonectomy for lung adenocarcinoma 9 years previously. Then the patient was diagnosed as lower thoracic ESCC (cT3N1M0 cStage III) at 2 months after pneumonectomy. He received dCRT consisting of CDDP/5-FU infusion and irradiation (60 Gy) and achieved complete response. No evidence of tumor recurrence was observed at endoscopic surveillance up until 6 years after dCRT. For this present surgery, a cervical wound was made and the intramediastinal procedure was performed under pneumomediastinum. After mobilization of upper/middle thoracic esophagus, the esophageal wall was safely separated from the remaining part and the stump of the left main bronchus. Dense adhesions between the esophagus and fibrotic tissue at the site of previous left mediastinal pleural resection was divided using a sealing device. In the abdomen, 5 ports were inserted to perform abdominal and transhiatal procedures under CO2 insufflation. After mobilization of the stomach, fibrotic scar tissue around the lower esophagus was divided using a sealing device and the peri-esophageal space dissected from cervical and transhiatal approach were connected to completely mobilize the thoracic esophagus. The esophagectomy was uneventfully carried out followed by reconstruction with gastric conduit via retrosternal rout. Pathological findings demonstrated a moderately differentiated ESCC (pT3-AD pN1 M0 pStage III), indicating that R0 resection was successfully performed. The patient has been closely observed as an outpatient and was alive and healthy at 3 months after the operation without tumor recurrence. Conclusion Mediastinoscopic esophagectomy is a safe and curative treatment strategy for esophageal cancer patients who had a previous pneumonectomy, even in salvage surgery for recurrent cancer after dCRT. Disclosure All authors have declared no conflicts of interest.

The purpose of this study was to determine reliable predictors of outcome of biliary atresia (BA) after Kasai's operation.Fifty-four BA cases that underwent Kasai's operation at our institution over two decades were reviewed. The cases were divided into two groups: Group I: cases that required liver transplantation or died (n=30) and Group II: cases alive with the native liver. Serum levels of total bilirubin (TB), direct bilirubin (DB), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and gamma-glutamyltransferase (GGT) were measured sequentially after surgery. For cut-off determination, receiver operating characteristic (ROC) analysis was employed.Serum TB, DB, AST, and ALT in Group I were significantly higher than those in Group II at 1, 2, and 3 months after surgery (p.05). The most reliable cut-offs determined by ROC analysis were DB of 0.7 mg/dl at 2 months (sensitivity; 93%, specificity; 75%) and AST of 94 IU/L at 2 months (sensitivity; 87%, specificity; 71%). The 54 cases were re-divided into three groups according to the cut-off values: group G (good) with DB and ASTcut-offs (n=16; Group I:II=1:15), group M (moderate) with DB or ASTcut-offs (n=9; Group I:II=4:5), and group P (poor) with DB and AST ≥ cut-offs (n=29; Group I:II=25:4). The 15-year survival rate in groups G, M, and P was 94%, 44%, and 22%, respectively (p.001).The combination of serum DB and AST at 2 months after Kasai's operation is a reliable predictor of long-term BA outcome.

To investigate the impact of cow's milk allergy (CMA) on infants with Hirschsprung's disease (HD).Twenty-four patients, who developed gastrointestinal symptoms before the age of 60 days and underwent surgery for HD in the period between January 2003 and December 2012, were enrolled in this study. They were divided into two groups based on CMA-related findings: stimulation index of lymphocyte stimulation test300 % and the presence of eosinophilic infiltration in the resected colon. Ten patients were determined specimen as not having CMA (Group A), because they did not satisfy any of the criteria. The remaining 14 were determined as having possible CMA (Group B), because they satisfied either or both findings. Patient background characteristics, pre- and postoperative clinical history, and laboratory data were compared between Groups A and B.Pre- and postoperative enterocolitis did not occur in Group A patients. Postoperative enterocolitis was more frequent in Group B than in Group A (p = 0.04). Other clinical and laboratory data did not show significant difference between the two groups.CMA is a possible risk factor for postoperative enterocolitis in patients with HD.

A newly synthesized 1,3-thiazole derivative ZSY-39 increased the force of contraction in a concentration-dependent manner in association with elevation of tissue cyclic AMP levels in the isolated canine ventricular trabeculae electrically driven at 0.5 Hz at 37 degrees C. ZSY-39 shortened the duration of isometric contractions mainly by abbreviation of the relaxation time. The maximal response to and EC50 of ZSY-39 were 0.7 (isoproterenol = 1.0) and 4.6 x 10(-5) M. Bupranolol (3 x 10(-7) M) did not affect the positive inotropic effect of ZSY-39. The time course of increases in the force of contraction induced by ZSY-39 (10(-4) M) coincided with that of cyclic AMP accumulation. The concentration-response curve for the increase in the force of contraction produced by ZSY-39 was superimposable on that of the elevation of cyclic AMP levels. Carbachol (3 x 10(-6) M) shifted the concentration-response curve for the increase in force by ZSY-39 to the right and downward, and decreased the accumulation of cyclic AMP induced by ZSY-39 (10(-4) M). ZSY-39 (10(-5) M) enhanced significantly the positive inotropic effect of isoproterenol. The relationship between the force of contraction and cyclic AMP levels after the administration of ZSY-39 was not modified by the addition of carbachol or isoproterenol. These findings indicate that cyclic AMP plays an important role in the positive inotropic effect of ZSY-39 on canine ventricular muscle.