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Robotic gastrectomy (RG) is a good alternative to laparoscopic gastrectomy, as it improves treatment outcomes and reduces the burden of technical difficulties; however, prolonged operative time may be a disadvantage. This study aimed to identify measures to shorten the operative time during the initial introduction of RG at an institution.We assessed 33 patients with gastric cancer who underwent radical distal gastrectomy with Billroth-I reconstruction and divided them into three groups: laparoscopic distal gastrectomy (LDG), robotic distal gastrectomy in the early phase (RDG-E), and in the late phase (RDG-L). Operative time, six technical steps, and junk time, including the roll-in/roll-out, docking/undocking, and instrument exchange times, were compared among the groups.The median (range) overall operative times of LDG, RDG-E, and RDG-L were 248 (179-323), 304 (249-383), and 263 (220-367) min, respectively, but no significant differences were observed. For each surgical step of RG, RDG-L in suprapancreatic lymph node dissection was significantly shorter than that in RDG-E. The median (range) junk times of LDG, RDG-E, and RDG-L were 16.7 (12.7-26.4), 48.3 (38.6-67.7), and 42.0 (35.4-49.2) min, respectively. Junk time was significantly longer in RDG-L than in LDG (p = 0.003), but not significant between RDG-E and RDG-L. The learning curve effect of overall, console, and junk times were achieved in four cases of RDG.Junk time is a major factor in prolonging RDG operative time. However, to reduce the time after initial introduction, measures to promote robot-specific standardization and more effective use of robotic instruments are essential.

Background/Aim: The Barthel index and Katz index are useful in assessing the physical function status of patients. We prospectively evaluated the relationship between the Barthel and Katz indices and postoperative complications in older patients undergoing gastrointestinal surgery. Patients and Methods: We enrolled 250 patients aged ≥65 years who underwent gastrointestinal surgery between September 2018 and April 2020. Postoperative complications within 30 days after surgery were categorized using the Clavien-Dindo classification. The primary endpoint was the incidence of postoperative complications of Clavien-Dindo grade ≥II. Results: Of the 250 patients (age, 74.1±6.2 years), 149 (59.6%) were male and 101 (40.4%) were female. The Barthel index was

The present study examined the changes in and risk factors for body composition (BC) during the first postoperative month when dynamic biological reactions occur.We retrospectively assessed 202 patients who underwent gastrectomy. The BC was assessed using a bioelectrical impedance analysis and evaluated within 1 month preoperatively, 1 week postoperatively, and 1 month postoperatively. Multiple regression analyses were performed to identify predictive factors for BC change.The mean reduction rate in BC at 1 month postoperatively was - 6.0, - 10.5, - 5.6, - 1.1, - 10.1, and + 1.2% for body weight, body fat, skeletal muscle, bone mineral, extracellular water/total body water, and the whole-body phase angle, respectively. A multiple regression analysis revealed that independent risk factors for weight loss were complications, operative time, and type of gastrectomy (P = 0.004, 0.011, 0.015, respectively), and those for skeletal muscle loss were complications and gastrectomy type (P = 0.002, 0.010, respectively). A segmental lean mass analysis revealed that the lower limbs were markedly reduced at 1 week postoperatively (- 8.0%), and these independent risk factors were the female sex and Stage II/III disease (P = 0.008, 0.036, respectively).Detailed analyses of BC might help elucidate the mechanisms underlying postoperative physical changes, which might be useful for perioperative management.

[Background] As antithrombin III (AT-III) is produced in the hepatocytes, its serum activity decreases at the time of liver failure, in addition to ischemia reperfusion injury, vascular endothelial dysfunction, and disseminated intravascular coagulation (DIC). Here, we examined whether the serum AT-III value after hepatectomy could be a prognostic factor for hepatocellular carcinoma (HCC). [Methods] Of 141 patients who underwent hepatectomy for HCC, data for 101 patients in whom serum AT-III activity was measured on the first postoperative day were extracted. Patients with serum AT-III activity > 50% and ? 50% were assigned to high value (72 cases) and low value (29 cases) groups, respectively. We examined the clinical and prognostic differences between these two groups. [Results] The average age of enrolled patients (83 men and 18 women) was 68.0 years. The 5-year overall survival rate was 88% and 60% in the high and low value groups, respectively (P < 0.01). Furthermore, the 2-year relapse-free survival rate was 71% and 54% in the high and low value groups, respectively (P = 0.03). [Conclusion] This is the first study to demonstrate that serum AT-III levels on the first postoperative day may serve as a prognostic factor in HCC patients.

Background/aim Maspin is a tumor-suppressor protein expressed in >90% of pancreatic ductal adenocarcinoma (PDAC) cases. We aimed to assess the prognostic value of subcellular localization of maspin. Patients and methods Ninety-two resected PDAC specimens were immunohistochemically analyzed. Cytoplasmic-only expression observed in >10% of the tumor was defined as maspin-positive. Results The maspin-positive status (21.7%) was inversely correlated with well-differentiated histological type and indicated a shorter recurrence-free survival (RFS) and overall survival (OS). Cox's multivariate analysis showed that maspin-positive status was an independent factor for shorter RFS and OS. Maspin was localized to cytoplasm in AsPC-1 cells, but to both nucleus and cytoplasm in BxPC-3 cells. In AsPC-1 cells, cell invasion was significantly reduced in response to maspin suppression via transfection with siRNA targeting maspin, whereas no reduction was observed in BxPC-3 cells. Conclusion Cytoplasmic-only expression of maspin could be an independent unfavorable prognostic indicator for patients with PDAC.

Background Decreased mean platelet volume (MPV) predicts poor prognosis in some cancers. However, its significance as a prognostic indicator in pancreatic cancer (PC) remains unclear. Methods A total of 91 PC patients who underwent pancreatectomy were included in this study. MPV and serum carbohydrate antigen 19-9 (CA19-9) were measured within 1 week before surgery. Results We divided patients into MPVhigh (≥ 8.65; n = 40), MPVlow (high (≥ 66.3; n = 47), and CA19-9low (low than in the MPVhigh group (16.9% and 56.3%, respectively; P = 0.0038), and the 5-year disease-specific survival (DSS) rates in the MPVlow group and MPVhigh group were 20.5% and 62.2%, respectively (P = 0.0031). Multivariate analysis identified MPV as an independent prognostic indicator for both OS and DSS. The patients were then divided into groups A (MPVhigh and CA19-9low), B (MPVhigh and CA19-9high), C (MPVlow and CA19-9low), and D (MPVlow and CA19-9high), with 5-year OS rates of 73.2%, 40.4%, 25.8%, and 10.3%, respectively (P = 0.0002), and 5-year DSS rates of 80.8%, 44.9%, 27.3%, and 16.4%, respectively (P = 0.0003). Conclusions Classification based on MPV and CA19-9 might be useful for predicting long-term outcomes in patients with PC.

By administering ICG test immediately before laparoscopic liver cyst fenestration, the biliary tract can be easily identified and intraoperative bile duct damage and postoperative bile fistula formation can be avoided, as demonstrated in this case.

We present a very rare case of a laparoscopically-assisted repair of a small bowel perforation secondary to multiple metastases of undifferentiated pleomorphic sarcoma from the posterior mediastinum. A 46-year-old man presented with middle to upper abdominal pain during chemotherapy for lung metastases from undifferentiated pleomorphic sarcoma. Computed tomography revealed intra-abdominal free air, and emergency laparoscopy was performed. Consequently, a perforation was detected in the jejunum, and partial jejunal resection was performed by mini-laparotomy. Pathological examination demonstrated an ulcerated tumor with perforation and four additional tumors in the resected jejunum. Pathological examination also revealed undifferentiated pleomorphic sarcoma in all five tumors. To our knowledge, our case is the first report of a laparoscopically-assisted repair of a small bowel perforation secondary to metastasis of undifferentiated pleomorphic sarcoma. Although the perforation site was unclear preoperatively, laparoscopic observation readily identified the lesion in this patient. Therefore, minimally invasive surgery could be performed successfully with mini-laparotomy following laparoscopic observation. Laparoscopic techniques for the small intestine are viable options, even in acute and uncommon situations, and small bowel perforation secondary to metastasis should be considered in patients with undifferentiated pleomorphic sarcoma and acute abdomen.

Background/Aim: Indocyanine green (ICG) clearance test is one of the most popular dynamic methods for evaluating preoperative liver function to avoid posthepatectomy liver failure (PHLF). Tc-99m-diethylenetriamine-penta-acetic acid-galactosyl human serum albumin scintigraphy (GSA) also facilitates the direct estimation of functional hepatocytes and can estimate the ICG retention rate (R15); however, in some cases, there is a discrepancy between results of a preoperative examination of ICG-R15 and the estimated ICG-R15 obtained by 99mTc-GSA (GSA-R15). This study evaluated the gap between ICG-R15 and GSA-R15 (ΔICG) for predicting background liver fibrosis in patients who underwent hepatectomy. Patients and Methods: Sixty-four consecutive patients who underwent hepatectomy and preoperative ICG-R15 and GSA-R15 examinations from 2016 to 2019 were retrospectively evaluated. The gap between GSA-R15 and ICG-R15 was defined as ΔICG and the factors predicting liver fibrosis were investigated. Results: In the pathologically-proven cirrhotic group, platelet counts were significantly lower and ΔICG values were significantly larger than those in the non-/early-cirrhotic group. A multivariate analysis identified a higher total bilirubin level, a higher AST level, and a larger ΔICG level as significant predictive factors for liver cirrhosis. Conclusion: Larger ΔICG was found to be an independent preoperative predictor of liver fibrosis and may positively contribute to decision-making before hepatectomy to avoid PHLF.

Background/aim The efficacy and safety of early drain removal following distal pancreatectomy in elderly patients are unclear. We aimed to investigate the short-term surgical outcomes following early drain removal after distal pancreatectomy in elderly patients. Patients and methods Fifty-seven patients aged ≥70 years who underwent distal pancreatectomy at our Hospital were enrolled in the study. Data were retrospectively analyzed to evaluate the short-term surgical outcomes following early drain removal after distal pancreatectomy in elderly patients. Results The incidence of pancreatic fistula following distal pancreatectomy in the early-removal group was significantly lower vs. the conventional group (p=0.022). Multivariate analysis revealed that early drain removal was an independent factor for reducing the risk of pancreatic fistula after distal pancreatectomy in elderly patients (p=0.042). Conclusion Early drain removal following distal pancreatectomy is an effective and safe surgical perioperative management procedure to prevent pancreatic fistula in elderly patients.

Background The albumin-bilirubin (ALBI) grade assesses the severity of liver dysfunction in patients with hepatocellular carcinoma. Herein we investigated the prognostic significance of the combination of the ALBI grade with serum carbohydrate antigen 19-9 (CA 19-9) concentration, the most frequently used tumor marker in pancreatic cancer (PC) in resected patients with PC. Materials and methods Included patients (n=100) had a histopathological diagnosis of pancreatic cancer and underwent pancreatectomy. Serum concentrations of albumin, bilirubin, and CA19-9 were measured within 5 days before surgery. Patients were divided into groups with high and low CA19-9 (cut-off ≥35 U/ml) and ALBI grade (2 and 3 vs. 1). Results The 5-year overall survival (OS) rates of the ALBIHigh and ALBILow groups were 21.6% and 35.3%, respectively (p=0.015). The 5-year OS rates of the CA19-9High and CA19-9Low groups were 22.2% and 41.5%, respectively (p=0.017). Patients were divided into groups A (ALBIHigh and CA19-9High), B (ALBIHigh and CA19-9Low or ALBILow and CA19-9High), and C (ALBILow and CA19-9Low). The 5-year OS rates of groups A, B, and C were 13.8%, 31.0%, and 43.3%, respectively (p=0.0006). Multivariate analysis revealed that the ALBI grade combined with the CA19-9 concentration, served as an independent prognostic indicator. Conclusion The combination of ALBI grade and CA19-9 concentration predicted the prognosis of patients with PC.

Background/Aim: Recent studies have investigated a novel inflammation-based prognostic system using the combination of platelet count and neutrophil–lymphocyte ratio (COP-NLR). As platelet count decreases with liver damage, we hypothesized that COP-NLR could indicate both inflammation and hepatic reserve in patients with hepatocellular carcinoma (HCC). This study was conducted to clarify the prognostic significance of preoperative COP-NLR in patients with HCC. Patients and Methods: We enrolled 176 patients with histologically-proven HCC who underwent initial curative hepatectomy. Patients were assigned one point each for low platelet count (

Although Child-Pugh grade A patients with hepatocellular carcinoma (HCC) are candidates for curative resection, some may have a poor prognosis. The albumin-bilirubin (ALBI) grade, a measure of liver function based on albumin and bilirubin, has the potential to detect Child-Pugh grade A HCC patients with poor prognosis. Because components of the ALBI grade can be measured easily even after surgery, we explored the predictive values of ALBI in patient prognosis after HCC resection.In this retrospective case-control study, we included 136 HCC patients who underwent curative resection between January 2004 and December 2013 at our hospital. ALBI grade was calculated from laboratory data recorded the day before surgery and at post-operative day 5.Pre- and post-operative ALBI grade predicted patients' long-term outcomes (P = 0.020 and P 0.001, respectively, for overall survival, and P = 0.012 and P = 0.015, respectively, for recurrence-free survival). Post-operative ALBI grade was associated with patients' surgical factors of repeated hepatic resection (P = 0.012), intra-operative bleeding (P = 0.006), and surgery duration (P = 0.033). Furthermore, post-operative ALBI grade, rather than pre-operative ALBI grade, was an independent predictive factor of long-term outcome of Child-Pugh grade A patients with HCC.Post-operative ALBI grade is useful to predict the prognosis in patients after HCC resection.

Background The geriatric nutritional risk index (GNRI), originally developed as a nutritional assessment tool to evaluate mortality and morbidity in older hospitalized patients (i.e., those aged ≥65 years), is regarded as a prognostic factor in several cancers. Body composition is also an important consideration when predicting the prognosis of patients with cancer. This study aimed to investigate the relationship between the GNRI and psoas muscle volume (PMV) for survival outcomes in patients with pancreatic cancer. Methods This retrospective study evaluated the prognostic significance of the GNRI and PMV in 105 consecutive patients aged ≥65 years who underwent pancreatectomy for histologically confirmed pancreatic cancer. The patients were divided into high (GNRI > 98) and low GNRI groups (GNRI ≤98), and into high (PMV > 61.5 mm3/m3 for men and 44.1 mm3/m3 for women) and low PMV (PMV ≤ 61.5 mm3/m3 for men and 44.1 mm3/m3 for women) groups. Results Both the 5-year overall survival (OS) and recurrence-free survival (RFS) rates were significantly greater among patients in the high GNRI group than among patients in the low GNRI group. Similarly, both the 5-year OS and RFS rates were significantly greater among patients in the high PMV group than among patients in the low PMV group. Patients were stratified into three groups: those with both high GNRI and high PMV; those with either high GNRI or high PMV (but not both); and those with both low GNRI and low PMV. Patients with both low GNRI and low PMV had a worse 5-year OS rate, compared with patients in other groups (P P = 0.003). Conclusions The combination of the GNRI and PMV might be useful to predict prognosis in patients aged ≥65 years with pancreatic cancer.

Background Sarcopenia is a prognostic factor in various cancers. However, the impact of sarcopenia in patients with recurrent pancreatic cancer remains unclear. This study evaluated the prognostic significance of sarcopenia in patients with recurrent pancreatic cancer. Methods Seventy-four patients who developed postoperative recurrence of pancreatic cancer after undergoing pancreatectomies were enrolled. Sarcopenia in these patients was defined according to the psoas muscle index (PMI) measured via computed tomography at the third vertebra. Results The mean PMIs at the time of recurrence were 4.47 ± 1.27 cm2/m2 for men and 3.26 ± 0.70 cm2/m2 for women. Of the 74 patients, 65 (87.8%) were diagnosed with sarcopenia with low PMI. The 2-year post-recurrence survival curve in the sarcopenia group was significantly worse than that in the non-sarcopenia group (P = 0.034). Multivariate analysis revealed that sarcopenia at the time of recurrence was an independent prognostic factor (P = 0.043) along with a high neutrophil-to-lymphocyte ratio (P = 0.004), early recurrence (P = 0.001), and chemotherapy after recurrence (P = 0.005) in patients with recurrent pancreatic cancer. Furthermore, the area under the curve (AUC) of the combination of sarcopenia and time to recurrence for predicting 2-year survival was 0.763, which was much higher than that of sarcopenia alone (AUC = 0.622). Conclusions Sarcopenia is a useful prognostic factor in patients with recurrent pancreatic cancer. The combination of sarcopenia and time of recurrence may more accurately predict post-recurrence survival than can sarcopenia alone.

BACKGROUND: C-reactive protein (CRP) levels reflect ongoing inflammation and/or tissue damage, and studies suggest that platelets play a role in tumor invasion and metastasis. P-CRP is defined as the multiplied product of serum CRP and platelet levels. Here the prognostic value of pre- and post-operative P-CRP levels in pancreatic cancer (PC) patients was assessed. METHODS: This retrospective study used data from 107 consecutive PC patients who had undergone either pancreaticoduodenectomy or distal pancreatectomy. Clinicopathological parameters and pre/post-operative laboratory data derived from patient records were used for analyses. P-CRP was defined as the product of peripheral thrombocyte count (/uL) × serum CRP level (mg/dL) divided by 10(4); the optimal P-CRP cut-off value was defined using receiver operating characteristic curves. RESULTS: PC patients were classified as either P-CRP(Low) (< 1.782; n = 49) or P-CRP(High) (≥ 1.782; n = 58), based on the cut-off value of 1.782. Univariate analysis revealed that performance status, clinical stage, pathological T and N stages, P-CRP, and carbohydrate antigen 19-9 (CA19-9) significantly affected overall survival (OS). Multivariate analysis revealed that independent risk factors for OS were pathological N stage, P-CRP, and CA19-9. Additionally, 103 PC patients for whom postoperative data were available were classified into four groups (P-CRP(Low-Down), P-CRP(Low-Up), P-CRP(High-Down) and P-CRP(High-Up)), based on preoperative P-CRP and postoperative trend of P-CRP, and we found that prognosis, in terms of OS, was significantly different among these groups (P = 0.012). CONCLUSION: Pre- and post-operative P-CRP values are a potential predictor of prognosis in PC patients.

Background/aim Probe-based confocal laser endomicroscopy (pCLE) is a novel diagnostic technique that can provide real-time imaging of tissues at the cellular level. In this study, pCLE was applied to liver tumors and its diagnostic value was evaluated. Patients and methods Ten patients who underwent hepatectomy for liver tumors were evaluated with pCLE from February to May 2017. Immediately after liver resection, pCLE evaluation was performed in the operating room as an ex vivo study. The newly-adopted "fluorescein-dripping method" was used for the observation. Results First, the optimal fluorescein exposure time for the surface of liver was defined in the fluorescein-dripping method. Next, the distinctive findings in the cancerous region were investigated. The characteristic appearance of irregular arrangements of concentrated cells under fluorescein dripping was observed in six of seven hepatocellular carcinoma (HCC) tumors. Conclusion In all HCC specimens, discrimination of the cancerous region from normal liver was possible with pCLE.

【Background】Indirubin, a constituent of the Chinese herbal medicine “Qing-Dai,” has anti-cancer and anti-inflammatory activities. We aimed to evaluate the efficacy of indirubin for ameliorating colonic inflammation in a mouse model of inflammatory bowel disease. 【Methods】Mice with dextran sulfate sodium (DSS)induced acute and chronic colitis were treated with indirubin in their diet. Clinical and histologic changes were evaluated. In addition, colon levels of interleukin-6, a critical pro-inflammatory mediator, was detected by enzyme-linked immunosorbent assay. 【Results】In the model of acute colitis, indirubin treatment improved the loss of body weight. Histology of colonic tissue revealed that indirubin treatment improved the histology grading of colitis (P = 0.02), the extent of submucosal fibrosis (P = 0.018), the number of mucosal toluidine blue-positive cells (P = 0.004) and colon length (P = 0.01). In the model of chronic colitis, indirubin treatment had no significant effect on pathologic findings except for colon length (P = 0.003). However, indirubin administration significantly reduced colon levels of interleukin-6 in the chronic-colitis model (P = 0.001). 【Conclusion】Our study clearly showed that oral intake of indirubin can improve murine DSS-induced colitis (which mimics human inflammatory bowel disease).

BACKGROUND/AIM The usefulness of C-reactive protein-to-albumin ratio (CAR) as a predictive indicator for clinically-relevant postoperative pancreatic fistula (CR-POPF) after pancreaticoduodenectomy (PD) is unclear. We performed a retrospective analysis to identify reliable inflammatory indicators for prediction of CR-POPF after PD. PATIENTS AND METHODS We enrolled 160 consecutive patients who underwent PD. Multivariate logistic regression analysis was performed. The areas under curves (AUCs) were compared with the discriminatory ability of inflammatory indicators, namely, C-reactive protein (CRP), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), platelet count multiplied by C-reactive protein (P-CRP), and CAR. RESULTS The AUC for CAR on POD 3 to predict CR-POPF was 0.782 (p

BACKGROUND/AIM To evaluate the impact of DEPDC1 expression on patient prognosis after hepatic resection for hepatocellular carcinoma (HCC). PATIENTS AND METHODS We reviewed data from 75 patients who underwent hepatic resection for HCC between 2004 and 2013. Recurrence at 2 years following resection, which mainly included metastatic recurrence, was defined as late recurrence. RESULTS DEPDC1 was up-regulated in HCC tissue and in non-tumor tissue of patients with HCC compared to normal liver (p

【Background】 The neutrophil lymphocyte ratio (NLR) has been proposed to be a surrogate marker of inflammation and immunological status and to have prognostic value in various malignancies. This study was conducted to clarify the prognostic significance of preoperative NLR in hepatocellular carcinoma (HCC). 【Methods】 We enrolled 135 patients with histologicallyproven HCC who underwent initial curative hepatectomy. Based on the median NLR values, patients were divided into: NLR ? 2.0 (NLR-high, n = 69) and NLR < 2.0 (NLR-low, n = 66). 【Results】 In univariate analysis, the 5-year overall survival (OS) rates were 59.8 % ± 6.7% and 75.6% ± 6.5% (P = 0.028) in the NLR-high and NLR-low groups, respectively. Furthermore, the 5-year disease specific survival rates were 68.6% ± 6.7%, and 81.2 ± 6.4% (P = 0.048) in the NLR-high and NLR-low groups, respectively. 【Conclusion】 Our results showed that high NLR was an independent predictor for OS in hepatectomy-treated HCC, suggesting that NLR may be a novel prognostic biomarker for HCC. On the other hand, NLR also has a limitation to predict postoperative prognosis of HCC patients by itself.

Objectives It is widely accepted that postoperative pancreatic fistula (POPF) accompanied by bacterial infection results in a worse outcome than POPF alone. However, few studies evaluating predictive indicators of POPF have focused on bacterial infection. Methods A consecutive 100 patients who underwent pancreaticoduodenectomy at our institute for periampullary disease were enrolled. POPF was assessed according to the International Study Group of Pancreatic Fistula consensus guidelines; grades B and C were defined as clinically relevant POPF (CR-POPF). The patients’ characteristics, perioperative surgical factors, and laboratory data including the results of culture and smear testing performed using drainage fluid on postoperative days (PODs) 1 and 3 were analyzed. Results The overall incidence of CR-POPF was 25%. Univariate analyses revealed that the factors associated with CR-POPF were male sex, soft pancreas, MPD diameter, higher serum C-reactive protein concentration and white blood cell count on POD 3, higher amylase concentration in drainage fluid, and culture and/or smear positivity of drainage fluid. Multivariate analysis newly revealed that the smear positivity of drainage fluid on POD 3 was the independent risk factors for CR-POPF (p = 0.027). Conclusions Smear positivity of drainage fluid on POD 3 after pancreaticoduodenectomy may be a new predictor of CR-POPF.

We conducted this study to evaluate the impact of the postoperative mean arterial pressure (MAP) on surgical complications after hepatic resection. The subjects of this study were 199 patients who underwent hepatic resection for primary liver malignancy between 2004 and 2013. A clinically relevant postoperative complication was defined as a Clavien–Dindo grade ≥ III complication. Based on an MAP cut-off value of 81.1 mmHg, the patients were grouped as follows: low MAP on both postoperative days (PODs) 1 and 2 (continuously low MAP), normal MAP on both PODs 1 and 2 (normal MAP), and others (transiently low MAP). The continuously low MAP group had the highest incidence of complications and the normal MAP group had the lowest incidence of complications compared with the expected incidence for this cohort (p

BACKGROUND/AIM We retrospectively investigated the relationship between prognosis and combined neutrophil-to-lymphocyte ratio (NLR) and serum carbohydrate antigen 19-9 (CA19-9) levels in patients with recurrent pancreatic cancer. PATIENTS AND METHODS We enrolled 66 patients whose pancreatic cancer recurred. RESULTS Based on ROC analysis results, the patients were divided into NLRHigh (NLR ≥1.69) or NLRLow (NLR

Highlights • Internal supravesical hernia is very rare. • Most previous reports performed closure of the hernial sac by open laparotomy. • We could successfully repair intraoperatively-diagnosed internal supravesical hernia by the anterior approach alone., Introduction Internal supravesical hernia is one of the rarest types of inguinal hernia. The hernial orifice is surrounded by the transverse vesical fold, median umbilical fold, and medial umbilical fold. Presentation of case A 75-year-old male presented with lower abdominal pain and nausea. Plain abdominal CT showed that the bladder was suppressed by small bowel near the left internal inguinal ring. A part of the small bowel wall seemed to be inlaid, and so the patient was diagnosed with a strangulated left inguinal hernia. The hernia repair operation was performed via the anterior approach. There was no internal hernial sac found, but there was a walnut-sized mass in the properitoneal space. A diagnosis was made intraoperatively of internal supravesical hernia with strangulated small bowel. Small bowel resection and hernial orifice closure were performed. Discussion Although internal supravesical hernia can present with distinctive CT findings, preoperative diagnosis is extremely difficult. Internal supravesical hernia in previous reports has been repaired via open laparotomy or laparoscopic surgery; however, we successfully repaired this intraoperatively-diagnosed internal supravesical hernia by the anterior approach alone. Conclusion The patient with internal supravesical hernia diagnosed intraoperatively could be treated via the anterior approach alone successfully. Depending on the situation, the anterior approach can be an option.

A 3-year-old boy presented with anemia and a palpable abdominal tumor. The operative finding was a 10.5×9.6×4.6-cm tumor that infiltrated the anterior wall of the stomach. Local excision was performed. The tumor was histopathologically diagnosed as leiomyosarcoma with immunoreactivity for alpha-smooth muscle actin and muscle actin, but not for CD34, c-kit, and S-100. The tumor was characterized as highly malignant because of its size, high mitotic count, nuclear atypia, and high MIB-1 labeling index. After 6 months of follow-up, recurrence developed in the remnant stomach and liver metastasis was observed. Partial gastrectomy and lateral segment resection of the liver were performed. Subsequently, multiple recurrences in the remnant liver and peritoneal dissemination occurred. The patient underwent follow-up without adjuvant therapy and was well for more than 10 years after liver metastases and peritoneal dissemination after the initial surgery. This case represents the different biological behavior of pediatric gastrointestinal leiomyosarcoma compared to adult gastrointestinal leiomyosarcoma. Keywords: Leiomyosarcoma, Pediatric, Prognosis, Metastasis, Surgery