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Background An open abdomen with frozen adherent bowels is classified as grade 4 in Björck’s open abdomen classification, and skin grafting after wound granulation is a typical closure option. We achieved delayed primary fascia closure for a patient who developed open abdomen with enteroatmospheric fistulas due to severe adherent small bowel obstruction. We present here the details of his management. Case presentation A 52-year-old man suffered acute abdominal pain during a flight and received an emergency laparotomy due to adhesive small bowel obstruction. Repeated laparotomies were required, and later open abdomen and proximal site jejunostomy were selected. After negative pressure wound therapy, he was transferred to our institution. Two enteroatmospheric fistulas emerged on the exposed intestine, and we diagnosed the condition as a Björck grade 4 open abdomen. After 8 months of wound care and parenteral nutrition, we decided to attempt primary wound closure because the patient required permanent oral restriction and total parenteral nutrition due to short bowel syndrome. A circular incision along the circumference of the exposed bowel allowed us to take a safe approach into the abdominal cavity. We removed the intestinal adhesions completely and resected the bowels, including the fistulas and anastomosed parts. Finally, the abdominal wall defect was reconstructed using the component separation technique, and the patient was discharged without an ostomy. Conclusions Primary fascia closure for grade 4 open abdomen is hard, but leaving a long interval before radical surgery and applying pertinent wound management may help solve this adverse situation.

Background: Transmediastinal esophagectomy for esophageal cancer occasionally causes postoperative accumulation of pleural effusion despite the preservation of the mediastinal pleura. Transhiatal chest drainage has been reported to be useful for thoracic esophagectomy; however, its use in transmediastinal esophagectomy remains unelucidated. This study aimed to evaluate the effectiveness and safety of transhiatal chest drainage in transmediastinal esophagectomy.Methods: This retrospective study included patients who underwent transmediastinal esophagectomy for esophageal cancer from 2018 to 2021. Transhiatal chest drainage involved the insertion of a 19-Fr Blake® drain from the abdomen to the left thoracic cavity through the hiatus. We assessed its effectiveness and safety by the daily drainage output, accumulation of postoperative pleural effusion, frequency of postoperative thoracentesis, and other complications. The drainage group comprising 24 patients was compared with the non-drainage group comprising 13 patients in whom a transhiatal chest drainage tube was not placed during transmediastinal esophagectomy.Results: The median daily output of the transhiatal chest drainage was 230 mL on day 1, 385 mL on day 2, and 313 mL on day 3. The number of patients with postoperative pleural effusion was significantly reduced from 10/13 (76.9%) in the non-drainage group to 4/24 (16.7%) in the drainage group (p=0.001). The frequency of thoracentesis in the drainage group was significantly lower than that in the non-drainage group (p=0.002). There were no significant differences in the occurrence of other postoperative complications.Conclusions: Transhiatal chest drainage could evacuate pleural effusion effectively and safely after transmediastinal esophagectomy.

Aim To evaluate the efficacy of a novel hydrogel sheet in preventing postoperative pancreatic fistula (POPF). Background Postoperative pancreatic fistula is a life‐threatening complication. As no study has reported the use of hydrogel sheets in preventing POPF, their effectiveness for that purpose remains unclear. Methods A novel hydrogel sheet made of polyvinyl alcohol (PVA) was prepared by the freeze‐thaw method. The pancreatic ducts and surrounding pancreatic parenchyma of rats were transected to induce a pancreatic fistula. Next, the sheet was attached to the transection site. Ascitic fluid amylase and lipase concentrations were measured. Neoveil®, a nonwoven polyglycolic acid (PGA) felt, is already clinically used as an absorbable reinforcing material at pancreatic transection sites. Neoveil® was used for comparison, as was VIEWGEL®, which is marketed as a wound dressing. Results The hydrogel sheet remained in place 48 hours postoperatively. The ascitic amylase concentrations in the control, VIEWGEL®‐treated, Neoveil®‐treated, and hydrogel‐treated rats, respectively, were 4992.4 ± 5355.7, 1068.4 ± 269.1, 730.2 ± 425.2, and 303.1 ± 240.1 IU/L; the ascitic lipase concentrations were 2279.8 ± 3395.2, 169.5 ± 100.6, 90.4 ± 71.0, and 86.8 ± 59.8 IU/L. The ascitic amylase and lipase levels were significantly lower in the hydrogel group than in the other groups (P, Highlight Kemmochi and colleagues developed a novel hydrogel sheet made of polyvinyl alcohol to prevent postoperative pancreatic fistula. Rat pancreases were transected to induce pancreatic fistula, and Viewgel®, Neoveil® or the hydrogel sheet were attached to the transected site. The hydrogel sheet showed a higher preventive effect than existing medical materials.

Background and Aim The incidence of non‐alcoholic steatohepatitis (NASH)‐related hepatocellular carcinoma (HCC) is progressively increasing. However, the pathophysiology and etiology of NASH progression to HCC are unknown. We hypothesized that steatosis was the key factor in NASH‐related hepatocarcinogenesis and aimed to evaluate the effects of long‐term liver X receptor (LXR) agonist stimulation on hepatic steatosis induced by a high‐fat diet and oxidative stress. Methods We used an LXR agonist (T0901317) and CCl4 to induce hepatic steatosis and oxidative stress, respectively. C57BL/6 mice fed with a high‐fat diet were treated with either T0901317 + CCl4 (T09 + CCl4 group) or CCl4 alone (CCl4 group). T0901317 (2.5 mg/kg) and CCl4 (0.1 mL/kg) were intraperitoneally administered twice weekly for 24 weeks. Results The liver‐to‐body weight ratio was significantly higher in the T09 + CCl4 group than in the CCl4 group. Mice in the T09 + CCl4 group exhibited abnormal lipid metabolism and NASH‐like histopathological features. Additionally, all mice in the T09 + CCl4 group developed liver tumors diagnosed as well‐differentiated HCC. The genes identified via microarray analysis were related to NASH and HCC development. Conclusions By combining long‐term LXR agonist stimulation with oxidative stress and a high‐fat diet, we successfully reproduced liver conditions in mice similar to those in humans with NASH and progression to HCC. Our results provide new insight into NASH‐related HCC progression and therapy.

Total or proximal gastrectomy of the upper-third early gastric cancer (u-EGC) often causes severe post-gastrectomy syndrome, suggesting that these procedures are extremely invasive for patients without pathologically positive lymph node (LN) metastasis. This study aimed to evaluate the clinical applicability of a stomach function-preserving surgery, local resection (LR), with prophylactic left gastric artery (LGA)-basin dissection (LGA-BD).The data of patients with u-EGC (pathologically diagnosed as T1) were retrospectively analyzed. Total gastrectomy was performed in 30 patients, proximal gastrectomy in 45, and subtotal gastrectomy in 6; the LN status was evaluated assuming that the patients had already underwent LR + LGA-BD. This procedure was considered feasible in patients without LN metastases or in patients with cancer in the LGA basin. The reproducibility of the results was also evaluated using an external validation dataset.Of the 82 eligible patients, 79 (96.3%) were cured after undergoing LR + LGA-BD, 74 (90.2%) were pathologically negative for LN metastases, and 5 (6.1%) had LN metastases, but these findings were only observed in the LGA basin. Similarly, of the 406 eligible tumors in the validation dataset, 396 (97.5%) were potentially curative. Tumors in the lesser curvature, post-endoscopic resection status, and small tumors (20 mm) were considered to be stronger indicators of LR + LGA-BD as all subpopulation cases met our feasibility criteria.More than 95% of the patients with u-EGC might be eligible for LR + LGA-BD. This function-preserving procedure may contribute to the development of u-EGC without pathological LN metastases, especially for tumors located at the lesser curvature.

Background A 4-week administration of tegafur/gimeracil/oteracil (S-1) followed by a 2-week rest is the standard adjuvant chemotherapy for surgically resected advanced gastric cancer. This study aimed to evaluate the oncological feasibility of a 2-week S-1 administration followed by a 1-week rest, which is frequently applied in clinical practice to reduce toxicity and improve drug adherence. Methods We retrospectively enrolled patients with stage II/III gastric cancer who received S-1 adjuvant chemotherapy following radical gastrectomy from 2006 to 2016 in three institutions. Two-week and 4-week regimen cohorts were compared for relative dose intensity (RDI) as a primary outcome, and treatment completion rate, adverse event incidence, overall survival (OS), and relapse-free survival (RFS) as secondary outcomes. Confounders were adjusted for using propensity score matching (PSM). Results One hundred and thirty-four patients received the 2-week regimen and 121 patients received the 4-week regimen. Ninety-five patients were extracted from each group after PSM. The RDIs of S-1 in the 2-week and 4-week cohorts were 73.5 and 69.9%, respectively (p = 0.35), which were not significantly different. The treatment completion rate (54.7 vs. 53.7%, p = 1.0), incidence of grade ≥3 adverse events (7.4 vs. 12.6%, p = 0.33), 3-year OS (76.4 vs. 82.7%, p = 0.78), and 3-year RFS (71.3 vs. 73.4%, p = 0.70) did not significantly differ between both cohorts. Conclusions The 2-week S-1 adjuvant chemotherapy could not improve drug adherence in terms of RDI, but its relapse rates were not significantly different compared with those of the 4-week regimen. The 2-week regimen might be considered as an option depending on the patient’s status.

Background: Transmediastinal esophagectomy for esophageal cancer occasionally results in the postoperative accumulation of pleural effusion despite the preservation of the mediastinal pleura. Transhiatal chest drainage has reported utility in thoracic esophagectomy; however, its use in transmediastinal esophagectomy remains unelucidated. This study aimed to evaluate the effectiveness and safety of transhiatal chest drainage in transmediastinal esophagectomy.Methods: This retrospective study included patients who underwent transmediastinal esophagectomy for esophageal cancer from 2018 to 2020. The transhiatal chest drainage involved the insertion of a 19-Fr Blake® drain from the inferior hepatic space to the left thoracic cavity through the hiatus. The drainage group comprising 13 patients was compared with the non-drainage group comprising 13 patients in whom a transhiatal chest drainage tube was not placed during transmediastinal esophagectomy.Results: The frequency of thoracentesis in the drainage group was significantly lower than that in the non-drainage group (p = 0.03). There were no significant differences between the two groups in terms of the occurrence of other postoperative complications, duration of oxygen administration, and postoperative hospital stay.Conclusions: Transhiatal chest drainage could evacuate pleural effusion effectively and safely after transmediastinal esophagectomy. Therefore, this procedure is clinically useful in transmediastinal esophagectomy for esophageal cancer.

General surgeons are at high risk for work-related musculoskeletal disorders (WRMSDs), especially in their neck and back. The prevalence and risk factors for surgeons' WRMSDs in Japan have not been well surveyed.A cross-sectional questionnaire survey on WRMSDs was conducted among general surgeons in Japan. Surgeons were asked about the presence and degree of neck, shoulder, and back disability in relation to open and laparoscopic surgery.The questionnaire was sent to 174 general surgeons in 21 hospitals and 106 (60.9%) responded. The prevalence of WRMSDs in the last month was 65.1%, and the prevalence at least once in a lifetime was 79.2%. The rate of WRMSDs of the neck and back was higher after open surgery (44.3%, 42.5%) than after laparoscopic surgery (28.2%, 31.1%), but there was no marked difference in shoulder pain. Age was the strongest risk factor for WRMSDs, and the pain scores, prevalence of chronic pain, and rate of WRMSD-related absence from work tended to increase with age.A questionnaire survey of surgeons in Japan showed that about 80% of surgeons suffer from WRMSDs. Countermeasures for WRMSDs among surgeons are urgently desired to ensure that limited numbers of surgeons work in the operating theatre throughout their career.Registry name: a survey of surgeons' musculoskeletal pain associated with performing surgery. University of Tsukuba Institutional Review Board registration number: 1519.

Introduction: Obstetric severe perineal laceration can frequently occur as a surgical site infection (SSI), which sometimes leads to rectovaginal fistula after repair. We encountered a rare case of a rectoperineal fistula 5 months after repair of a severe perineal laceration.Case presentation: The patient was a 39-year-old woman who underwent repair of a fourth-degree perineal laceration after vaginal delivery. Five months after primary repair, she presented with perineal swelling and pain followed by uncontrollable flatulence or passage of feces at the perineum, which was finally diagnosed as a rectoperineal fistula. Transperineal repair with fistulous tract excision was performed for the rectoperineal fistula. Closure of the rectum, perineal body, and vagina was performed layer-by-layer constructing a thick perineum to prevent anal dysfunction. The fistula was successfully closed, and the patient did not show any symptoms of fecal incontinence 6 months after surgery.Discussion: As the rectoperineal fistula might have resulted in SSI at the primary repair of the obstetric injury, the delayed occurrence of the rectoperineal fistula was unusual. A perineal approach should be performed for complete fistulous tract excision, reconstruction of a robust perineal structure, and preservation of anal sphincter function.

Background Persistent pancreatic leakage (PL) due to disconnected pancreatic duct syndrome (DPDS) is associated with severe morbidity and mortality and it usually treated with internal drainage. However, in cases without localized fistula formation, internal drainage is challenging to perform. We report an original one-stage surgical approach for nonlocalized persistent PL, namely, the “intentional internal drainage tube method”. Case presentation A 49-year-old woman whose main pancreatic duct was penetrated during endoscopic retrograde cholangiopancreatography experienced severe PL. Peritoneal lavage and a second operation involving central pancreatectomy failed to relieve the symptoms, and nonlocalized PL persisted due to DPDS. Although we attempted a radical resection of the pancreatic remnants as a third strategy, the highly inflamed tissue and massive bleeding prevented the completion of the procedure. We sutured the pancreatic head margin and performed a pancreaticojejunostomy to the distal margin. Because these two cut margins could possibly be the source of the persistent PL, we created a hole at the Roux-en-Y jejunal limb, and a silicone drainage tube was inserted into the peritoneal space via this hole. Postoperatively, we continuously suctioned the intentional internal drainage tube, and the residual PL cavity gradually diminished. Even after removal of the tube, the residual PL drained internally into the jejunum through this hole. Conclusions We present this intentional internal drainage tube method as a novel alternative approach for the management of nonlocalized PL consequential of DPDS. Due to the simplicity and minimally invasive nature of this method, we propose this technique may also be used to treat various types of nonlocalized persistent PL or be used prophylactically for central pancreatectomy.

BACKGROUND: Stomal mucocutaneous separation (SMS) is a serious and common short-term and long-term complication of ostomy surgery, but optimal methods to help prevent it have not been established. The authors hypothesized that seromuscular-dermal (SM-D) suturing may be better than all layer-dermal (AL-D) suturing to help prevent SMS. METHODS: This retrospective study evaluated the short-term SMS rate of patients who underwent colostomy or ileostomy surgery between 2015 and 2019. Patient demographics, medical and surgical history variables, as well as SMS outcomes were abstracted. Postoperative SMS severity was categorized by extent as follows: grade A (mild), grade B (moderate), and grade C (severe). RESULTS: In total, 105 patients (AL-D group, 45 patients; SM-D group, 60 patients) were enrolled in the study. SMS occurred in 24 patients (23%). The overall SMS rate was 18% (n = 11) in the SM-D group and 29% (n = 13) in the AL-D group (P = .202). The occurrence of severe (grade C) or moderate and severe SMS (grades B + C) in the SM-D compared with the AL-D group was significantly different (2% vs 16% [P = .011] and 10% vs 24% [P = .047], respectively). A history of steroid use was a risk factor for moderate and severe SMS (P = .016, odds ratio 5.694). Stomal height ≤1 cm was a a risk factor for all cases of SMS (P = .037, odds ratio 2.650). AL-D suture technique and a history of steroid use were independent risk factors for severe and moderate plus severe SMS (P = .021, odds ratio 12.844 and P = .027, odds ratio 4.808, respectively). CONCLUSION: In this study, use of the AL-D suturing technique and a history of steroid use were independent risk factors for the short-term development of moderate or severe SMS. Patients whose stoma was secured using the SM-D technique had a significantly lower rate of moderate or severe SMS.

Background Various minimally invasive surgery (MIS) procedures are used for gastric submucosal tumors (SMTs), and their technical difficulties vary. Preoperative understanding of difficulties is crucial; however, objective indicators are lacking. Methods Gastric SMTs requiring MIS (n = 36) were retrospectively analyzed. Preoperative factors were evaluated using a multivariate linear regression analysis. A scoring system was then constructed, and its feasibility was evaluated. Results Three factors were identified and scored based on the weighted contribution for predicting surgical time: tumor location (cardia, score of “2”; posterior wall of fundus, “1”); tumor size (greater than 4 cm, “1”); and tumor growth appearance (intraluminal, “1”). The summed scores could stratify the surgical time stepwise in each score, and patients who scored higher than 3 had larger intraoperative blood loss and a longer hospital stay. Conclusion Our scoring system predicted surgical difficulties and may, therefore, be useful in selecting appropriate surgical approaches for gastric SMTs.

This is the first study to compare the long-term outcomes between neoadjuvant chemotherapy + surgery and definitive chemoradiotherapy with proton beam therapy for locally advanced esophageal squamous cell carcinoma. We reviewed patients with clinical stage IB–III esophageal squamous cell carcinoma (UICC 7th edition) who underwent neoadjuvant chemotherapy + surgery or definitive chemoradiotherapy with proton beam therapy (2009–2017). Overall survival, progression-free survival, and recurrence or regrowth rates were compared between the two treatment groups. Subgroup analyses of overall survival according to baseline characteristics were also performed. Forty-three patients received neoadjuvant chemotherapy + surgery (median follow-up 47.4 months) and 60 received definitive chemoradiotherapy with proton beam therapy (median follow-up 51.5 months). Baseline characteristics were similar between the groups except for sex, tumor location, and cT classification. The neoadjuvant chemotherapy + surgery and definitive chemoradiotherapy with proton beam therapy groups had similar 3-year overall survival rates (73.1% and 61.7%, respectively, hazard ratio: 0.88, 95% confidence interval 0.49–1.58, p = 0.66), 3-year progression-free survival rates (46.5% and 45%, respectively, hazard ratio: 1.03, 95% confidence interval 0.62–1.70, p = 0.92), and recurrence or regrowth rates (53.5% vs. 50.0%, p = 0.84). In the subgroup analysis, favorable survival was observed after definitive chemoradiotherapy with proton beam therapy for cT1–2 disease (hazard ratio 2.58, 95% confidence interval 0.84–7.99) and after neoadjuvant chemotherapy + surgery for cT3 or higher disease (hazard ratio 0.32, 95% confidence interval 0.15–0.67, p-for-interaction = 0.002). Long-term outcomes were comparable between the treatments. The choice of the treatment according to cT classification might affect survival.

Background Present treatment strategy for unresectable locally advanced (UR-LA) pancreatic ductal adenocarcinoma (PDAC) patients is controversial. Hence, a triple-modal therapy, which is a multidisciplinary strategy, was designed for patients with UR-LA PDAC by adding hyperthermia to conventional chemoradiotherapy at our institution. In this study we aimed to evaluate the effectiveness of this strategy. Methods Data of 21 UR-LA PDAC patients who underwent the triple-modal treatment were retrospectively analyzed for evaluating the safety and oncological effect of the treatment. The treatment schedule included, five concurrent infusions of gemcitabine (800 mg/m2) followed by hyperthermia (1 h) and X-ray (2 Gy) or proton beam radiation (2.7 Gy) on days 1, 8, 15, 29, and 36. Additional radiotherapies applied a total dose of 50 Gy/25 fr for X-ray radiation or 67.5 Gy/25 fr for proton beam radiation. Results Median overall survival (OS) was 23.6 months. Conversion surgery was performed in 5 patients (23.8%), and a R0 margin could be achieved in 4 of them; however, their median OS (16.3 months) tended to be shorter than that of the patients who did not undergo resection (23.6 months, p = 0.562). Further, the median OS of patients who underwent proton beam radiation (28.0 months) was significantly longer than that of patients who underwent X-ray radiation (13.9 months, p = 0.045). Most adverse events were manageable, except for one grade 3 gastric ulcer. The median tumor size and marker reduction rates were −17% and −91%, respectively. The tumor responses were partial response, stable disease, and progressive disease in 3, 15, and 3 patients, respectively. Conclusion Triple-modal strategy, especially when combined with proton beam radiation, is feasible and results in favorable survival outcomes in patients with UR-LA PDAC.

Objective Laparoscopic surgery for diverticular colovesical fistula (CVF) is technically challenging, and the incidence of conversion to open surgery (COS) is high. This study aimed to review our experience with laparoscopic surgery for diverticular CVF and identify preoperative risk factors for COS. Results This was a single institution, retrospective, observational study of 11 patients (10 males and 1 female) who underwent laparoscopic sigmoid colon resection with fistula resection for diverticular CVF from 2014 to 2019. Preoperative magnetic resonance imaging (MRI) was performed to evaluate the fistula location in the bladder, patency of the rectovesical pouch (i.e., the destination of dissection procedure between sigmoid colon and bladder) and estimate the contact area between the sigmoid colon and bladder. The relationship between preoperative variables and COS incidence was analyzed between completed laparoscopy and COS groups. The overall incidence of postoperative morbidity (Clavien–Dindo classification Grade II or higher) was 36% (4/11). Severe morbidity, reoperation, and mortality were not observed. The incidence of COS was 27% (3/11). Posterior bladder fistulas were significantly associated with COS. CVFs located on the posterior bladder appears to be a risk factor for COS. Identifying risk factors for COS preoperatively could help guide the intraoperative course.

Background When considering “early stoma closure”, both standardized inclusion/exclusion criteria and standardized methods to assess anastomosis are necessary to reduce the risk of occult anastomotic leakage (AL). However, in the immediate postoperative period, neither have the incidence and risk factors of occult AL in patients with diverting stoma (DS) been clarified nor have methods to assess anastomosis been standardized. The aim of this study was to elucidate the incidence and risk factors of occult AL in patients who had undergone rectal resection with DS and to evaluate the significance of computed tomography (CT) following water-soluble contrast enema (CE) to detect occult anastomotic leakage. Methods This was a single institutional prospective observational study of patients who had undergone rectal resection with the selective use of DS between May and October 2019. Fifteen patients had undergone CE and CT to assess for AL on postoperative day (POD) 7, and CT was performed just after CE. Univariate analysis was performed to assess the relationship between preoperative variables and the incidence of occult AL on POD 7. Results The incidence of occult AL on postoperative day 7 was 6 of 15 (40%). Hand-sewn anastomosis, compared with stapled anastomosis, was a significant risk factor. Five more cases with occult AL that could not be detected with CE could be detected on CT following CE; CE alone had a 33% false-negative radiological result rate. Conclusions Hand-sewn anastomosis appeared to be a risk factor for occult AL, and CE alone had a high false-negative radiological result rate. When considering the introduction of early stoma closure, stapled anastomosis and CT following CE could be an appropriate inclusion criterion and preoperative examination, respectively.

BackgroundIn the immediate postoperative period, neither have the incidence and risk factors of occult anastomotic leakage (AL) in patients with diverting stoma (DS) been clarified, nor have methods to assess anastomosis been standardized. Before introducing “early stoma closure”, both standardized inclusion and exclusion criteria and standardized methods to assess anastomosis are necessary. The aim of this study was to elucidate the incidence and risk factors of occult AL in patients who had undergone rectal resection with DS and to evaluate the significance of computed tomography (CT) following water-soluble contrast enema (CE) to detect occult anastomotic leakage.MethodsThis was a single institutional prospective observational study of patients who had undergone rectal resection with DS between May and October 2019. All patients had undergone CE and CT to assess for anastomosis on postoperative day (POD) 7, and CT was performed just after CE. Univariate analysis was performed to assess the relationship between preoperative variables and the incidence of occult AL on POD 7ResultsThe incidence of occult AL on postoperative day 7 was 40%. Hand-sewn anastomosis, compared with stapled anastomosis, was a statistically significant risk factor (p=0.0406). Five more cases with occult AL that could not be detected with CE could be detected on CT following CE; CE alone had a 33% false-negative radiological result rate.ConclusionsHand-sewn anastomosis was a risk factor for occult AL, and CE alone had a high false-negative radiological result rate. When considering the introduction of early stoma closure, stapled anastomosis and CT following CE could be an appropriate inclusion criterion and preoperative examination, respectively.

Background Pancreatic acinar cell carcinoma (PACC), a rare variant of pancreatic malignancy, is generally managed the same way as pancreatic ductal adenocarcinoma (PDAC). Surgical resection is the gateway to curing it; however, once it metastasizes (usually to the liver, lungs, lymph nodes, or peritoneal cavity), systemic chemotherapy has been the only option, but with unfavorable results. Case presentation A 67-year-old man with symptoms of loss of appetite and weight underwent surgery for malignancy of the pancreatic tail extending into the entire pancreas. The pathological diagnosis was PACC following total pancreatectomy. Twenty-four months after the pancreatectomy, a solitary liver metastasis was treated by partial hepatectomy, and, subsequently, 4 months later, he presented with melena. Further examination revealed a type-2 rectal tumor. Histological examination following biopsy revealed it to be rectal metastasis of PACC, and it was treated by abdominoperineal resection. Subsequently, the patient did not have tumor recurrence as of 40 months after pancreatectomy. Conclusions This is a rare case of PACC presenting with metachronal metastases in the liver and rectum, and we successfully treated them by surgical resections. Since the malignant behavior of PACC is usually less than that of PDAC, surgical resection could be an option even for metastatic lesions when the number and extent of metastases are limited.

Although several non-alcoholic steatohepatitis (NASH) models have been reported to date, few of these models fully reflect the histopathology and pathophysiology of human NASH. The aim of this study was to establish a novel NASH model by feeding a high-fat (HF) diet and administering both carbon tetrachloride (CCl4 ) and the Liver X receptor agonist T0901317. Male C57BL/6J mice were divided into four groups (each n = 5): HF, HF + CCl4 , HF + T0901317, and the novel NASH model (HF + CCl4 + T0901317). CCl4 (0.1 mL/kg) and T0901317 (2.5 mg/kg) were intraperitoneally administered four times and five times, respectively. The livers of the novel NASH model group presented a whitish colour. The serum levels of TNF-α and IL-6 were significantly increased in the novel NASH model group, and mice in this group exhibited histopathological features and insulin resistance reflective of NASH, i.e., macrovesicular hepatic steatosis, ballooning hepatocytes, Mallory-Denk bodies, lobular inflammation and fibrosis. The novel NASH model group presented significantly upregulated expression levels of mRNAs related to lipogenesis, oxidative stress, fibrosis and steatosis and significantly downregulated expression levels of mRNAs related to triglyceride export. We successfully established a novel experimental NASH model that exhibits similar histopathology and pathophysiology to human NASH.

Delayed gastric emptying (DGE) is a critical complication after pancreaticoduodenectomy (PD). Antecolic gastrojejunostomy has long been adopted as standard procedure because it is thought to reduce DGE. However, we have used retrocolic gastrojejunostomy (retro-GJ) for more than 10 years and have not observed high DGE rates. We aimed to clarify whether our retro-GJ approach produced comparable outcomes in preventing DGE.A total of 211 patients who underwent pylorus-resecting PD with retro-GJ at our institution between 2005 and 2016 were retrospectively analyzed. The incidence rate of DGE and the length of postoperative hospital stay were assessed.The overall incidence of DGE with our retro-GJ procedure was 13% (n = 28), and the rate of clinically relevant DGE (grade B or C based on the International Study Group of Pancreatic Surgery criteria) was 4% (n = 8). The median postoperative hospital stay was 17 days (interquartile range, 13-25 days). Major complications (Clavien-Dindo grade ≥III) occurred in 37% (n = 79) of patients and were not associated with the occurrence of clinically relevant DGE (P = 0.47).Our retro-GJ approach after PD with gastrojejunostomy, which involves careful positioning at the left-sided inframesocolic point, satisfactorily prevents DGE.

A 62-year-old woman had developed polymyositis 12 years previously and had taken oral steroids. Chest and abdominal computed tomography showed pneumomediastinum and free air in the abdominal cavity. Although a colon perforation was suspected, the perforation site could not be identified on the image. In addition, a diagnosis of oesophageal rupture could not be excluded from the findings of pneumomediastinum. After general anaesthesia, an upper gastrointestinal endoscopy was performed before surgery. Because there was no obvious perforation in the oesophagus, a laparotomy approach was used. A perforation was found on the mesentery side of the sigmoid colon, and a perforation of the sigmoid colon’s diverticulum towards the mesentery was diagnosed. A Hartmann’s procedure was performed. Colon perforations are rarely associated with pneumomediastinum. Preoperative endoscopy is useful to help diagnose and determine the surgical procedure if an obvious perforation cannot be identified.

A 78-year-old woman with malignant lymphoma of the stomach underwent total gastrectomy with a jejunal-pouch (J-pouch) reconstruction in 1994. Twelve years after surgery the patient began to suffer epigastric distress and reflux symptoms. Eventually, she was unable to take anything by mouth. A series of diagnostic images seemed to indicate that the main cause of the dysfunction was flaccidity of the J-pouch and deformity of the outflow route induced by chronic excessive dilatation of the pouch wall. Because all conservative managements only led to temporary improvement and ended in failure, she hoped to receive the operation. We designed “pouch plasty” capable of ameliorating the pouch dysfunction. The aim of pouch plasty was to improve uneven tension of the pouch wall and repair deformity of the outflow route of the food. After the operation, the J-pouch resumed adequate drainage and had good reservoir function. More than 7 years later, the patient had no further complications.

Background and Aim: Although there are some reports of an adverse effect of low serum high-density lipoprotein cholesterol (HDL-C) levels on gastrointestinal cancers, the specific correlation between serum HDL-C levels and gastric cancer remains unknown. Methods: Preoperative serum HDL-C levels were retrospectively examined in 184 patients who had undergone gastrectomy. The patients who had undergone gastrectomy were divided into two groups: the normal-HDL-C group and the low-HDL-C group. We examined the characteristics and outcomes of these two groups. Univariate and multivariate analyses were performed to investigate the association between serum HDL-C levels and gastric cancer. Results: There was no significant difference between the groups in terms of the progression of gastric cancer. In the low-HDL-C group, lymphatic and vascular invasion was significantly increased. The prognosis of the patients in the normal-HDL-C group was significantly better than those in the low-HDL-C group. Conclusions: In this study, a positive correlation between low preoperative serum HDL-C levels and prognosis for gastric cancer was demonstrated. Serum HDL-C level may be a clinical prognostic factor for gastric cancer patients.

Background and Aim: Platelets provide many functions in the body, especially to the liver. The purpose of this study is to investigate the effect of thrombocytosis with acute hepatitis induced by anti-Fas antibody and its mechanism. Methods: Acute hepatitis was induced by administration of anti-Fas antibody in normal and thrombocytotic C57BL6J mice. For thrombocytosis, thrombopoietin; PEG-rHuMGDF was injected 5 days before and just prior to administration of anti-Fas antibody. To investigate the mechanisms, hepatocyte cell line (AML12) and sinusoidal endothelial cell line (M1) were induced apoptosis by staurosporine. They were cultured with platelets or thrombopoietin. Examination items were as follows: platelet number, alanine aminotransferase (ALT), histological findings, TUNEL (TdT-mediated dUTP-biotin Nick End Labeling) staining, and the expression of proteins associated with apoptosis in vivo and in vitro. Results: Platelets were significantly increased in the thrombocytotic group (P

We recently developed a telemetry system for recording neural activity in the brains of unrestrained pigs. To test the fidelity of waveform reproduction, we compared local field potentials in the temporal hippocampus of six pigs by simultaneous recording with a cable system. We analyzed differences between the telemetry and cabled data filtered through a low-cut filter at 1, 4, or 30 Hz. Analysis of 10,000 data recorded while pigs were lying down showed a higher correlation with low-cut filtering at 4 or 30 Hz than at 1 Hz. Over 97% of differences in amplitude between the telemetry and cable data lay within the 95% confidence interval. Measurements were reproducible. A box plot of the differences clearly showed increased data symmetry and reduced skewness by low-cut filtering at 4 or 30 Hz. Almost the same results were obtained in two animals during feeding. Thus, the local field potentials in the temporal hippocampus were telemetered with almost the same accuracy as by cable measurement during both resting and feeding. However, artifacts in the first 100 ms (low-cut filtering at 1 or 4 Hz) or 5 ms (30 Hz) of measurements had to be removed for analysis.

Platelets develop tissue repair and promote liver regeneration. We investigated whether platelets prevented acute liver damage after extended hepatectomy in pigs. Thrombocytosis was induced by the following two methods; afterwards 80% hepatectomy was performed in pigs. In the first method, the pigs received administration of thrombopoietin [TPO (+) group], and they were compared with a control group [TPO (−) group]. In the second method, the pigs received a splenectomy [Sp (+) group], and theywere compared with another control group [Sp (−) group]. Platelet counts, biochemical examination of blood, and histopathological findings of the residual liver were examined. Serum aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP), and total bilirubin (T-Bil) levels were significantly decreased in the thrombocytotic groups compared with the control groups in the early period after hepatectomy. In the histopathological findings, hemorrhagic necrosis with a bile plug was observed in the control groups, but this phenomenon was not observed in the thrombocytotic groups. On transmission electron microscopy, the sinusoidal endothelial lining was destroyed and detached into the sinusoidal space with enlargement of Disse’s spaces in the thrombocytotic groups, but these findings were not observed in the control groups. An increased number of platelets prevents acute liver damage after extended hepatectomy.

Background/Aims The autonomic vagus nerve is thought to play an essential role in liver regeneration since hepatic vagotomy delays hepatic DNA synthesis. However, how the parasympathetic vagus nerve is involved in liver regeneration remains obscure. Kupffer cells are located in liver sinusoids adjacent to hepatocytes and might regulate liver regeneration by releasing interleukin-6 (IL-6). The present study examines the role of the vagus nerve and how Kupffer cells are involved in parasympathetic nerve-mediated liver regeneration in mice. Methods We performed surgical vagotomy of the hepatic branch and then partial hepatectomy (PH); some mice received acetylcholine (ACh) agonist/antagonist before PH. We then evaluated liver regeneration and signal transducer and activator of transcription-3 (STAT3) activation. We also investigated whether ACh stimulates IL-6 release from Kupffer cells. Results Surgical vagotomy impaired liver regeneration. STAT3, which is activated by IL-6 after hepatectomy and plays a pivotal role in liver regeneration, was less activated in vagotomized mice after PH. Post-PH STAT3 activation was recovered by administering vagotomized mice with an ACh agonist. Furthermore, ACh stimulated IL-6 release in Kupffer cells in vitro. Conclusion The parasympathetic system (vagus nerve) contributes to liver regeneration after hepatectomy by stimulating IL-6 release from Kupffer cells followed by STAT3 activation in hepatocytes.