Background/Aim: Japanese Gastric Cancer Treatment Guidelines do not recommend adjuvant chemotherapy after radical gastrectomy for pathological stage (p) T1N+ or pT2~3N0 gastric cancer. However, some patients experience disease recurrence. This study aimed to identify the risk factors for recurrence in pT1N+ or pT2-3N0 gastric cancer. Patients and Methods: The study included 157 patients with diagnosed pT1N+ or pT2-3N0 gastric cancer who underwent radical gastrectomy at our institution between January 2001 and December 2020. Clinicopathological data and surgical data were obtained. Independent prognostic factors were analyzed using a Cox proportional hazards regression model. Results: Thirteen patients (8.3%) experienced disease recurrence. Multivariate analysis revealed that the number of examined lymph nodes was an independent prognostic factor for recurrence-free survival (hazard ratio=10.90; 95% confidence interval=1.39-85.86; p=0.023). The group with ≤35 examined lymph nodes had significantly worse recurrence-free survival compared with the group with ≥36 examined lymph nodes (80.7% versus 98.7%; p=0.0005). Conclusion: The number of examined lymph nodes (≤35) was an independent risk factor for recurrence after radical gastrectomy with pT1N+ or pT2-3N0 gastric cancer.

目的:膵上縁リンパ節郭清を伴う腹腔鏡下胃切除術後の膵液瘻を予防する目的で，われわれは2017年1月より膵臓を直接的に圧排しない手術手技を採用している．

BACKGROUND/AIM:Identifying useful biomarkers is central to selecting optimal therapeutic strategies for esophageal squamous cell carcinoma (ESCC). Serum p53 antibody (S-p53Ab), squamous cell carcinoma antigen (SCC-Ag), and carcinoembryonic antigen (CEA) were investigated to evaluate the significance of single and combined tumor markers in determining the diagnosis and prognosis of ESCC.MATERIALS AND METHODS:Serum samples were obtained preoperatively from 133 patients with histologically-confirmed ESCC, including 32 patients with stage I (24.1%). Levels of S-p53Ab were assessed by enzyme-linked immunosorbent assay, using a new version of a highly specific, quantitative kit. The cut-off value for S-p53Ab was 1.3 U/ml.RESULTS:S-p53Ab was detected in 39.1% (52 out of 133) of patients with ESCC, including 40.0% (20 out of 50) of patients with early-stage ESCC. Positive rates for S-p53Ab, CEA, and SCC-Ag among patients with stage I ESCC (n=32) were 40.6%, 12.5%, and 31.3%, respectively. Positivity for S-p53Ab was not associated with positivity for CEA or SCC-Ag (p=0.249 and 0.747, respectively). The positive rate for diagnosis of ESCC increased from 39.1% to 65.4% when S-p53Ab was combined with SCC-Ag in this study. We found no significant correlation between the presence of S-p53Ab in ESCC and overall survival. Conversely, Cox regression analysis revealed that the International Union Against Cancer/TNM classification and systemic inflammation score were independent prognostic factors for ESCC in this series (hazard ratio(HR)=3.811, 95% confidence interval(CI)=1.548-9.378, p=0.004; and HR=2.218; 95% CI=1.087-4.523, p=0.029, respectively). Kaplan-Meier analysis revealed significant differences between patients with elevated S-p53Ab and SCC-Ag and patients with elevated levels of only one or neither of these factors (p=0.009).CONCLUSION:The diagnostic rate with S-p53Ab was better than that with SCC-Ag and CEA in patients with early-stage ESCC. Combined detection of S-p53Ab and SCC-Ag can markedly improve diagnostic sensitivity and may permit more accurate stratification of patients with ESCC.

The aim of the present study was to investigate the prognostic value of the C-reactive protein-to-albumin ratio (CAR) and compare it with other inflammation-based prognostic scores (Glasgow prognostic score, modified Glasgow prognostic score, neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, prognostic nutritional index and prognostic index) in patients with esophageal squamous cell cancer (ESCC). A database of 116 patients with primary ESCC who underwent treatment at the Division of Surgical Oncology at Nagasaki University Hospital between January 2007 and August 2014 was retrospectively reviewed and the correlations between CAR and overall survival (OS) were investigated. Kaplan-Meier and Cox regression analyses were used to assess independent prognostic factors. The area under the curve (AUC) was used to compare the prognostic value of different scores. According to the receiver operator characteristics analysis, the recommended cut-off value for CAR was 0.042, with an AUC of 0.678 (sensitivity 31.1%, specificity 66.7%). Thus, patients were dichotomized into low (<0.042) and high (≥0.042) CAR groups. On multivariate analysis, CAR was found to be significantly associated with OS in patients with ESCC [hazard ratio (HR)=2.350; 95% confidence interval (CI): 1.189-4.650; P=0.014], as was tumor-node-metastasis stage (HR=3.059; 95% CI: 1.422-6.582; P=0.004). In addition, CAR had a higher AUC value (0.678) compared with several other systemic inflammation-based prognostic scores (P<0.001). This study suggested that CAR is a novel and promising inflammation-based prognostic score in patients with ESCC. Due to its simplicity, affordability and availability, CAR may be important for improving clinical decision-making and may contribute to more rational study design and analyses.

BACKGROUND:The aim of this retrospective study was to evaluate the clinical relevance of serum p53 antibody (S-p53Ab) as a biomarker and to investigate whether its diagnostic value could be improved when combined with other biomarkers of gastric cancer (GC).PATIENTS AND METHODS:Serum samples were obtained preoperatively from 208 patients with histologically-confirmed GC, including 126 stage I patients (60.6%). Levels of S-p53Ab were assessed by a commercial laboratory using an anti-p53 detection kit. The cut-off value for S-p53Ab was 1.3 U/ml.RESULTS:S-p53Ab was detected in 16.3% (34 of 208) of patients with GC, including 13.6% (22 of 162) of patients with early-stage GC. The positive rates for S-p53Ab, carbohydrate antigen 19-9 (CA19-9), and carcinoembryonic antigen (CEA) of patients with stage I GC were 10.3% (13/126), 2.4% (3/126), and 8.7% (11/126), respectively. Positivity for S-p53Ab was not associated with CA19-9 or CEA positivity (p=0.098 and 0.053, respectively). The positive rate for a diagnosis of GC increased from 16.3% to 29.3% when S-p53-Ab was combined with CEA in this study. We found no significant correlation between the presence of S-p53Ab in GC and overall survival. Conversely, Cox regression analysis revealed that a high level of CA19-9 was an independent prognostic factor for GC in this series (hazard ratio(HR)=3.864; 95% confidence interval(CI)= 1.248-11.959; p=0.019). Kaplan-Meier analyses demonstrated significant differences in survival between patients with elevated levels of both S-p53Ab and CEA and those with elevated levels of only one or neither.CONCLUSION:The diagnostic rate of S-p53Ab was better than that of CA19-9 and CEA in patients with stage I GC. Combined detection of S-p53Ab and CEA may improve the diagnostic sensitivity and may permit more accurate stratification of GC patients.

Title Usefulness of Omental Wrapping to Prevent Biliary Leakage and Delayed Gastric Emptying in Left Hepatectomy Author(s) Nanashima, Atsushi; Tobinaga, Syuuichi; Abo, Takafumi; Nonaka, Takashi; Kunizaki, Masaki; Takeshita, Hiroaki; Hidaka, Shigekazu; Sawai, Terumitsu; Yasutake, Toru; Nagayasu, Takeshi Citation Hepato-gastroenterology, 59(115), pp.847-850; 2012 Issue Date 2012-05 URL http://hdl.handle.net/10069/28627 Right © H.G.E. Update Medical Publishing S.A. NAOSITE: Nagasaki University's Academic Output SITE

Title Numerical Chromosome Aberrations In A Recurrent Malignant Fibrous Histiocytoma of the Retroperitoneum Author(s) Sawai, Terumitsu; Tsuji, Takashi; Yamaguchi, Eiichiro; Nanashima, Atsushi; Jibiki, Masaaki; Yamaguchi, Hiroyuki; Yasutake, Toru; Nakagoe, Tohru; Ayabe, Hiroyoshi; Tagawa, Yutaka Citation Acta medica Nagasakiensia. 1998, 43(3-4), p.88-91 Issue Date 1998-12-16 URL http://hdl.handle.net/10069/16123 Right NAOSITE: Nagasaki University's Academic Output SITE

BACKGROUND/AIMSPylorus-preserving pancreaticoduodenectomy (PPPD) has the advantage of achieving good nutritional status postoperatively, but delayed gastric empty (DGE) is a frequent complication leading to a longer fasting period. Subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) is an alternative option to preserve nutritional status and shorten the fasting period. We retrospectively compared clinical results between PPPD and SSPPD.METHODOLOGYPPPD was performed in 28 patients and SSPPD in 27, between 2000 and 2009.RESULTSPancreatic carcinoma was more frequent in the SSPPD group (p = 0.041). Operating time was longer in the SSPPD group (610 min) than in the PPPD group (540 min; p = 0.031). Blood loss was greater in the SSPPD group (1810 mL) than in the PPPD group (1306 mL; p = 0.048). Period of NG intubation and fasting period were shorter in the SSPPD group (6 days and 9 days, respectively) compared to the PPPD group (15 days and 19 days, respectively; p <0.01 each). Severe DGE was 7% in the SSPPD group and 46% in the PPPD group (p <0.01). Postoperative complications and nutritional status in the early period did not differ between groups, although incidence of fatty liver was higher in the SSPPD group (78%) than in the PPPD group (25%; p <0.01).CONCLUSIONSSSPPD is a useful alternative for pancreaticoduodenectomy. Further prospective studies with longer follow-up are warranted to clarify the superiority and problems associated with this procedure.

Background/Aims: Surgical resection is a radical treatment option for hilar bile duct carcinoma (HBDC); however, it is still difficult to cure and postoperative morbidity is high at this stage. Methodology: We examined the demographics, surgical records and outcome in 38 patients with hilar cholangiocarcinoma undergoing operation. Results: Five patients (13%) underwent probe laparotomy because of peritoneal dissemination or liver metastasis. Of 33 patients, extended hemi-hepatectomy was performed in 32 patients. Postoperative complications were observed in 46% including hepatic failure in 3 and hospital death was observed in 4 patients. Advanced tumor stage more than stage III was observed in 23 patients. Curability of operation was A in 5 patients, B in 17 and C in 11 and postoperative adjuvant chemotherapy was administered in 24% including photodynamic therapy in 3. Tumor recurrence was observed in 41% of HBDC patients. The 3- and 5-year tumor-free survival was 38% and 10%, respectively and 3- and 5-year overall survival was 48% and 32%, respectively. By comparison with tumor stage or final curability, survival rates were not significantly different between groups. Conclusions: Surgical resection is still the only curative treatment option to improve patient survival even in advanced stage HBDC.

Laparoscopic surgery is a less invasive treatment option for tumors in the intraabdominal organs; however, the safety and indication of laparoscopic or laparoscopy assisted pancreaticoduodenectomy (LPD) is still controversial. We attempted LPD in four cases for intraductal papillary mucinous neoplasm (IPMN) located in the pancreatic head and we report the surgical re- cords and short-term outcome. LPD was carried out in four patients including three patients with the combined type IPMN and one with the branch type, based on the International Consensus Guidelines. None of the patients had invasive carcinoma based on preoperative imaging diagnosis. Laparoscopic procedures were performed until isolation of the pancreas head and duodenum, and final resection of PD and intestinal reconstruction were performed using small incision laparotomy (7-8cm). The mean total operating time was 882 minutes (820-932 minutes), mean blood loss was 925ml (610-1550ml) and red cell transfusion was not required in any patients. One patient underwent reoperation for bleeding at the pancreaticojejunostomy site at day 1. Mean duration until patients were able to walk was 3.5 days (2-6 days) and duration of use of analgesia was lim- ited to within 7 days. Grade B pancreatic fistula was observed in one patient and jejunal ileus was observed in one patient. There were no deaths. LPD was safely performed and blood loss was limited, although the operating time was long. Postoperative recovery in patients without complications might be better than the conventional PD under laparotomy. Future study is necessary. ACTA MEDICA NAGASAKIENSIA 56: 93-97, 2011

BACKGROUND/AIMS Surgical resection is a radical treatment option for pancreatic carcinoma (PC); however, it is still difficult to cure and patient prognosis is poor at this stage. METHODOLOGY We examined the demographics, surgical records and outcome in 64 patients with hilar PC undergoing surgical resection. RESULTS Pancreatoduodenectomy (PD) was carried out in 48 patients, distal pancreatectomy (DP) in 14 and total pancreatectomy in two. Postoperative complications were observed in 18 patients (28%) but no hospital deaths. All stage I patients showed carcinoma in situ of intraductal papillary mucinous carcinoma (IPMC). Postoperative adjuvant chemotherapy was performed in 15 patients (23%) using gemcitabine or S-1. Cancer recurrence was observed in 36 patients (56%) and 31 died of carcinoma. The 5-year cancer-free and overall survival rate was 12% and 14%, respectively. CA19-9 level, morphological type, T category, lymph node metastasis, extrapancreatic nerve plexus invasion, retropancreatic tissue invasion, distal bile duct invasion, duodenal invasion and arterial system invasion were significant poor prognostic factors; however, portal vein system invasion was not significantly associated with prognosis. Cancer infiltration at bile duct cut-end and dissected peripancreatic tissue margin and presence of residual tumor showed a poor prognosis. Surgical prognosis in only non-invasive IPMC was satisfactory. CONCLUSIONS Radically extended surgical resection is necessary and newly effective adjuvant chemotherapy is a promising modality to improve patient survival in PC patients.

INTRODUCTION: Hepatocellular carcinoma (HCC) is a major cause of cancer-related deaths around the world. Nearly half of patients with HCC display metastatic disease at the time of initial diagnosis, frequently involving the liver, bone, brain, lungs, and adrenal glands, but gastrointestinal involvement is rare. Melena occurring secondary to a metastatic tumor from HCC is particularly rare. Herein, we present a case of melena secondary to metastatic HCC after chemoradiation to lung and brain metastases from HCC, diagnosed preoperatively by double-balloon enteroscopy. To the best of our knowledge, this represents the first such case to be reported.PRESENTATION OF CASE: 60-Year-old man had been diagnosed with hepatitis B virus-associated hepatocellular carcinoma (HCC). He was readmitted for investigation of general fatigue and iron-deficiency anemia. Esophagogastroduodenoscopy, total colonoscopy, and CT failed to identify any cause for gastrointestinal bleeding. Double-balloon enteroscopy, however, revealed small bowel metastasis from HCC preoperatively. After 5 days of conservative management, segmental small bowel resection and end-to-end anastomosis were performed. The histological appearances were considered typical for moderately differentiated HCC.DISSCUSSION: Endoscopic findings of gastrointestinal metastasis from HCC vary, such as raised and centrally ulcerated lesions, polypoid tumors, or submucosal tumors. Immunohistochemical findings are thus key to differentiating HCC from adenocarcinoma in the diagnosis of GIT metastasis. Some patients with gastrointestinal bleeding remain undiagnosed even after upper endoscopy and total colonoscopy, and most such patients will display bleeding sites in the small bowel. Video capsule endoscopy and DBE have been introduced recently for the evaluation of the small bowel. DBE, which was developed by Yamamoto et al.,(5) allowed us to obtain biopsy specimens, circumventing one limitation of capsule endoscopy. In this case, DBE contributed significantly to diagnosis and treatment.CONCLUSION: DBE thus seems to represent a valuable method, particularly in the preoperative setting, due to the possibility of precisely identifying the tumor site and achieving preoperative diagnosis. (C) 2012 Surgical Associates Ltd. Published by Elsevier Ltd.

BACKGROUND/AIMSTo identify the clinical significance of the omental wrapping (OW) technique after left hepatectomy to reduce bile leakage and delayed gastric emptying. We examined clinical and surgical parameters after left hepatectomy with or without biliary reconstruction in 79 patients.METHODOLOGYThis was a retrospective study of data from 14 patients undergoing OW compared to 65 patients in the control group.RESULTSBile leakage and delayed emptying after hepatectomy were observed in 15 and 11 patients, respectively. Gender, background liver function, liver diseases and preoperative liver function tests were not significantly different between both groups. Prevalence of extent of hepatectomy, existence of segment 1 resection, biliary-enteric anastomosis, operating time and blood loss were also not significantly different between groups. Prevalence of bile leakage was similar between the OW and the control group (14 vs. 20%) (p=0.91). Prevalence of delayed gastric emptying was not significantly different between groups, but this complication was not observed in the OW group in comparison with the control group (0% vs. 20%) (p=0.31). Prevalence of other complications and hospital stay after hepatectomy were similar between groups.CONCLUSIONSSignificant differences for preventing left hepatectomy related complications were not found; however, it is possible that OW could reduce delayed gastric emptying.

BACKGROUND/AIMS:The present study aimed to elucidate the relationship between microvessel count (MVC) according to CD34 expression and clinicopathological characteristics or prognosis in pancreatic carcinoma (PC) patients who underwent hepatectomy.METHODOLOGY:CD34 expression was analyzed using immunohistochemical methods. Mean MVC in 5 areas per specimen and clinicopathological factors were consecutively examined in 42 PC patients.RESULTS:Median MVC for PC patients was 123/mm2, which was applied as a cut-off value. Higher MVC was significantly associated with the advanced Japanese tumor-node-metastasis stage IVa and IVb (p=0.034). Univariate survival analysis identified higher carcinoembryonic antigen (CEA) and CA19-9 level, infiltrative type on macroscopic examination, invasive ductal carcinoma, node metastasis and higher tumor-node-metastasis classification were significantly associated with poor survival. The 5-year overall survival rate in the higher MVC group tended to be lower than that in the higher MVC group (37 vs. 55%), but not statistically significant (p=0.15).CONCLUSIONS:Tumor MVC might be a candidate prognostic marker of PC patient survival after pancreatectomy and further investigation in a larger series is warranted to clarify the significance of this marker.

Purpose: Single-incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain and accelerated recovery. Although there have been reports of cholecystectomy and appendectomy using SILS, there have been few reports of gastric resection with intracorporeal reconstruction of the digestive tract using SILS. The first single-incision laparoscopic gastrectomy with intracorporeal reconstruction is reported.Methods: Preliminary experience with single-incision laparoscopic gastrectomy with intracorporeal reconstruction for a patient with an intractable gastric ulcer is reported.Results: Single-incision laparoscopy-assisted subtotal gastrectomy and Roux-en-Y reconstruction were performed. Operative time for gastrectomy and paraduodenal hernioplasty was 412 minutes, and blood loss was 90 g. No intraoperative or postoperative complications developed.Conclusions: Single-incision laparoscopy-assisted gastrectomy for intractable gastric ulcer is technically feasible. Intracorporeal reconstruction of the digestive tract was performed safely using a linear endoscopic stapler. This surgical approach is a further advance toward scarless surgery of the stomach.

AIM:The indication for hepatectomy is still controversial in elderly patients with hepatocellular carcinoma (HCC). We examined the clinicopathological features and survival of 188 HCC patients who underwent hepatectomy. PATIENTS/METHODS:Patients were divided into four age groups: Age(<50) group (young patients <50 years of age, n = 9), Age(50-69) group (between 50-69 years, n = 110), Age(70-79) group (70-79 years, n = 57), and Age(≥80) group (≥80 years, n = 12). Physiologic ability and surgical stress (E-PASS) score, including preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were assessed. RESULTS:Proportion of patients of Age(70-79) and Age(≥80) groups increased significantly in the last 5 years (P < 0.01). Co-morbidity, performance status, and American Society of Anesthesiologists score significantly increased with age (P < 0.05). Proportions of patients with irregular findings and necro-inflammatory activity were significantly lower in Age(70-79) and Age(≥80) groups than in other groups (P < 0.05). Systemic postoperative complications were high in Age(70-79) and Age(≥80) groups. PRS increased significantly with age (P < 0.05). Multivariate analysis identified PRS ≥0.32 and age ≥70 years as significant determinants of systemic complications (P < 0.05). There were no significant differences in postoperative survivals among the groups. CONCLUSIONS:Careful follow-up and proper decision on hepatectomy upon assessment of PRS are important in elderly HCC patients.

A 77-year-old woman with a history of coronary artery bypass grafting 5 years earlier presented with anemia and was diagnosed with advanced gastric cancer involving the pylorus. Preoperative angiography revealed that the right gastroepiploic artery (RGEA) graft was patent. Multidetector-row computed tomography showed the running pattern of the RGEA graft and also revealed a vascular anomaly belonging to type V of Adachi's classification. Adachi's type V is a rare vascular anomaly in which the common hepatic artery originates from the superior mesenteric artery. The patient was treated successfully with a distal gastrectomy and removal of the D2 lymph node with preservation of the RGEA graft. Because of the difficulty in confirming the running pattern of the artery during the surgery, it is important to define the arterial running pattern preoperatively by using multidetector-row computed tomography, including 3-dimensional angiographic imaging.

Background. Indocyanine green retention rate at 15 min (ICGR15) is a useful marker of liver function in deciding on the extent of hepatectomy. To determine ICGR15 regardless of liver condition, we sought to establish a formula for converted ICGR15 based on conventional blood tests and technetium-99 m galactosyl human serum albumin ((99m)Tc-GSA) scintigraphy.Materials and Methods. We measured liver function parameters, including ICGR15, in 307 patients, including 265 liver cancer patients without biliary obstruction (no obstruction group) and 42 with biliary obstruction (obstruction group).Results. In the no obstruction group, multiple regression analysis identified blood pool clearance ratio (HH15), liver uptake ratio (LHL15) calculated by heart and liver activity between 3 and 15 min after injection of (99m)Tc-GSA, and serum hyaluronic acid as significant correlates (P < 0.05). The calculated converted ICGR15 was then equal to 0.02* HA D 0.276*(HH15*100)-0.501*(LHL15*100) + 41.41. The mean difference between actual and converted ICGR15 was significantly lower in the obstruction than in the no obstruction group (P = 0.031). A significantly larger proportion of patients of the obstruction group had lower converted ICGR15 than those of the no obstruction group (P = 0.045).Conclusion. The converted ICGR15 is useful for evaluating hepatic function in patients with biliary obstruction who plan to undergo major hepatectomy. (C) 2011 Elsevier Inc. All rights reserved.

症例は48歳の男性で，検診にて食道癌を指摘され，手術目的で当科入院となった．術前精査の胸腹部造影CTで，腸回転異常および肝部下大静脈欠損・奇静脈拡張・多脾症等の解剖学的異常を認めた．手術は，胸部食道全摘出術＋D2郭清・脾臓摘出術，胸骨後経路胃管再建術（頸部吻合）を行い，術後経過は良好で術後32日目に退院した．腸回転異常症は種々の血管異常を合併することがあり，しばしば手術困難であった例が報告されている．今回，我々は，腸回転異常症・血管走行異常を合併した食道癌の1切除例を経験したので報告する．