Objective:. To determine whether the clip-on-staple method reduces clinically relevant postoperative pancreatic fistula (CR-POPF) following distal pancreatectomy (DP). Background:. CR-POPF remains the most significant source of morbidity after DP, particularly in patients with thick pancreatic parenchyma. Effective, pragmatic strategies to reduce CR-POPF are needed. Methods:. The CLIP-DP trial was a multicenter, single-blind, randomized controlled study conducted at 16 Japanese institutions (UMIN000042217). Adults undergoing DP were randomized 1:1 to reinforced stapler closure alone (Arm A) or the clip-on-staple method (Arm B). Allocation employed a central system with minimization method stratified by pancreatic thickness (≤12 mm vs >12 mm), surgical approach, and institution. The primary endpoint was CR-POPF (grade B/C) or death within 30 days. Analyses were prespecified for both the full-analysis set (FAS) and per-protocol set (PPS). Results:. Among 190 randomized patients, 177 were included in the FAS (Arm A, n = 85; Arm B, n = 92) and 170 in the PPS (Arm A, n = 82; Arm B, n = 88). In the FAS, CR-POPF or death occurred in 23.5% of Arm A versus 15.2% of Arm B (P = 0.184, 2-sided α = 0.20). In the PPS, corresponding rates were 24.4% and 12.5% (P = 0.049). Subgroup analysis showed a pronounced reduction in CR-POPF among patients with pancreatic thickness >12 mm (FAS: 32.4% vs 11.9%, P = 0.032; PPS: 32.3% vs 7.5%, P= 0.004). Secondary outcomes and safety profiles were comparable, with no deaths within 90 days. Conclusions:. The clip-on-staple method reduces CR-POPF after DP compared with stapler closure alone, with the greatest benefit in thick pancreas.

Laparoscopic transabdominal preperitoneal inguinal hernia repair (TAPP) is useful for resident training. However, the association between the operative interval and skill acquisition remains unclear. We evaluated the learning curve of resident-performed TAPP and explored the association between the operative interval and operative time changes. We retrospectively analyzed 67 consecutive TAPP cases performed by a single surgical resident. A cumulative sum (CUSUM) analysis was based on the adjusted operative time, with bilateral cases weighted by 0.6. Breakpoints were estimated using segmented regression, and the relationship between the operative interval and the change in adjusted operative time between consecutive cases (ΔTime) was assessed using exploratory analyses. A CUSUM analysis estimated breakpoints at 16.0 (95

Background Six months of adjuvant S-1 is the standard treatment for resected pancreatic cancer in Japan. Metformin has demonstrated potential anticancer effects in preclinical and observational studies. This study aimed to evaluate whether adding metformin to S-1 improves 2-year survival after pancreatic cancer resection. Methods This multicenter, randomized, open-label Phase II trial enrolled patients with histologically confirmed Stage I–II invasive pancreatic ductal carcinoma who underwent curative resection. Patients were randomized to receive S-1 plus metformin (Group A) or S-1 alone (Group B). S-1 was administered for 6 months in both groups, and metformin for 2 years in Group A. The primary endpoint was 2-year overall survival; secondary endpoints were recurrence-free survival and safety. The sample size was calculated assuming a 2-year survival rate of 65% with S-1 alone and 78% with S-1 plus metformin (hazard ratio: 0.58), providing 80% power with a one-sided α of 0.20. Glycemia-related safety was monitored using Common Terminology Criteria for Adverse Events-defined hyperglycemia and hypoglycemia. Results Seventy-six patients were randomized (38 per group). The 2-year survival rate was 66.7% in Group A and 66.1% in Group B (hazard ratio 1.09; 95% confidence interval 0.55–2.16; p = 0.93). Median overall survival was 53.8 versus 58.0 months, and median recurrence-free survival was 17.9 versus 12.6 months ( p = 0.78). No grade ≥ 4 adverse events occurred; Grade 3 toxicities were infrequent and comparable between groups. Conclusions Adding metformin to adjuvant S-1 did not improve survival in patients with resected pancreatic cancer.

Liver abscesses can be associated with biliary disease and are occasionally accompanied by portal vein thrombosis. Hepatic artery obstruction has been reported to result from aneurysms, thrombosis, iatrogenic factors, and arterial dissection; however, to the best of our knowledge, no cases of liver abscess with obstruction of the portal vein and hepatic artery have been reported. A 51-year-old man presented with a chief complaint of heartburn. A detailed investigation revealed common bile duct stones and an 8-cm multilocular abscess in the left lobe of the liver. Choledocholithiasis was achieved by endoscopic retrograde cholangiopancreatography. Despite antibiotic treatment with meropenem, his symptoms and inflammatory reaction did not improve, and computed tomography (CT) revealed obstruction of the left branch of the portal vein and left hepatic artery. Because it proved difficult to control his infection, we performed a left hepatic lobectomy. Histopathological examination of the operative specimen revealed a hepatic abscess with portal vein thrombosis and left hepatic artery dissection. The postoperative course was favorable, and the patient was discharged on postoperative day eight. Thirty months later, he continues to do well. We here report a patient with a liver abscess with portal vein thrombus and hepatic artery dissection whose infection was successfully controlled by hepatectomy.

AbstractAimsSplenic vein occlusion (SpVO) due to a pancreatic tumor may result in the development of collateral circulation and left‐sided portal hypertension. This study aimed to investigate the impact of SpVO on distal pancreatectomy (DP) and provide insights about the management of such cases.MethodsThis retrospective analysis included 124 patients who underwent DP from 2014 to 2022. A subgroup analysis was performed on 88 patients who underwent DP for pancreatic ductal adenocarcinoma (PDAC).ResultsSpVO was found in 26 (20.8%) patients. The patients with SpVO had significantly larger splenic volumes and lower platelet counts. Compared to the patients with patent splenic veins (SpVs), the patients with SpVO underwent significantly longer operations (p = 0.006), with a higher incidence of postoperative complications (p = 0.002). We classified the collateral routes associated with SpVO into five patterns. The most common pattern was the left gastroepiploic vein type, which was associated with a tumor of the pancreatic body. In patients with PDAC, SpVO was associated with larger tumors, microscopic vascular permeation, and peritoneal recurrence. However, the differences between overall and recurrence‐free survival rates in the patients with SpVO vs those with patent SpVs were not significant.ConclusionsSpVO causes left‐sided portal hypertension, which can be a risk for perioperative complications in DP. Operative planning based on the classification of collateral flow patterns may help prevent intraoperative congestion and perioperative complications.

We aimed to define borderline resectable colorectal liver metastases (CRLM) based on the analysis of risk factors for early surgical failure and investigate the efficacy of neoadjuvant chemotherapy in these patients. This was a retrospective analysis of a multi-institutional cohort of patients diagnosed with technically resectable CRLM. Early surgical failure within 6 months of liver surgery was defined as ESF6. We classified CRLM into three grades (A, B, and C) according to the definition of the Japanese Society for Cancer of the Colon and Rectum. Among the 249 patients with technically resectable CRLM, 46 (18.5

目的:門脈ガス血症・腸管気腫症に対する手術適応判断におけるバイオマーカーを探索するためにneutrophil lymphocyte ratio(以下,NLRと略記)やpan-immune-inflammation value(以下,PIVと略記)を含めて検討した.方法:2002年~2022年に当院で門脈ガス血症・腸管気腫症と診断された26例を腸管切除適応群12例と腸管切除非適応群14例に群別化し,臨床因子を比較した.結果:腸管切除適応群は腸管切除非適応群と比較し腹膜刺激徴候や腸管壊死を疑うCT所見を高率に認めたが,腹水や遊離ガス像に差はなかった.白血球数,CRP,CKは群間で差を認めなかったが,乳酸値,好中球数は腸管切除適応群で有意に高かった.PIVは腸管切除適応群で腸管切除非適応群と比較して有意に高かったが,NLRは群間で差は認めなかった.Receiver operating characteristic曲線解析ではPIV,好中球数,乳酸値のカットオフ値はそれぞれ373(感度58.3%,特異度92.9%),11,168.4(感度66.7%,特異度85.7%),1.9(感度90.9%,特異度58.3%)であった.結語:門脈ガス血症・腸管気腫症例においてPIV,乳酸値は手術適応判断の一助となる可能性が示唆された.

Background/Aim: Peritoneal metastasis (PM) of gastric cancer (GC) leads to poor clinical outcomes. Tumor-derived exosomes promote metastasis via communication between tumor cells and host cells. In this study, we investigated the effect of Rab27, which is required for exosome secretion, on the PM of GC. Materials and Methods: We established a stable knockdown of two Rab27 homologs, Rab27a and Rab27b, in human GC cells (58As9) with a high potential of PM. We examined the level of exosome secretion from Rab27-knockdown 58As9 cells by Western blotting and the ability of Rab27b knockdown to suppress PM in 58As9 cells using a mouse xenograft model. In vitro proliferation and invasion assays were performed in the Rab27b-knockdown cells. Next, Rab27b expression was evaluated in human GC tissues by immunohistochemistry. Finally, we assessed the clinicopathological and prognostic significance of Rab27b expression by RT-qPCR in both our and other TCGA datasets of GC. Results: Rab27a and Rab27b knockdown in 58As9 cells decreased the secretion of exosomes, characterized by the endocytic marker CD63. Rab27b knockdown decreased PM in vivo without affecting the in vitro proliferation or invasion ability of 58As9 cells. In human GC tissues, Rab27b was overexpressed in tumor cells. The overall and recurrence-free survival rates were significantly lower in GC patients with high compared to low Rab27b mRNA expression in our and other TCGA datasets. Conclusion: Rab27b expression potentially serves as a poor prognostic biomarker, possibly affecting PM via exosome secretion from GC cells.

<p>Isotopomer distribution analysis using [U-¹³C]glucose in HuH7 cells with or without ectopic FBP1 expression.</p>

FBP1 expression and mutational profiles across 234 HCC cases from The Cancer Genome Atlas.

<p>Promoter methylation and copy number profiles of FBP1 in liver cancer cell lines from the Cancer Cell Line Encyclopedia.</p>

Background. This study aimed to elucidate the effect of early enteral nutrition on graft loss within 12 h after living-donor liver transplantation (LDLT) using propensity score-matching analysis and subsequently examine the risk factors for graft loss after LDLT. Methods. We retrospectively reviewed the data of 467 LDLT patients who were assigned to the early and non-early groups based on the optimal cutoff value of 12 h for the starting time of early enteral nutrition after LDLT to predict graft loss. Results. The 1-year graft survival rate of the early group before propensity score-matching was 92.1%, whereas the 1-year graft survival rate of the non-early group was 86.2%. There was no significant difference between the 2 groups (P = .067). The incidences of early allograft dysfunction (EAD), small-for-size graft (SFSG) syndrome, acute cellular rejection (ACR), and sepsis were not statistically different between the 2 groups (P = .12, .91, .46, and .056, respectively). After propensity score-matching, the 1-year graft survival rate of the early group was 94.4%, whereas the 1-year graft survival rate of the non-early group was 85.4% (P = .034). The incidences of EAD, SFSG syndrome, and ACR were not statistically different between the 2 groups (P = .43, .81, and .24, respectively). However, the incidence of sepsis was statistically different between the 2 groups (non-early: 10.7% vs early: 3.6%, P = .038). Conclusion. Early enteral nutrition within 12 h after LDLT may contribute to better graft survival in LDLT patients by preventing sepsis.

Backgroud The systemic inflammation score (SIS), which is based on the preoperative lymphocyte-to-monocyte ratio (LMR) and serum albumin (Alb) level, is a prognostic indicator for several cancer types. However, the prognostic significance of the SIS in pancreatic ductal adenocarcinoma (PDAC) remains unknown. Methods Seventy-eight patients who underwent radical surgery for PDAC were categorized as follows: SIS 0 (LMR ≥3.51 and Alb ≥4.0 g/dl), n = 26; SIS 1 (LMR <3.51 or Alb <4.0 g/dl), n = 29 and SIS 2 (LMR <3.51 and Alb <4.0 g/dl), n=23. Results The tumour size sequentially increased in SIS 0, 1 and 2 groups. A higher SIS was associated with increased vascular invasion, perineural invasion and surgical margin positivity rate. Recurrence-free survival (RFS) rates between the SIS 1 and 2 groups showed no significant difference However, patients of the SIS 1 and 2 groups had poorer outcomes than those of the SIS 0 group for RFS. Overall survival (OS) rates between the SIS 1 and 2 groups also showed no significant difference. However, patients of the SIS 1 and 2 groups had poorer outcomes than those of the SIS 0 group for OS. The SIS was an independent prognostic factor for RFS and OS. Discussion The SIS is a simplified prognostic factor for patients with PDAC.

Overall survival based on the expression levels of genes specific to gluconeogenesis and aerobic glycolysis.

BACKGROUND:Increasing evidence indicates that increased systemic inflammation is correlated with poorer cancer-specific survival in various cancer types. This study aimed to evaluate the prognostic value of various combinations of inflammatory factors in patients who underwent surgical resection for pancreatic cancer (PC).METHODS:We retrospectively analyzed 97 consecutive patients with PC who underwent pancreatectomy. We assessed the predictive impact for recurrence using a combination of 5 inflammatory markers and focused on the lymphocyte-C-reactive protein ratio (LCR) to elucidate its prognostic and predictive value for recurrence-free survival (RFS) and overall survival (OS) in univariate and multivariate analyses using the Cox proportional hazards model.RESULTS:Low preoperative LCR was correlated with low serum hemoglobin, low serum albumin concentration, high frequency of microscopic vascular invasion, and high frequency of microscopic perineural invasion. The low LCR group had significantly worse RFS and OS. Lower preoperative LCR was an independent predictor of shorter RFS and OS in this cohort.DISCUSSION:Preoperative LCR is a novel and convenient prognostic marker for patients with PC. Patients with low LCR may require more favorable intensive therapy.

Abstract Aim This study was performed to investigate the relationship between the preoperative cachexia index (CXI) and long‐term outcomes in patients who have undergone radical resection of pancreatic ductal adenocarcinoma (PDAC). Methods In total, 144 patients who underwent pancreatic resection for treatment of PDAC were retrospectively analyzed. The relationship between the CXI and the patients' long‐term outcomes after PDAC resection was investigated. The CXI was calculated based on the preoperative skeletal muscle index, serum albumin level, and neutrophil‐to‐lymphocyte ratio. After propensity‐score matching, we compared clinicopathological features and outcomes. Results The multivariate analysis showed that lymph node metastasis (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.16–3.23; P = 0.0118), R1 resection (HR, 57.20; 95% CI, 9.39–348.30; P < 0.0001), and a low CXI (HR, 2.10; 95% CI, 1.27–3.46; P = 0.0038) were independent and significant predictors of disease‐free survival (DFS) after PDAC resection. Moreover, a low CXI (HR, 3.14; 95% CI, 1.71–5.75; P = 0.0002) was an independent and significant predictor of overall survival (OS) after PDAC resection. After propensity‐score matching, the low CXI group had a significantly worse prognosis than the high CXI group for both DFS and OS. Conclusion The CXI can be a useful prognostic factor for DFS and OS after pancreatic resection for treatment of PDAC.

Supplementary Materials and Methods, and Legends for Supplementary Figures.

<p>Copy number and expression profiles of FBP1 in liver cancer cell lines from the Cancer Cell Line Encyclopedia.</p>

INTRODUCTION:The management of patients with a cerebrospinal fluid (CSF) shunt located in the peritoneal cavity undergoing laparoscopic surgery is an issue that has not yet been settled. These patients are at risk of increased intracranial pressure caused by peritoneal insufflation, shunt dysfunction, and shunt infection/retrograde meningitis. This study aimed to determine the need for perioperative shunt intervention in CSF shunt patients undergoing laparoscopic cholecystectomy.METHODS:We reviewed and analyzed five shunt patients who underwent laparoscopic cholecystectomy in our institution between 2012 and 2022, as well as 17 patients described in previous reports.RESULTS:Among the 22 patients, shunt type was ventriculoperitoneal in 14 and lumboperitoneal in eight. The most common indication for CSF shunt was hydrocephalus caused by cerebral vascular accident (50.0%). Laparoscopic cholecystectomy was performed for cholecystolithiasis in 13 patients (59.1%), acute cholecystitis in eight (36.4%), and gallbladder polyp in one (4.5%). Shunt clamping or externalization was performed in six patients. Two patients in the group that did not undergo shunt clamping or externalization experienced complications (intra abdominal abscess and subcutaneous emphysema). However, the incidence of short-term complications (both overall and shunt-related) and median length of hospital stay did not significantly differ between the two groups.CONCLUSION:Routine shunt clamping, externalization, or removal might not be necessarily required in patients with a ventriculoperitoneal or lumboperitoneal shunt undergoing laparoscopic cholecystectomy.

BACKGROUND:Patients on long-term dialysis are prone to hemorrhagic complications, particularly uremic bleeding, but gallbladder hemorrhage is rare, even in patients on dialysis. There have been occasional reports of a Dieulafoy lesion being a cause of gastrointestinal hemorrhage, but its occurrence within the gallbladder is quite rare. This report describes a case of gallbladder hemorrhage from a Dieulafoy lesion in a patient on hemodialysis that was diagnosed early and successfully treated by laparoscopic cholecystectomy.CASE PRESENTATION:The patient was a 68-year-old woman on long-term hemodialysis with end-stage renal failure who presented with epigastralgia and back pain. There was no history of trauma or oral administration of antiplatelet or anticoagulant agents. There were no signs of an inflammatory reaction or hyperbilirubinemia. Contrast-enhanced computed tomography revealed a slightly hyperdense area in the distended gallbladder and extravasation within the gallbladder lumen but no gallstones. A severe atherosclerotic lesion was also found. She was diagnosed to have gallbladder hemorrhage and emergency laparoscopic cholecystectomy was performed. Although the postoperative course was complicated by drug fever, she was discharged on postoperative day 10 in a satisfactory condition. Histology revealed hemorrhagic ulceration with an exposed blood vessel accompanied by abnormal arteries in the submucosa. Arteriosclerosis with eccentric intimal hyperplasia in a small-sized artery was also seen. The diagnosis was gallbladder hemorrhage from a Dieulafoy lesion.CONCLUSIONS:A Dieulafoy lesion should be kept in mind as a cause of gallbladder hemorrhage in a patient with severe arteriosclerosis and a bleeding diathesis, particularly if on dialysis, and treated as early as possible.