Aim
This study aimed to evaluate the prognostic impact of total neoadjuvant therapy (TNT) for borderline resectable pancreatic cancer with arterial involvement (BR‐A) pancreatic cancer.
Methods
We ...analyzed 81 patients initially diagnosed as BR‐A who received initial treatments between 2007 and 2021. Among them, 18 patients who received upfront surgery were classified as the UFS group, while 30 patients who were treated with neoadjuvant chemoradiotherapy were classified as the NACRT group. Furthermore, 33 patients who planned to receive a combination treatment of over 6 months of systemic chemotherapies followed by chemoradiotherapy before surgery were classified as the TNT group.
Results
There were no significant differences in the patients’ backgrounds between the three groups at the time of initial treatment. The resection rates of the UFS, NACRT, and TNT groups were 89%, 77%, and 67%, respectively. NACRT had no impact on the prognosis compared to upfront surgery. In sharp contrast, the TNT group had a significantly better prognosis compared to the other groups, especially after pancreatic resection. Multivariate analysis demonstrated that TNT and resection were independent prognostic factors for the patients of BR‐A.
Conclusion
TNT can be a promising therapeutic strategy for patients with BR‐A.
The total neoadjuvant strategy for patients with borderline resectable pancreatic cancer with arterial involvement improved the prognosis compared with upfront surgery or neoadjuvant chemoradiotherapy. Total neoadjuvant therapy can be a promising therapeutic strategy.
Postoperative nonalcoholic fatty liver disease (NAFLD) after pancreaticoduodenectomy (PD) has recently become recognized. However, the pathoetiology of postoperative NAFLD is largely unknown. ...Furthermore, the optimal treatment has not been established. The aim of this prospective study was to clarify whether pancrelipase, which contains digestive pancreatic enzymes, could reverse NAFLD.
A collaborative clinical trial has been conducted (UMIN000006841). A total of 30 patients who developed NAFLD after PD were prospectively treated with pancrelipase. NAFLD was defined and evaluated by the liver-to-spleen attenuation ratio on computed tomography (CT). Clinical symptoms and laboratory findings were also assessed.
The mean liver-to-spleen CT ratio before surgery in 30 patients was 1.233. It declined to 0.453 at diagnosis of NAFLD. It was significantly improved by the treatment and the CT ratios at 1, 3 and 6 months after treatment were 0.762, 0.958 and 0.904, respectively (vs. pretreatment, P < 0.001). The mild liver dysfunction was also improved. Total protein, albumin and total cholesterol levels were significantly improved by the treatment. Importantly, relatively severe diarrhea seen in 11 patients was also ameliorated.
Pancrelipase has a significant beneficial impact on NAFLD after PD. Maldigestion after pancreatic surgery may be a main cause for the development of postoperative NAFLD.
Background
Solid pseudopapillary neoplasms of the pancreas are rare. Moreover, pancreatoduodenectomy (PD) and postoperative care are not common in pediatric surgery. Herein, we report a case of PD ...and nonalcoholic fatty liver disease (NAFLD) after PD and present a literature review.
Case presentation
A 10-year-old girl with a suspected liver tumor was referred to our hospital. Echography, enhanced computed tomography and magnetic resonance imaging showed that the tumor coexisted with the solid and cystic parts of the pancreatic head. Since the patient was a young woman and the imaging findings were consistent with that of pancreatic solid pseudopapillary neoplasms (SPNs), we diagnosed her with pancreatic SPN. Thereafter, PD was performed, and she was discharged 10 days after the operation. Although her postoperative course was mostly uneventful, she experienced few episodes of abdominal pain and diarrhea before hospital discharge. These symptoms subsequently became more frequent and severe. The patient was urgently readmitted to the hospital for watery steatorrhea and lower abdominal colic pain. Her serum aspartate aminotransferase and alanine aminotransferase levels were elevated, and a fatty liver was detected on echography. The patient was diagnosed with steatorrhea, peristaltic pain, and NAFLD after PD. Pancrelipase (containing pancreatic digestive enzymes), antidiarrheal agents, and probiotics were started. Dosage increase of these drugs reduced the defecation frequency and abdominal pain and switched diarrhea to loose stools. However, more lipids in meals or more meals caused diarrhea and abdominal pain. Therefore, the doses of these drugs were further increased, and another antidiarrheal agent, loperamide hydrochloride, was added. Exocrine pancreatic enzymes supplementation and careful follow-up should prevent NAFLD progression after PD. At present, the patient has occasional abdominal pain, but has tangible soft stools once or twice a day. Although echography still shows a mottled fatty liver, her hepatic enzymes are only mildly elevated.
Conclusions
Pediatric PD is rare, and residual pancreatic function is usually sufficient, unlike in adult cases. However, we experienced a case of NAFLD after PD for a pediatric pancreatic SPN, in which pancreatic enzyme supplementation effectively improved this condition. Further attention must be paid to worsening of NAFLD that can develop nonalcoholic steatohepatitis.
Purpose
Recent advances in multidisciplinary treatments are improving the postoperative prognosis of pancreatic ductal adenocarcinoma (PDAC). However, the prognosis even after potentially curative ...resection remains poor. The aim of this study was to identify the clinical and pathological features of actual 5-year survivors under current circumstances.
Methods
A total of 128 patients who underwent pancreatectomy for PDAC at our institution between January 2006 and December 2011 were retrospectively analyzed.
Results
The actual 5-year overall survival rate for all patients was 30.9%, with a median survival time of 33.1 months. Of 128 patients, 25 (19.5%) survived for 5 years after surgery without disease recurrence. A univariate analysis showed that the pretreatment serum CA19–9 value, tumor depth, lymph node metastasis, and UICC stage at resection were significant predictive factors for the actual long-term survival. A multivariate analysis showed that a pretreatment serum CA19–9 value ≥ 110 U/mL was a significant unfavorable prognostic indicator. In addition, all subjects in the 5-year survival group completed adjuvant chemotherapy. The recurrence rate in the liver was significantly lower and that in the lung significantly higher in the long-term survival group than in the short-term survival group.
Conclusions
The factors contributing to the long-term survival of PDAC were the pretreatment CA19–9 value and the completion of adjuvant chemotherapy. To achieve the actual long-term survival and cure after pancreatectomy for pancreatic cancer, further treatment strategies enhancing the completion rate of adjuvant chemotherapy are required.
Objetivo. Describir las características fenotípicas y genotípicas de cepas de Neisseria meningitidis aisladas de enfermedad meningocócica en Paraguay entre 1996 y 2015. Métodos. Se estudiaron por ...métodos microbiológicos convencionales y técnicas moleculares 114 aislamientos de N. meningitidis y 12 muestras clínicas sin aislamiento confirmadas por reacción en cadena de la polimerasa (PCR) que fueron remitidas por los diferentes centros centinelas y centros colaboradores de Paraguay. Resultados. El grupo de edad más afectado fue el de menores de 1 año (19,0%), seguido por el de 1 a 5 años (17,5%). Un mayor porcentaje de las cepas se aisló de casos de meningitis (81,7%) y el serogrupo B se encontró en 60,3% de los casos. Los fenotipos más frecuentes fueron B:4:P1.14 (16,0%), B:15:P1.5, C:NT:NST y W:NT:P1.2 (10,5%), respectivamente. Los complejos clonales prevalentes fueron ST-11/ET37 complex 29,6% (8/27) con predominio del serogrupo W (6/8), ST-35 complex 18,5% (5/27) en el serogrupo B (4/4), y ST-32/ET5 complex 14,8% (4/16) en el serogrupo B (5/5). Conclusiones. En Paraguay la enfermedad meningocócica es relativamente infrecuente. Los análisis de distribución de serogrupo muestran que el más frecuente es el B y en los últimos dos años aumentaron los casos de enfermedad meningocócica por C y W. Los complejos clonales encontrados se correlacionan con los hallados en la región del Cono Sur. Debido al alto nivel de virulencia de N. meningitidis, su vigilancia debe constituir una prioridad estratégica de los sistemas de salud pública nacionales y regionales para prevenir brotes epidémicos y apoyar la toma de decisiones en salud pública.
Although recent large-scale clinical studies have shown that preoperative renal insufficiency is associated with increased risk of postoperative complications after pancreatoduodenectomy (PD), it is ...unknown whether asymptomatic renal dysfunction has an impact on postoperative course after PD.
Two hundred and fifty-four patients who underwent PD between 2007 and 2013 were enrolled. Renal function was evaluated by the preoperative estimated glomerular filtration rate (eGFR). Patients were divided into two groups according to the cutoff value of 55 of eGFR.
Thirty-five patients were classified as the low eGFR group, while 219 were classified as the normal group. There were differences between groups in age, comorbidity and pancreatic texture. The incidence of overall postoperative complication, grade B/C pancreatic fistula and severe complication in the low eGFR group was significantly higher than that in the normal group. Multivariate analysis identified low eGFR as an independent risk factor for severe postoperative complications and grade B/C pancreatic fistula after PD. However, there were no differences in mortality and survival between the low and normal eGFR groups.
We have demonstrated for the first time that preoperative asymptomatic renal dysfunction may be a significant risk factor for severe morbidity and clinically relevant pancreatic fistula after PD.
Background
There is no clear evidence that preoperative chemotherapy for resectable colorectal liver metastasis (CRLM) is superior to up-front surgery (UFS). The aim of this study was to identify the ...risk factors associated with poor prognosis after UFS for CRLM.
Methods
Data about consecutive patients with CRLM who underwent liver resection at Nara Medical University Hospital between January 2000 and December 2015 were retrieved from a prospective database. Recurrence that developed within 2 years after liver resection and could not be surgically resected was defined as unresectable recurrence (UR). Preoperative risk factors associated with UR after UFS were analyzed. Among the patients with the identified risk factors, the patients who were treated with UFS were compared with those who received preoperative chemotherapy via propensity score-matching analysis.
Results
There were 167 patients treated with UFS, and 71 of them developed UR (the UR group). The overall survival (OS) rate of the UR group was significantly worse than that of the non-UR group (5-year survival rate: 3.8 vs. 66.8%,
p
< 0.001). Multivariate analysis identified a primary colorectal cancer N factor of N2–3 as a risk factor for UR (hazard ratio 2.72,
p
= 0.004). Propensity score-matching analysis demonstrated that among patients with N2–3 primary colorectal cancer the post-initial treatment OS of the patients treated with UFS was significantly worse than that of the patients who received preoperative chemotherapy (5-year survival rate: 11.1 vs. 30.0%,
p
= 0.046).
Conclusions
Patients with CRLM with a primary colorectal cancer N factor of N2–3 should be considered for preoperative chemotherapy.
Background
Ehlers–Danlos syndrome (EDS) is a genetic disorder that causes fragility of the systemic connective tissues. Of the 13 subtypes, vascular EDS (vEDS) is associated with abnormalities in ...collagen production, resulting in arterial rupture and intestinal perforation. Herein, we report the case of a man with confirmed vEDS who survived a ruptured dissected splenic artery aneurysm triggered by perforation of the sigmoid colon.
Case presentation
A 48-year-old man presented to our hospital with sudden severe lower abdominal pain. The patient was genetically diagnosed with vEDS at the age of 43 years. Abdominal computed tomography (CT) showed fluid and free air surrounding the sigmoid colon. These findings suggested sigmoid colon perforation, and emergency surgery was needed. Hartmann’s procedure was performed. The resected specimen showed a 2-cm-sized depression around the perforation. Histopathological findings showed an abscess and exudate in the serosa of the perforation and thinning of the intrinsic muscular layer in the depressed area. The patient was doing well postoperatively; however, on the ninth postoperative day, sudden upper abdominal pain developed. CT revealed an intra-abdominal hemorrhage due to rupture of a dissecting splenic artery aneurysm. The aneurysm was not observed on preoperative CT and was distant from the surgical site. Urgent transcatheter arterial embolization was performed. Although embolization of the splenic artery was attempted during the procedure, the arterial dissection spread to the common hepatic artery. Moreover, the proper hepatic and gastroduodenal arteries were poorly visualized, probably due to vasospasm. Although complications associated with extensive embolization were a concern, embolization of the splenic and common hepatic arteries was necessary to save the patient’s life. After embolization, angiography showed that the left hepatic blood flow was maintained from the inferior phrenic artery, and the right hepatic inflow was maintained from the superior mesenteric artery via the peribiliary vascular plexus in the hilar area. The patient recovered well and was discharged on the 19th postoperative day.
Conclusions
vEDS can cause arterial rupture after intestinal surgery. Therefore, careful post-operative management is necessary. Moreover, cooperation with interventional radiologists is important for prompt treatment of vascular complications.
Purposes
The relationship between the results of bacterial drainage fluid cultures in the early postoperative period after liver resection and the development of surgical site infections (SSIs) is ...unclear. We evaluated the diagnostic value of bacterial cultures of drainage fluid obtained on postoperative day (POD) 1 after liver resection.
Methods
The cases of all consecutive patients who underwent elective liver resection from January 2014 to December 2016 were analyzed. The association between a positive culture result and the development of SSIs was analyzed.
Results
A total of 195 consecutive patients were studied. Positive drainage fluid cultures were obtained in 6 patients (3.1%). A multivariate analysis revealed that a positive drainage fluid culture was an independent risk factor for SSIs (odds ratio: 8.04,
P
= 0.035), and combined resection of the gastrointestinal tract was a risk factor for a positive drainage fluid culture (
P
= 0.006). Among the patients who did not undergo procedures involving the gastrointestinal tract, there was no association between drainage fluid culture positivity and SSIs.
Conclusions
The detection of positive culture results for drainage fluid collected on POD 1 after liver resection was associated with SSIs. However, among patients who did not undergo procedures involving the gastrointestinal tract, it was not a predictor of SSIs.
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