Izumi City General Hospital

Abstract Purpose: Postoperative pancreatic fistula (POPF) is a potentially fatal complication of distal pancreatectomy (DP) but the optimal prevention method is unknown. The standard methodology for DP is to dissect the pancreas using a stapler alone. This pilot study evaluated post-DP remnant closure by stapling plus a PGA felt patch and examined the predictors of POPF. Methods: We prospectively enrolled and analyzed 26 patients scheduled for DP in which the remnants were closed with staples and a PGA felt patch. Results: Primary disease included 17 pancreatic adenocarcinomas, 3 pancreatic neuroendocrine neoplasms, 2 mucinous cystic neoplasms, 2 solid pseudopapillary neoplasms, and 2 other disorders. The mean main pancreatic duct diameter at the excision site was 2.3 mm. The mean pancreatic parenchyma thickness was 12.3 mm. The mean pancreatic dissected line was 0.5 mm to the left from the left edge of the portal vein. We observed nine biochemical leaks and the formation of nine grade B POPFs. We found significant differences in the BMI, pancreatic parenchymal thickness, and pancreatic dissection line between patients with and without POPF. Conclusion: Although stapling and applying PGA felt did not show efficacy in preventing POPF, the pancreatic dissecting line was suggested as a risk factor.

Gastric adenoma and cancer are common in Asia, with early detection critical for prognosis. Synchronous multiple early gastric cancers (SMEGCs) occur in 6% to 14% of cases, but their clinicopathological characteristics remain unclear. This study analyzed synchronous multiple gastric neoplasms treated by endoscopic resection or surgery to aid early detection. Among 2,991 cases of early gastric cancer or adenoma diagnosed at our institution, 173 patients with 346 synchronous lesions (January 2016-March 2024) were analyzed. All lesions were mucosal or submucosal. Lesions were categorized as "1st" (larger) and "2nd" (smaller), and clinicopathological characteristics were compared using Chi-square and Fisher's exact tests with Cramér's V. Patients had a mean age of 73.2 years; 72.8% were male. Most lesions were in the lower/middle stomach, differentiated (92.2%), depressed (52.9%), and brownish on narrow-band imaging (65.3%). Mean tumor diameter was 13.4 mm. Although 1st lesions were larger, other features showed high concordance (≥ 0.25 Cramér's V) in location, morphology, histology, invasion depth, and coloration. Survival was 94.8% (nine unrelated deaths). Synchronous multiple gastric neoplasms tend to have similar endoscopic and histopathologic features and often occur within the same belt-like region along the short axis of the stomach. This pattern was named boundary equal lesions trends (BELT). When detecting one lesion, considering BELT is essential.

Although pathologic stage I (pStage I) non–small cell lung cancer (NSCLC) has a good prognosis, some patients experience disease recurrence. Identification of prognostic markers for pStage I NSCLC may facilitate personalized perioperative treatment by expanding the candidates for adjuvant treatment. Patients with NSCLC with ground-glass opacity have excellent survival outcomes. Therefore, in this study, we explored prognostic biomarkers in pure solid nonsquamous NSCLC. We focused on nonsquamous NSCLC because the gene expression status is distinct from that of squamous cell carcinomas. RNA sequencing was performed on frozen tumor specimens from 33 patients with nonsquamous NSCLC with disease recurrence (recurrence group) and 33 counterparts (control group) extracted from patients without disease recurrence using propensity score matching (cohort 1). The candidate genes were further refined using an independent real-world cohort 2a (N = 125) and validated in The Cancer Genome Atlas cohort. Through the analysis of cohort 1 and cohort 2a, we found that low expression of six genes (BMP6, KCNK3, NFASC, OLFM1, PEG3, and TNXB) was associated with disease recurrence. The prognostic impact of the six genes was confirmed using The Cancer Genome Atlas lung adenocarcinoma database. Multivariable proportional hazard analysis using the cohort 2a dataset revealed that the combination of BMP6 and OLFM1 status predicted recurrence-free survival. In conclusion, we found that low BMP6/OLFM1 gene status is a potential biomarker to identify patients with high-risk pStage I pure solid nonsquamous NSCLC after pulmonary resection.Significance:The identification of subgroups with a high risk of disease recurrence among patients with NSCLC with pStage I is an important clinical issue. We explored genetic factors in patients with pStage I NSCLC with a high-risk clinical feature and identified low expression of OLFM1 and BMP6 genes as candidate biomarkers. Clinical application of these biomarkers, together with others, will open an opportunity to administer adequate adjuvant treatment for these high-risk patients.

We present a case of mismatch repair deficient (dMMR) descending colon cancer complicated by peritoneal dissemination and adjacent organ invasion, initially considered unresectable. The patient, a 68-year-old male, experienced acute intra-abdominal hemorrhage due to spontaneous rupture of a pseudoaneurysm from segmental arterial mediolysis (SAM). Emergency surgery confirmed unresectability, prompting immunotherapy with pembrolizumab. Remarkably, after four cycles, significant tumor regression allowed for curative resection, with complete pathological response. Immunohistochemistry revealed a high density of tumor-infiltrating CD8 + T cells and PD-L1-positive stromal cells, indicating robust immune activation. This case underscores immunotherapy's emerging role in converting unresectable dMMR colorectal cancer into resectable disease. This highlights the significance of multidisciplinary management, incorporating immunotherapy, surgical interventions, and vascular assessment to optimize clinical outcomes in dMMR colorectal cancer complicated by vascular pathologies such as SAM. Further investigation into the relationship between vascular pathologies, such as SAM, and malignancy is warranted.

Abstract Background Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome rather than a single entity. Left ventricular (LV) remodeling patterns may be associated with this heterogeneity. Population-based studies have shown that LV volume decreases with aging, a key factor for HFpEF development. HFpEF associated with small LV may represent a distinctive phenotype characterized by older age and unique clinical features. Purpose This study aims to investigate the characteristics and clinical outcomes of HFpEF wih small LV. Methods We analyzed 1,140 patients from PURSUIT-HFpEF registry, a multicenter prospective observational registry of acute decompensated HFpEF patients. Clinical data were collected during the compensated phase, after stabilization following acute decompensated HF treatment. The study population was divided into groups with small, normal, and large LV based on LV end-diastolic dimension per the American Society of Echocardiography references. We examined the impact of LV size on all-cause mortality. Results Of 1,140 patients, 161 (14.1%) patients were identified with small LV, and 71 (6.2%) patients were identified with large LV. Patients with small LV were older and had higher heart rates, lower systolic blood pressure, lower body mass index, higher hemoglobin levels, higher estimated glomerular filtration rate, and elevated NT pro-BNP levels. The Kaplan-Meier analysis revealed that LV size was significantly associated with mortality (Log-rank p< 0.001). After adjusting for covariates, small LV remained independently associated with mortality compared with the normal LV group (adjusted hazard ratio: 0.64 [95% confidence interval: 0.49-0.83], p<0.001). Conclusions HFpEF with small LV represents a distinct phenotype characterized by older age, elevated NT-proBNP, fewer comorbidities, and higher mortality. These findings highlight the need for tailored management strategies for this subgroup.

ABSTRACTObjectivesEndoscopic ultrasound‐guided hepaticogastrostomy (EUS‐HGS) is useful in cases of endoscopic retrograde cholangiopancreatography failure. However, the procedure has a high incidence of procedure‐related early adverse events (PRAEs). This study retrospectively evaluated risk factors for such events post‐EUS‐HGS.MethodsThis multicenter study included 222 patients (120 males and 102 females; median age = 73 years) who underwent initial EUS‐HGS. The clinical success rate and PRAE incidence, and risk factors were analyzed. PRAEs were defined as AEs occurring within 2 weeks.ResultsThe median procedure time was 41 min. Metal or plastic stents were used for EUS‐HGS in 107 and 115 patients, respectively. Fistula dilation and concomitant antegrade stenting (AGS) were performed in 166 and 45 patients, respectively. The clinical success rate and PRAE incidence were 85.1% and 22.1%, respectively. Identified PRAEs included acute peritonitis (9.5%), fever (6.8%), abdominal pain (2.3%), and acute pancreatitis (1.4%). Multivariate analysis identified dilation device use (p = 0.01) and AGS (p = 0.03) as PRAE risk factors. AGS in patients who underwent fistula dilation (p = 0.02) and procedure time ≥41 min in those who underwent EUS‐HGS with AGS (p = 0.01) were PRAE risk factors.ConclusionsFistula dilation and AGS are associated with an increased risk of PRAEs post‐EUS‐HGS. Careful postoperative follow‐up for such events is required in patients undergoing fistula dilation for EUS‐HGS with AGS and prolonged procedure time.

ObjectiveTo clarify how the preoperatively determined position of the Cupid's bow peak on the lateral lip element affects postoperative nasolabial formation in patients with unilateral cleft lip. We hypothesize that setting the proposed peak of the Cupid's bow close to the nostril floor causes the cleft-side nasal alar base to droop while positioning it near the oral commissure shortens the red lip, causing an elevated cleft-side oral commissure.DesignRetrospective study.SettingSingle institution.PatientsTwenty-seven patients with non-syndromic complete unilateral cleft lip and palate (UCLP) who received primary lip plasty at our department.InterventionsPrimary lip repair for patients with UCLP.Main outcome measuresWe tested our hypothesis using three-dimensional facial images taken before and 1 year after primary lip repair. Bilateral measurements included lip height (distance between the nasal alar base and the Cupid's bow peak), red lip length, and the vertical height of the nasal alar base and oral commissure.ResultsCorrelation analysis showed a significant relationship between preoperative cleft-side lip height and the postoperative position of the cleft-side nasal alar base (P = .0024, Pearson's correlation analysis). Preoperative short red lip remained short afterwards (P = .000036, Pearson's correlation analysis), causing a lip cant with an elevated cleft-side oral commissure (P = .012, Pearson's correlation analysis).ConclusionsPostoperative nasolabial formation is influenced by the preoperatively proposed position of the Cupid's bow peak. This study provides a comprehensive principle explaining the relationship between the location of the proposed Cupid's bow peak on the lateral lip elements and postoperative nasolabial formation in primary lip repair in patients with unilateral cleft lip.

Chemotherapy-induced neutropenia has been identified as a potential prognostic marker for multiple cancers. However, only one retrospective study, NN-2301, has investigated the relationship between neutropenia and treatment effects of nanoliposomal irinotecan/5-fluorouracil/folinic acid (NFF) in pancreatic cancer. In this prospective study, we aimed to clarify whether NFF-induced neutropenia could serve as a prognostic marker in pancreatic cancer. Data were analyzed from the prospective cohort of the NAPOLEON-2 trial, an observational study involving patients with unresectable pancreatic cancer treated with NFF. Neutropenia severity was categorized into three cutoffs: Cutoff A (Grade [Gr] 0 vs. Gr 1-4), cutoff B (Gr 0-1 vs. Gr 2-4), and Cutoff C (Gr 0-2 vs. Gr 3-4), using the Common Terminology Criteria for Adverse Events version 5.0, owing to conformity with previous studies and simplicity. The primary endpoint was overall survival (OS); progression-free survival (PFS) was the secondary endpoint. The neutropenic groups included Gr 1, 2, 3, and 4, with 79, 23, 34, and 7 patients, respectively. At each cutoff, OS and PFS were significantly better in the severe neutropenia groups. Higher neutropenia grades correlated with improved OS (log-rank trend test: χ2 = 8.62, p < .01). Multivariate Cox regression analysis revealed significant differences for all cutoffs: adjusted hazard ratios were 0.57 (95% confidence interval [CI] 0.40-0.83) (Cutoff A), 0.53 (95% CI 0.36-0.78) (Cutoff B), and 0.52 (95% CI 0.34-0.80) (Cutoff C). NFF-induced neutropenia is a valuable prognostic marker in pancreatic cancer and may guide treatment selection.