Immunotherapy Using Activated Natural Killer Cells Improves Postoperative Neutrophil-to-Lymphocyte Ratio and Long-Term Prognosis of Living Donor Liver Transplant Recipients With Hepatocellular Carcinoma

OBJECTIVE

Preoperative neutrophil-to-lymphocyte ratio (NLR) is a well-known prognostic indicator in various malignancies; however, the impact of postoperative NLR on living donor liver transplant (LDLT) recipients is unknown. Immunotherapy with donor liver-derived activated natural killer (NK) cells may improve postoperative NLR by coactivating immune cells or suppressing activated neutrophils. This study aims to clarify the clinical significance of postoperative NLR in recipients after LDLT with HCC and assess whether immunotherapy improves postoperative NLR.

METHODS

We conducted a retrospective study of LDLT recipients between 2001 and 2022 to evaluate the clinical significance of postoperative NLR. Furthermore, the correlation between postoperative NLR and the activation marker of infused NK cells was also evaluated. The postoperative NLR was examined 4 weeks after LDLT.

RESULTS

The postoperative high NLR group (N = 78) had preoperative lower NLR and higher model for end-stage liver disease and a higher rate of postoperative infection within 30 days after LDLT than the postoperative low NLR group (N = 41). Postoperative high NLR (hazard ratio [HR], 2.62; 95% confidence interval [CI], 1.01-6.79; P = .047) and nontreatment of immunotherapy (HR, 3.10; 95% CI, 1.33-7.22; P < .01) were independent risk factors for poor overall survival in multivariate analysis. Furthermore, the activation marker of infused NK cells is inversely correlated with decreased postoperative NLR.

CONCLUSIONS

The higher level of postoperative NLR was independently associated with poor prognosis in patients after LDLT with HCC. Immunotherapy using activated NK cells may improve postoperative NLR and long-term prognosis.

Donor Age Correlates With Liver-Resident Natural Killer Cell Activity in Adoptive Immunotherapy Using Donor Liver Natural Killer Cells in Liver Transplantation

BACKGROUND

Natural killer (NK) cells are involved in innate immunity and have been reported to play an important role in hepatocellular carcinoma recurrence and post-liver transplantation (LT) infection. However, the relationship between donor age and liver-resident NK cell activity remains to be elucidated.

METHODS

We successfully performed NK cell immunotherapy in 19 living donor LT recipients to prevent post-LT bloodstream infections. Liver mononuclear cells (LMNCs) were collected from the liver graft perfusate and stimulated with interleukin 2 for 3 days. Liver-resident NK cells were analyzed using flow cytometry and a chromium release assay before and after cell culture.

RESULTS

The median donor age was 44 years (range, 24-64 years). The graft weight was 492 g (range, 338-642 g), and the median number of LMNCs was 584 million cells (range, 240-1472 million cells). The proportion of NK cells before and after culture was 22% and 33%, respectively. A significant correlation was found between graft weight and the number of LMNCs. However, no correlation was found between donor age and the number or percentage of NK cells in the liver. Moreover, donor age showed a significant inverse correlation with NKp46 and NKp44 expression before culture and with NKp44, tumor necrosis factor-related apoptosis-inducing ligand, and CD69 expression after culture.

CONCLUSION

A significant inverse correlation was observed between donor age and NK cell activity in the liver. This information may be useful for cell therapy during LT.

Association of Abdominal Aortic Calcification With the Postoperative Metabolic Syndrome Components After Liver Transplantation

BACKGROUND

This study aimed to assess the risk factors for components of metabolic syndrome, such as diabetes mellitus, hypertension, and dyslipidemia, more than a year after liver transplantation.

METHODS

This study included 164 patients with liver failure secondary to acute and chronic liver disease or hepatocellular carcinoma who underwent liver transplantation between 2000 and 2019. Univariate and multivariate analyses were performed to identify the risk factors associated with metabolic syndrome components after liver transplantation.

RESULTS

The median follow-up period was 10.5 years. Of the 164 patients who underwent liver transplantation, 144 (87.8%) developed components of metabolic syndrome after liver transplantation. The most common cause of liver failure was hepatitis C virus infection (34.1%). The incidence of hepatocellular carcinoma was 36.0%. In univariate analysis, preoperative diabetes mellitus was a significantly more common component of metabolic syndrome than the others. In multivariate analysis, preoperative abdominal aortic calcification was a risk factor for the new onset of all components of metabolic syndrome after liver transplantation, despite the varying degree of calcification at risk of development (odds ratio for diabetes mellitus = 3.487, P = .0069; odds ratio for hypertension = 2.914, P = .0471; odds ratio for dyslipidemia = 3.553, P = .0030).

CONCLUSIONS

Preoperative abdominal aortic calcification was significantly associated with the development of each metabolic syndrome component after liver transplantation.

Anti-Donor T-Cell Responses Are Not Necessarily Attenuated During Cytomegalovirus Infection in Kidney Transplant Recipients

BACKGROUND

Cytomegalovirus (CMV), the most common opportunistic infection of kidney transplantation (KT), is preventable by prophylactic and preemptive antiviral drugs in CMV-immunoglobulin (Ig)G-positive donors. Our preemptive therapy optimized immunosuppressive doses based on mixed lymphocyte response (MLR) results, regardless of preoperative CMV-IgG serostatus pairing. This study used the MLR to compare the anti-donor T-cell responses between CMV antigenemia-positive and -negative cases.

METHODS

One hundred patients underwent KT using a cyclosporine (CsA)-based immunosuppressive regimen at Hiroshima University Hospital. CMV antigenemia-positive cells were defined as 4/50,000 CMVpp65-positive cells. T-cell responses to allo-antigens were measured using MLR assays to evaluate patients' anti-donor immune reactivity. After analyzing the proliferation of CD4+ and CD8+ T-cell subsets, the stimulation indices of CD4+ or CD8+ T cells were quantified. The study used no prisoners, and the participants were neither coerced nor paid. The manuscript was created in compliance with the Helsinki Congress and the Declaration of Istanbul.

RESULTS

Forty-three patients tested positive for CMV antigenemia within 3 months after KT. No significant differences were found between the CMV antigenemia-positive and -negative groups in the stimulation indices for CD4+ and CD8+ T-cell responses to anti-donor stimulation. However, T-cell responses to third-party stimuli during the postoperative month 1 were significantly less in the CMV antigenemia-positive than -negative group.

CONCLUSION

Anti-donor T-cell responses are not necessarily attenuated during CMV infection in KT recipients. In CMV-infected KT recipients, caution should be exercised against inadvertent dose reduction of immunosuppressants.

Atherosclerosis Deteriorates Liver Ischemia/Reperfusion Injury Via Interferon Regulatory Factor-1 Overexpression in a Murine Model

BACKGROUND

Abdominal aortic calcification (AAC) is associated with cardiovascular-related mortality, along with an elevated risk of coronary, cerebrovascular, and cardiovascular events. Notably, AAC is strongly associated with poor overall and recurrence free survival posthepatectomy for hepatocellular carcinoma. Despite the acknowledged significance of atherosclerosis in systemic inflammation, its response to ischemia/reperfusion injury (IRI) remains poorly elucidated. In this study, we aimed to clarify the impact of atherosclerosis on the liver immune system using a warm IRI mouse model.

METHODS

Injury was induced in an atherosclerotic mouse model (ApoE-/-) or C57BL/6J wild-type (WT) mice through 70% clamping for 1 hour and analyzed after 6 hours of reperfusion.

RESULTS

Elevated serum levels of aspartate and alanine aminotransferase, along with histological assessment, indicated considerable damage in the livers of ApoE-/- mice than that in WT mice. This indicates a substantial contribution of atherosclerosis to IRI. Furthermore, T and natural killer (NK) cells in ApoE-/- mouse livers displayed a more inflammatory phenotype than those in WT mouse livers. Reverse transcription-polymerase chain reaction analysis revealed a significant upregulation of interleukin (IL)-15 and its transcriptional regulator, interferon regulatory factor-1 (IRF-1) in ApoE-/- mouse livers compared with that in WT mouse livers.

CONCLUSIONS

These findings suggest that in an atherosclerotic mouse model, atherosclerosis can mirror intrahepatic immunity, particularly activating liver NK and T cells through IL-15 production, thereby exacerbating hepatic damage. The upregulation of IL-15 expression is associated with IRF-1 overexpression.

Effect of Abdominal Aortic Calcification on Recurrence Following Initial Hepatectomy for Colorectal Liver Metastases

BACKGROUND/AIM

The aim of the study was to analyze the association between abdominal aortic calcification (AAC) and patient prognosis following resection of colorectal liver metastases (CRLM). AAC potentially reflects intrahepatic immunity and is involved in tumor development and progression. However, the clinical effects of AAC on colorectal cancer (CRC) prognosis after curative-intent liver resection for CRLM remain unclear.

PATIENTS AND METHODS

We evaluated the effect of AAC on the clinical prognosis and metastatic patterns in 99 patients who underwent hepatectomy for CRLM between 2010 and 2019.

RESULTS

The high-AAC group had significantly worse overall survival (OS) and remnant liver recurrence rate (RR) after propensity score matching to adjust for differences in baseline characteristics of patients and tumors. In multivariate Cox regression analyses, high AAC volume was an independent risk factor for poor OS and liver RR, but not poor lung RR. The expression of tumor necrosis factor-related apoptosis-inducing ligand, known as an anti-tumor marker, in liver natural killer (NK) cells was lower in the high-AAC group than in the low-AAC group.

CONCLUSION

High AAC volume showed a strong relationship with remnant liver RR after curative resection of CRLM. High AAC volume may be responsible for the suppression of anti-tumor activity of liver NK cells, which results in an increased risk of liver recurrence and poor prognosis.

C-Reactive Protein/Albumin Ratio Is an Independent Risk Factor for Recurrence and Survival Following Curative Resection of Stage I-III Colorectal Cancer in Older Patients

BACKGROUND

The number of older patients with cancer has increased, and colorectal cancer is expected to be affected by this trend. This study aimed to compare prognostic factors, including nutritional and inflammation-based indices, between patients aged ≥ 70 and < 70 years following curative resection of stage I-III colorectal cancer.

PATIENTS AND METHODS

This study included 560 patients with stage I-III colorectal cancer who underwent curative resection between May 2010 and June 2018. A retrospective analysis was performed to identify prognosis-associated variables in patients aged ≥ 70 and < 70 years.

RESULTS

Preoperative low body mass index, high C-reactive protein/albumin ratio, and comorbidities were mainly associated with poor prognosis in patients aged ≥ 70 years. Tumor factors were associated with a poor prognosis in patients aged < 70 years. The C-reactive protein/albumin ratio was independently associated with poor overall survival and recurrence-free survival in those aged ≥ 70 years. The time-dependent area under the curve for the C-reactive protein/albumin ratio was superior to those of other nutritional and inflammation-based indices in most postoperative observation periods in patients aged ≥ 70 years.

CONCLUSIONS

Tumor factors were associated with a poor prognosis in patients aged < 70 years. In addition to lymph node metastasis, preoperative statuses were associated with poor prognosis in patients aged ≥ 70 years. Specifically, the preoperative C-reactive protein/albumin ratio was independently associated with long-term prognosis in patients aged ≥ 70 years with stage I-III colorectal cancer after curative resection.

Association between social background and implementation of postoperative adjuvant chemotherapy for older patients undergoing curative resection of colorectal cancers, sub-analysis of the HiSCO-04 study

PURPOSE

Adjuvant chemotherapy is recommended following colorectal cancer resection based on risk of recurrence. In older patients, treatment decisions should consider recurrence rates and tolerability, as well as functional prognosis, residual disease, and social factors. This study aims to investigate factors, including social background, influencing implementation of postoperative adjuvant chemotherapy in older patients undergoing curative resection for colorectal cancer.

METHODS

This multi-institutional prospective cohort study included 15 institutions belonging to the Hiroshima Surgical study group for Clinical Oncology. We analyzed 159 older patients aged ≥ 80 years, who underwent curative resection for stage III colorectal cancer between December 2013 and June 2018, as sub-analysis of the HiSCO-04 study.

RESULTS

In total, 62 (39.0%) patients underwent postoperative adjuvant chemotherapy. Four factors were significantly associated with its implementation: performance status < 2, Charlson Comorbidity Index < 2, prognostic nutritional index ≥ 40, and presence of a spouse or siblings as lifestyle supporters. No significant difference was found in the backgrounds between complete and incomplete postoperative adjuvant chemotherapy patients.

CONCLUSION

Performance status, Charlson Comorbidity Index, nutritional status, and presence of a spouse or siblings as lifestyle supporters are possible factors influencing the implementation of postoperative adjuvant chemotherapy in older patients. To select appropriate treatment options, including postoperative adjuvant chemotherapy, it is essential to consider physical condition and comorbidities of older patients, thoroughly explain the situation to their families, and establish a support system to enhance understanding of the available treatment options.

Impact of a new liver immune status index among patients with hepatocellular carcinoma after initial hepatectomy

Aim

The anti-tumor effects of natural killer (NK) cells vary among individuals. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) expressed on liver NK cells is a marker of anti-tumor cytotoxicity against hepatocellular carcinoma (HCC) in immune cell therapy. This study aimed to develop a liver immune status index (LISI) that predicts low TRAIL expression and validates its ability to predict recurrence after initial hepatectomy for primary HCC.

Methods

A functional analysis of liver NK cells co-cultured with interleukin-2 for 3 days was performed of 40 liver transplant donors. The LISI, which predicted low TRAIL expression (25% quartile: <33%) in liver NK cells, was calculated using multiple logistic regression analysis. Next, 586 initial hepatectomy cases were analyzed based on the LISI.

Results

Our model was based on the Fibrosis-4 index+0.1 (odds ratio [OR], 1.33), body mass index (OR, 0.61), and albumin levels+0.1 (OR, 0.54). The area under the receiver operating characteristic curve (AUC) of the LISI for low TRAIL expression was 0.89. Stratification of the recurrence rates (RR) revealed that LISI was an independent predictive factor of RR (moderate risk: hazard ratio, 1.44; high risk: hazard ratio, 3.02). The AUC was similar for the LISI, albumin-indocyanine green evaluation grade, albumin-bilirubin score, and geriatric nutritional risk index for predicting RR. Among the vascular invasion cases, the LISI was more useful than the other indexes.

Conclusion

Our model facilitates the prediction of RR in high-risk patients by providing LISI to predict the anti-tumor effects of NK cells.

The aryl hydrocarbon receptor maintains antitumor activity of liver resident natural killer cells after partial hepatectomy in C57BL/6J mice

BACKGROUND

Liver-resident natural killer (lr-NK) cells are distinct from conventional NK cells and exhibit higher cytotoxicity against hepatoma via tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). However, the mechanism by which partial hepatectomy (PH) significantly suppresses TRAIL expression in lr-NK cells remains unclear.

METHODS

This study aimed to investigate the PH influence on the function and characteristics of liver-resident NK (lr-NK) cells using a PH mouse model.

RESULTS

Here, we report that PH alters the differentiation pattern of NK cells in the liver, and an aryl hydrocarbon receptor (AhR) molecule is involved in these changes. Treatment with the AhR agonist 6-formylindolo[3,2-b]carbazole (FICZ) inhibited the maturation of NK cells. FICZ increased the immature subtype proportion of NK cells with high TRAIL activity and decreased the mature subtype of NK cells with low TRAIL activity. Consequently, FICZ increased the expression of TRAIL and cytotoxic activity of NK cells in the liver, and this effect was confirmed even after hepatectomy. The participation of AhR promoted FoxO1 expression in the mTOR signaling pathway involved in the maturation of NK cells, resulting in TRAIL expression.

CONCLUSION

Our findings provide direct in-vivo evidence that partial hepatectomy affects lrNK cell activity through NK cell differentiation in the liver. Perioperative therapies using an AhR agonist to improve NK cell function may reduce the recurrence of hepatocellular carcinoma after hepatectomy.

Predictive factors associated with anastomotic leakage after resection of rectal cancer: a multicenter study with the Hiroshima Surgical study group of Clinical Oncology

PURPOSE

Several factors have been reported as risk factors for anastomotic leakage after resection of rectal cancer. This study aimed to evaluate the risk factors for anastomotic leakage, including nutritional and immunological indices, following rectal cancer resection.

METHODS

This study used a multicenter database of 803 patients from the Hiroshima Surgical study group of Clinical Oncology who underwent rectal resection with stapled anastomosis for rectal cancer between October 2016 and April 2020.

RESULTS

In total, 64 patients (8.0%) developed postoperative anastomotic leakage. Five factors were significantly associated with the development of anastomotic leakage after rectal cancer resection with stapled anastomosis: male sex, diabetes mellitus, C-reactive protein/albumin ratio ≥ 0.07, prognostic nutritional index < 40, and low anastomosis under peritoneal reflection. The incidence of anastomotic leakage was correlated with the number of risk factors. The novel predictive formula based on odds ratios in the multivariate analysis was useful for identifying patients at high risk for anastomotic leakage. Diverting ileostomy reduced the ratio of anastomotic leakage ≥ grade III after rectal cancer resection.

CONCLUSIONS

Male sex, diabetes mellitus, C-reactive protein/albumin ratio ≥ 0.07, prognostic nutritional index < 40, and low anastomosis under peritoneal reflection are possible risk factors for developing anastomotic leakage after rectal cancer resection with the stapled anastomosis. Patients at high risk of anastomotic leakage should be assessed for the potential benefits of diverting stoma.

Arteriosclerosis Decreases Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand Expression on Liver Natural Killer Cells in Living Donor Liver Transplantation

BACKGROUND

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is critical for natural killer (NK) cell-mediated anti-tumor and anti-microbe killing. The TRAIL expression on the donor's liver NK cells from the liver perfusate after interleukin-2 stimulation varies between individuals and is unpredictable. This study aimed to clarify the risk factors for low TRAIL expression by analyzing perioperative donor characteristics.

METHODS

This retrospective study of living donor liver transplant (LDLT) donors between 2006 and 2022 was performed to analyze low TRAIL expression risk factors. Seventy-five donors who had undergone hepatectomy for LDLT were divided into 2 groups, low and high TRAIL, according to their TRAIL expression on liver NK cells, using median values.

RESULTS

The low TRAIL group (N = 38) was older and had lower nutrition and a higher low-density lipoprotein/high-density lipoprotein (LDL/HDL) cholesterol ratio, related to arteriosclerosis, than the high TRAIL group (N = 37). In multivariate analysis, the geriatric nutritional risk index (GNRI) (odds ratio, 0.86; 95% CI, 0.76-0.94; P < .001) and LDL/HDL cholesterol ratio (odds ratio, 2.32; 95% CI, 1.10-4.86; P = .005) were independent predictive factors for low TRAIL expression on liver NK cells. Furthermore, the TRAIL expression of liver NK cells decreased in donors who already had atherosclerosis and in donors at risk of potentially developing atherosclerosis.

CONCLUSIONS

The TRAIL expression on liver NK cells in donors had a strong relationship with atherosclerosis and GNRI. Atherosclerosis can reflect the TRAIL expression on liver NK cells.

Surgery-related disseminated intravascular coagulation predicts postoperative complications

PURPOSE

The rate of postoperative morbidity, including infectious complications, is still high after major hepatobiliary pancreatic (HBP) surgery. Although surgery-related disseminated intravascular coagulation (DIC) occurs in some cases, its significance has not been elucidated in HBP surgery. This study aimed to evaluate the influence of surgery-related DIC on the complication severity after HBP surgery.

METHODS

We analyzed the records of 100 patients with hepatectomy in two or more segments, hepatectomy with biliary tract reconstruction, and pancreaticoduodenectomy. The baseline characteristics and complications were compared between patients with and without surgery-related DIC on postoperative day 1 (POD1) after HBP surgery between 2010 and 2018. Complication severity was assessed using the Comprehensive Complication Index (CCI).

RESULTS

The DIC group (surgery-related DIC on POD1) had predictive factors, such as larger bleeding volume and higher liver enzyme levels. The DIC group exhibited significantly elevated rates of surgical site infection, sepsis, prolonged intensive care unit stay, more frequent blood transfusions, and higher CCI. Furthermore, compared with and without adjustment of DIC, odds ratio (OR) of AST level and operation time for  the risk of high CCI decreased (OR of AST level: 1.25 to 1.19 and OR of operation time: 1.30 to 1.23) and the significant differences had vanished.

CONCLUSIONS

Surgery-related DIC on POD1 could be a partial mediator between AST level, operation time and higher CCI. The prevention or proper management of surgery-related DIC on POD1 can be an important target to reduce the severity of postoperative complications.

Effectiveness of Thermal Barrier Bag for Prolonged Vascular Anastomosis in Kidney Transplantation

BACKGROUND

In kidney transplantation (KT), efforts to minimize rewarming and optimize anastomosis time during vascular anastomosis improve graft outcomes. We recently reported the safety and efficacy of a pouch-type thermal barrier bag (TBB) made of elastomer gel to reduce second-warm ischemic injury during vascular anastomosis. We aimed to examine the usefulness of the TBB in prolonged vascular anastomosis in KT performed by young transplant fellows.

METHODS

Young transplant fellows performed KT under the supervision of certified transplant surgeons. The kidney graft was placed inside the TBB with an outlet for vessels and preserved during vascular anastomosis. A non-contact infrared thermometer measured the graft surface temperature before and after vascular anastomosis. After completion of the anastomosis, the TBB was manually slid out of the transplanted kidney and removed before graft reperfusion. Clinical data, including patient characteristics and perioperative variables, were collected. The primary endpoint was the median graft surface temperature at the end of the anastomosis.

RESULTS

Ten living-donor kidney transplant recipients with a median age of 56.5 years (range, 40-69 years) underwent KT procedures performed by young transplant fellows. The median anastomosis time was 53 (43-67) min. At the end of anastomosis, the median graft surface temperature was 17.7°C (16.3-18.3°C); no serious adverse events or delayed graft function were observed.

CONCLUSION

The TBB can keep transplanted kidneys at a low temperature even with prolonged vascular anastomosis time, thus contributing to the functional preservation of transplanted kidneys and stable transplant outcomes.

Effect of abdominal aortic calcification on the prognosis and recurrence of colorectal cancer stages II-III: A retrospective cohort study

PURPOSE

Abdominal aortic calcification (AAC) is a well-known risk marker for cardiovascular disease. However, its clinical effect on patients who underwent radical surgery for colorectal cancer (CRC) stages II-III is unclear. This study aimed to analyze the associations between AAC and prognosis of patients with stage II-III CRC.

METHODS

To evaluate the effect of AAC on clinical outcomes, prognosis, and metastatic patterns of CRC, we analyzed 362 patients who underwent radical surgery for stage II-III CRC between 2010 and 2018.

RESULTS

The high AAC group had significantly worse overall survival (OS), cancer-specific survival (CSS), and recurrence-free survival (RFS) after propensity score matching to adjust for differences in baseline characteristics of patients and tumors. In the multivariate Cox regression analyses, a high AAC was an independent risk factor for poor OS (hazard ratio [HR], 2.38; 95% confidence interval [CI], 1.23-4.59; p = 0.01), poor CSS (HR, 5.22; 95% CI, 1.74-15.6; p < 0.01), and poor RFS (HR, 1.83; 95% CI, 1.19-2.83; p < 0.01). A high AAC was not associated with a risk of lung metastasis or local or peritoneal recurrence, but a risk for liver metastasis of CRC.

CONCLUSION

A high AAC showed a strong relationship with poor OS, CSS, and RFS after curative resection for stage II-III CRC. A high AAC was also associated with a risk for liver metastasis, which may worsen the prognosis in stage II-III CRC. AAC could be a new clinical tool for predicting the prognosis for patients in stage II-III CRC.

Duodenal diverticula perforation caused by an impacted bezoar successfully treated by endoscopic drainage and lithotripsy: A case report and literature review

Duodenal diverticula perforation due to an impacted bezoar is a rare disease. Surgical treatment is associated with high rates of complications and mortality; therefore, treatment strategies must be carefully decided. Endoscopic treatment offers significant benefits to patients over surgery.

Duodenal diverticula perforation due to an impacted bezoar was performed endoscopic treatment. Endoscopic treatment offers significant benefits to patients over surgery.

Validation of appendiceal stump invagination in laparoscopic appendectomy

INTRODUCTION

There are various methods for appendiceal stump dissection, but the necessity for stump invagination remains unclear. This study aimed to assess the efficacy of appendiceal stump invagination in patients with acute appendicitis after laparoscopic appendectomy (LA).

METHODS

We enrolled 327 patients with acute appendicitis who underwent LA between 2012 and 2020. Perioperative variables and surgical outcomes were analyzed between the invagination of the appendiceal stump and noninvagination groups. Propensity score-matched analysis (PSM) was performed.

RESULTS

More patients experienced severe inflammation and severe intra-abdominal contamination in the noninvagination group than in the invagination group. Patients in the noninvagination group had an older age, higher body mass index, and poorer American Society of Anesthesiologists physical status than the invagination group. Severe inflammation in the noninvagination group was associated with longer hospital stays and poorer postoperative complications than in the invagination group. PSM analysis was performed to minimize bias in the two groups. After PSM analysis, there were no significant differences in surgical site infection, postoperative intra-abdominal abscess, Clavien-Dindo class ≥IIIa, or postoperative stay between the two groups. During the follow-up period, the postoperative adhesive ileus was not significantly different between the invagination and noninvagination groups.

CONCLUSION

Invagination of the appendiceal stump during LA is not necessary to prevent short- and long-term complications. Even in cases dissected using a laparoscopic endostapler, the appendiceal stump per se is not related to postoperative adhesive ileus.

Laparoscopic resection of schwannoma in the hepatoduodenal ligament: a case report

Background

The occurrence of schwannomas in the hepatoduodenal ligament is rare, and its preoperative accurate diagnosis is difficult. Only few cases have been treated with laparoscopic surgery.

Case presentation

A 54-year-old man visited our hospital following abnormal abdominal computed tomography findings. He had no complaints, and his laboratory investigations were normal. Abdominal contrast-enhanced computed tomography revealed a tumor with enhancement at the margin of the hepatoduodenal ligament. The abdominal magnetic resonance imaging findings of the tumor showed hypointensity on the T1-weighted images and mixed hypointensity and hyperintensity on the T2-weighted fat-suppression images. Positron emission tomography showed localized accumulation of fludeoxyglucose only in the hepatoduodenal ligament tumor. The patient underwent laparoscopic tumor resection for accurate diagnosis. Histopathologically, the tumor was mainly composed of spindle cells, which were strongly positive for S-100 protein on immunohistochemical staining. The patient was discharged without any postoperative complications on day 5.

Conclusions

Complete tumor resection is essential for schwannomas to avoid recurrence. Laparoscopic surgery is useful for schwannomas occurring in the hepatoduodenal ligament and can be performed safely by devising an appropriate surgical method.

Imaging diagnosis of aberrant proper hepatic and gastroduodenal arteries prior to pancreaticoduodenectomy: A case report

In hepatobiliary and pancreatic surgery, an understanding of hepatic artery anomalies is of great importance to surgeons. Cases of the proper hepatic artery originating from the superior mesenteric artery and the gastroduodenal artery originating from the celiac trunk are extremely rare. To our knowledge, there are no reports of these arterial variants being diagnosed before hepatobiliary and pancreatic surgery. A 73-year-old woman underwent subtotal stomach-preserving pancreaticoduodenectomy and lymphadenectomy for duodenal carcinoma. Preoperative vascular construction with 3-dimensional computed tomography showed variants of the proper hepatic artery and gastroduodenal artery. The proper hepatic artery originated from the superior mesenteric artery, and the gastroduodenal artery originated from the celiac trunk. Intraoperative findings and preoperative vascular construction from 3-dimensional computed tomography were found to be matched exactly; both the proper hepatic artery and gastroduodenal artery were preserved. By diagnosing a rare arterial variant preoperatively, we were able to perform the surgery safely. In hepatobiliary and pancreatic surgery, understanding any potential variation of the hepatic artery before surgery is crucial to ensure the best patient outcomes.

Risk Factors for Anastomotic Leakage after Colorectal Surgery with Double-staple Technique Anastomosis: Impact of the Agatston Score

Objectives

Anastomotic leakage is associated with severe morbidity, mortality, and functional defects. Its risk factors remain unclear. However, blood perfusion may be a potential major risk factor. It has been reported that the Agatston score is an index for blood flow perfusion evaluation. Therefore, we evaluated the clinical indicators associated with anastomotic leakage, including the Agatston score, in patients who underwent colorectal surgery.

Methods

We retrospectively analyzed 147 patients who underwent elective colorectal surgery with the double-staple technique anastomosis for colorectal cancer between April 2015 and March 2020. The primary outcome was the presence or absence of anastomotic leakage. Univariate and multivariate analyses were employed to identify pre- and intraoperative risk factors.

Results

Of the 147 patients analyzed, anastomotic leakage occurred in 12 (8.16%). Male gender, history of angina and myocardial infarction, preoperative white blood cell count, the Agatston score, extent of bleeding, operation time, and intraoperative fluid volume were significantly related to a higher incidence of anastomotic leakage in univariate analysis. Multivariate analysis demonstrated that the incidence of anastomotic leakage was high in patients with a high Agatston score.

Conclusions

The Agatston score can predict the incidence of anastomotic leakage in patients following colorectal surgery. Thus, perioperative measures to prevent anastomotic leakage are recommended when a high Agatston score is observed. A prospective trial is required to demonstrate, with a high level of evidence, that the Agatston score can be useful as a risk score for anastomotic leakage following colorectal surgery.

Appendicitis with submucosal fecalith mimicking a submucosal tumor: a case report

Background

Submucosal fecalith(s) mimicking submucosal tumors of the gastrointestinal lumen are rare. Moreover, accurate preoperative diagnosis of these entities is exceedingly difficult, and the mechanism(s) of their formation remains unclear.

Case presentation

A 40-year-old woman visited the authors’ hospital due to lower abdominal pain and diarrhea. She had previously been treated for endometriosis. Laboratory investigation revealed increased C-reactive protein levels. Abdominal contrast-enhanced computed tomography revealed thickening of the appendix wall and dilation of the small intestine. The patient was diagnosed with paralytic ileus caused by appendicitis, and interval appendectomy was scheduled. She underwent laparoscopic-assisted appendectomy after conservative treatment. Partial cecal resection was selected due to the presence of an elastic mass in the cecum. The final pathological diagnosis was submucosal fecalith, not submucosal tumor. On day 5, the patient was discharged without any postoperative complications.

Conclusions

In cases of appendicitis with fecalith(s) that appear as submucosal tumor(s) on colonoscopy, submucosal fecalith mimicking submucosal tumor should be considered in the differential diagnosis.

Validation of the Tokyo guideline 2018 treatment proposal for acute cholecystitis from a single-center retrospective analysis

INTRODUCTION

The revised Tokyo guideline 2018 (TG18) recommends early laparoscopic cholecystectomy (LC) in patients with acute cholecystitis (AC) who satisfy the Charlson Comorbidity Index criteria and the ASA Physical Status Classification (ASA-PS). Our study aims to determine the efficacy of the TG18 treatment strategy.

METHODS

We enrolled 324 patients who had been diagnosed with AC according to the TG18 and who underwent cholecystectomy between 2010 and 2018. Perioperative variables and surgical outcomes were analyzed according to the TG18 treatment strategy and severity grading.

RESULTS

The Charlson Comorbidity Index and ASA-PS scores were significantly higher in patients with Grade II and Grade III AC than in those with Grade I AC. In patients with a higher severity grading, LC failed, necessitating blood transfusion and bailout surgery. Among patients treated by the TG18 strategy were a higher proportion with Grade I or II AC; their ASA-PS scores were significantly lower than patients with Grade III AC. Compared to patients not treated by the TG18 strategy, this group demonstrated significant differences in the achievement of LC, bailout surgery, postoperative hospital stays, and 90-day mortality rates. Intraoperative blood loss and blood transfusion were significantly higher in those not treated by the TG18 strategy.

CONCLUSIONS

Our study shows that the TG18 treatment strategy is well-designed and efficacious. Given the high rate of blood transfusion and conversion surgery in treatment strategies other that TG18, special attention should be paid when selecting the optimal treatment strategy.

Iatrogenic hepatic granuloma (suspected liver metastatic lesion on imaging) caused by liver retraction during laparoscopic gastrectomy: A case report

There are no previous reports of hepatic granuloma secondary to intraoperative liver retraction. Using softer hepatic retraction instruments and keeping hepatic retraction time to a minimum are vital in preventing postoperative liver damage.

Impact of low skeletal muscle mass index and perioperative blood transfusion on the prognosis for HCC following curative resection

BACKGROUND

This study aimed to assess the prognostic factors including low skeletal muscle mass index (SMI) and perioperative blood transfusion for patients with hepatocellular carcinoma (HCC) following curative surgery.

METHODS

This study included 139 patients with HCC who underwent hepatectomy between 2005 and 2016. Univariate and multivariate analyses were performed to identify variables associated with overall survival (OS) and recurrence-free survival (RFS).

RESULTS

Low SMI was significantly related with poor OS, while blood transfusion had a strong impact on RFS. The male ratio and body mass index in the low SMI group were significantly higher than those in the high SMI group. There were no significant differences in age, virus etiology, laboratory data, liver function, tumor makers, and operative variables between the groups. Tumor factors such as tumor diameter, tumor number, poor differentiation, and intrahepatic metastasis (IM) did not significantly differ between the two groups. Operation time, intraoperative blood loss volume, and recurrence ratio were significantly higher in the blood transfusion group than in the non-transfusion group. IM was associated with poor OS and RFS.

CONCLUSIONS

Low SMI and blood transfusion were independently related with long-term prognosis in patients with HCC following curative surgery.

A Case of Isolated Adrenocorticotropic Hormone Deficiency Caused by Pembrolizumab

Pembrolizumab (Keytruda®) is an anti-programmed cell death 1-specific monoclonal antibody that has become the standard second-line chemotherapy for unresectable advanced microsatellite instability-high colorectal cancer. Several immune-related adverse events (irAEs), particularly endocrinopathy, are linked to the administration of pembrolizumab. We report here a case of pembrolizumab-induced isolated adrenocorticotropic hormone deficiency in a patient with metastatic colon cancer. A 65-year-old woman visited our hospital for complaints of fatigue with a recent history of primary resection of cecal mucinous cancer and hepatectomy for liver metastasis 3 years ago. Peritoneal dissemination was detected 2 years after surgery. Several chemotherapeutic regimens of cytotoxic and molecular targeted drugs were administered; however, the metastases progressed gradually. Pembrolizumab monotherapy was started because of resistance to treatment. After 2 cycles of pembrolizumab, the patient was severely fatigued. Laboratory data demonstrated that the cortisol level was extremely low. All the other values were within the normal range. Magnetic resonance imaging indicated no mass in the pituitary gland. From multiple tolerance tests, we diagnosed isolated adrenocorticotropic hormone deficiency caused by pembrolizumab. The patient's symptoms improved promptly with cortisol treatment. An abdominal contrast-enhanced computed tomography scan after 5 cycles of pembrolizumab demonstrated that the size of the peritoneal dissemination remained unchanged. However, her serum level of carcinoembryonic antigen had decreased to normal levels. Endocrine disorders are very rarely seen as irAEs. Careful laboratory data follow-up is required to inhibit the progression of severe endocrine disorders.

Case report of hepatic pseudocyst: A rare manifestation of liver metastasis from an anal squamous cell carcinoma

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Liver metastasis of anal squamous cell carcinoma with a presented pseudocyst is very rare.

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Some hepatic diseases such as infections, simple biliary cysts, and neoplasms demonstrate a cystic change of the liver.

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Metastasis should be suspected when CT findings in patients with a history of gastrointestinal cancer show cystic changes involving the liver.

Introduction

Liver metastasis of an anal squamous cell carcinoma (SCC) with a pseudocyst is uncommon. There are many diseases which form hepatic cystic lesions and sometimes it is difficult to arrive at an accurate diagnosis.

Presentation of case

A 69-year-old woman visited our hospital with complaints of bloody stool and difficult defecation. A palpable mass in the anal canal was found on digital examination. The laboratory tests revealed anemia and raised levels of SCC antigen. On endoscopy a type 2 tumor was identified in the anal canal and biopsy revealed SCC. The patient was diagnosed with advanced anal SCC (cT2N1aM0, cStage IIIA) as a result of the examination and underwent chemoradiotherapy (CRT); unfortunately the tumor persisted after CRT. A salvage abdominoperineal resection with D2 and left lateral lymph node dissection was conducted. Histopathologically, the tumor was diagnosed as poorly differentiated SCC. She was readmitted for fever 3 weeks after surgery, and the abdominal CT showed multiple low density areas with enhancement at the edge of the liver, suggesting abscess or metastasis. The metastatic SCC was revealed by cytology of liver drainage and liver biopsy.

Discussion

Anal cancers are sometimes encountered however; a pseudo cystic presentation of a liver metastasis is very rare which makes it difficult to distinguish from other diseases.

Conclusion

We present a case of SCC in the anal canal with liver metastasis presenting as a hepatic pseudocyst.

[A Case of Laparoscopic Abdominoperineal Resection of Anorectal Malignant Melanoma]

A 56-year-old woman with complaints of anal bleeding and pain visited our hospital, and an elastic soft mass was detected in the anal canal on digital examination.Colonoscopy showed a black Isp polypoid lesion with a black pit from the anal canal to the lower rectum(P-Rb).She was diagnosed with malignant melanoma based on colonoscopic biopsy.Tumor marker levels(CEA, CA19-9)were not increased.No distant metastasis was detected on abdominal CT.No direct invasion was detected on MRI of the pelvis.The patient underwent laparoscopic abdominoperineal resection and D2 lymph node dissection. Histopathology showed a malignant melanoma(pT4b, N0, M0, pStageⅡC).The patient received interferon therapy as adjuvant therapy.There is no sign of recurrence 2 years and 1 month after the surgery.Anorectal malignant melanoma is relatively rare, so establishment of therapy by the accumulation of cases is desired.

A spontaneous mesenteric hematoma with a fistula between the transverse colon resected by laparoscopic surgery: A case report

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A mesenteric hematoma with a fistula to the colon is very rare, and the etiology remains unclear.

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The patients with mesenteric hematoma who are stable can opt for the non-operative treatment.

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Laparoscopic surgery may be a useful treatment option compared to open surgery with respect to postoperative recovery.

Introduction

A spontaneous mesenteric hematoma is rare, and its etiology is unclear. We present a very rare case of spontaneous mesenteric hematoma with a fistula to the transverse colon.

Presentation of case

A 90-year-old male visited our hospital because of lower abdominal pain. The physical examination revealed tenderness in the lower abdomen. The laboratory data revealed anemia and low estimated glomerular filtration rate (eGFR). The abdominal contrast-enhanced computerized tomography (CT) indicated a mass with coexisting low- and high-density areas adjacent to the transverse colon. The mass was diagnosed as a mesenteric hematoma. We selected conservative therapy, because the patient’s condition was stable. After 15 days from discharge, he was admitted to the hospital again for the complaint of bloody stool. A fistula with blood flowing out at the splenic flexure was reported on colonoscopy. In the laparoscopic operative findings, the hematoma adhered to the stomach, pancreas and omentum. A hand-assisted laparoscopic transverse colectomy including hematoma in the mesentery was successful. The pathological reports revealed that a spontaneous mesenteric hematoma formed the fistula to the colon. The patient was discharged without any postoperative complication on day 10.

Discussion

Generally, laparotomy is often chosen for the treatment of mesenteric hematoma. The laparoscopic approach for mesenteric hematoma is useful under the specific condition that the preoperative patient’s condition is stable.

Conclusions

This is the first case of a spontaneous mesenteric hematoma with a fistula to the colon resected safely by laparoscopic surgery.

The gastric carcinosarcoma with severe venous invasion: a case report

Background

Gastric carcinosarcoma with severe venous invasion is extremely rare, and to the best of our knowledge, this is the first reported case.

Case presentation

A 79-year-old man visited the Onomichi General Hospital following abnormal upper gastrointestinal series findings. Laboratory data demonstrated no anemia, and the serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels were not elevated. Endoscopy identified a Borrmann type III lesion in the cardiac end of the stomach. Abdominal contrast-enhanced computerized tomography (CT) indicated that the lesser curvature of the stomach wall was modestly enhanced with bulky lymph nodes. Pathological biopsy examination identified a group 5, papillary adenocarcinoma. We diagnosed advanced gastric cancer with bulky lymph nodes (cT4aN3M0, cStage IIIC). Following neoadjuvant chemotherapy, the patient underwent open total gastrectomy with D2 lymph node dissection. Histopathologically, the tumor consisted of two components: a tubular adenocarcinoma and a sarcoma. The tumor cells were mainly intravenous and were not detected in the gastric wall stroma; this resulted in a venous invasion. Immunohistochemical analysis revealed that the tumor was positive for vimentin and partly positive for desmin and cytokeratin CAM5.2. We diagnosed a true gastric carcinosarcoma with severe venous invasion. Abdominal CT 2 months after surgery showed a low density area in the liver, suggesting metastasis.

Conclusions

Carcinosarcomas with lymph node metastasis are sometimes reported, but progression into the vasculature is very rare. We present a case of carcinosarcoma with unusual progression characteristics.

[Twenty-Five Cases of Locally Advanced Rectal Cancer That Underwent Laparoscopic Surgery after Preoperative Chemotherapy]

Several recent reports have described the administration of preoperative chemotherapy for locally advanced rectal cancer. In our hospital, preoperative chemotherapy based on oxaliplatin was administered for locally advanced rectal cancer with a tumor diameter of 5 cm or more and half semicircularity or more, and curative resection with laparoscopic surgery was performed after tumor shrinkage. We have experienced 25 cases that underwent preoperative chemotherapy for local advanced rectal cancer in our hospital from May 2012 to April 2016. No tumor increased in size during preoperative chemotherapy and there were no cases where R0 resection was impossible. In addition, no distant metastasis during chemotherapy was observed. Postoperative complications were observed in 3 cases(12%), and anastomotic leakage was observed in 1 case (4%), but conservative treatment was possible. Multidisciplinary treatment of preoperative chemotherapy and surgery should be considered as a therapeutic strategy for locally advanced rectal cancer, mainly in medical institutions without radiation treatment facilities.

Complete torsion of gallbladder following laparoscopic cholecystectomy: A case study

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Accurate preoperative diagnosis of gallbladder torsion is challenging because of the absence of clinical characteristics associated with it.

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Careful attention to symptoms during clinical presentation, including acute severe pain in the right quadrant and gallbladder deviation observed during radiological investigation, is required for accurate diagnosis of the condition.

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Upon confirmation of diagnosis, laparoscopic cholecystectomy would be the gold-standard treatment option rather than open cholecystectomy.

Introduction

Gallbladder torsion is mainly associated with a floating gallbladder. From an anatomical perspective, laparoscopic cholecystectomy is a more optimal treatment than open cholecystectomy.

Presentation of case

An 84-year-old woman visited the Onomichi General Hospital because of progressive pain in the right upper quadrant of her abdomen. Physical examination revealed a positive Murphy sign and peritoneal irritation. Laboratory data demonstrated that inflammatory marker levels were increased. Abdominal ultrasonography showed that blood flow in the cystic artery was reduced and the gallbladder was swollen. Abdominal contrast-enhanced computerized tomography indicated that the swollen gallbladder was modestly enhanced and the fundus was displaced under the midline and detached from the gallbladder bed. The cystic duct was twisted. Magnetic resonance cholangiopancreatography showed that the root of the cystic duct was unclear and the extrahepatic bile duct had V-shaped distortion. The gallbladder neck showed a tapering interruption with the common biliary duct. We made a preoperative diagnosis of gallbladder torsion. Accordingly, emergency laparoscopic cholecystectomy was performed. The intraoperative findings included a dark swollen gallbladder that was twisted in the counterclockwise direction. The patient was discharged without any postoperative complications on day 7.

Discussion

Combined acute onset of abdominal pain with characteristic radiological findings made it possible to precisely diagnose gallbladder torsion.

Conclusion

Laparoscopic cholecystectomy can be the gold standard treatment for gallbladder torsion after a preoperative diagnosis is made.