Colonic gallstone ileus treated by a transanal ileus tube followed by spontaneous gallstone dislodgement: A case report

A 71‐year‐old obese woman was referred to our hospital with lower left abdominal pain. Computed tomography showed a 46 mm elliptic calcification lodged in the sigmoid‐descending colon junction (SDJ), which had been detected 5 years prior but was not within the gall bladder at presentation. Therefore, we diagnosed colonic gallstone ileus with obstructive colitis caused by a gallstone. Colonoscopy revealed a smooth gallstone impacted at the sigmoid‐descending colon junction, which was not fixed and could be pushed proximally with the endoscope. Dislodgement of the stone was unsuccessful with both a large polypectomy snare and a retrieval basket. Considering the high risk of surgery, we chose a non‐surgical treatment strategy for obstructive colitis. Accordingly, a transanal ileus tube was placed to drain the proximal portion of the gallstone. The drainage of the colon by the ileus tube was satisfactory; the proximal colon was decompressed, ameliorating the obstructive colitis. Five days after tube placement, a colonoscopy revealed spontaneous passage of the gallstone into the rectum where it was finally removed. Cholecystocolonic fistula formation was confirmed by magnetic resonance imaging. We decided to surgically close the cholecystocolonic fistula to prevent future retrograde biliary infections. The surgery used a surgical stapler and was successful, with an uneventful postoperative course. Since radical surgical treatment of colonic gallstones and cholecystoenteric fistulas has a risk of postoperative morbidity and mortality, this case illustrates the importance of thoroughly considering nonsurgical interventions and surgeries for the safe treatment of colonic gallstone ileus.

Delayed Presentation and Referral Time from General Practitioners Contribute to Increased Complicated Appendicitis during the Initial COVID-19 Pandemic Period in Japan

Objectives

This study aims to investigate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the situation of acute appendicitis (AA) with respect to patients' and general practitioners' behaviors in a general community hospital in Japan.

Methods

The surgical outcomes and periods from symptom onset to medical presentation besides practitioners' referral time for consecutive AA patients were compared between the control (January 2016 to March 2020) and COVID-19 periods (April 2020 to April 2021).

Results

Eighty-three patients who underwent emergency surgery for AA were reviewed. Complicated appendicitis significantly increased in the COVID-19 period (63.6% vs. 31.2%, P = 0.023). In the COVID-19 period, the time from symptom onset to the medical presentation (2.2 vs. 0.9 days, P < 0.001) was significantly longer than in the control period. Among the patients who first presented to a general practitioner, the referral time from the practitioner to our hospital was significantly longer in the COVID-19 period (1.6 vs. 0.7 days, P = 0.017). Furthermore, among patients with a fever of higher than 38°C at medical presentation, the time from symptom onset to medical presentation was significantly longer in the COVID-19 period (3.0 vs. 0.7 days, P = 0.015). There was no difference in severe postoperative complications.

Conclusions

Hesitation to seek surgical treatment for AA was seen in both the patients and practitioners in the COVID-19 period. The delay in surgical treatment presumably led to the increase in severe AA. In a pandemic era, timely care for emergent conditions is a crucial challenge.

Proposal of a Novel Index of Abdominal Compliance and the Association With Postoperative Pain After Laparoscopic Inguinal Hernia Repair

BACKGROUND

In laparoscopic surgery, low pneumoperitoneum pressure is reported to reduce pain, which suggests that easing abdominal expansion is crucial for less postoperative pain. However, although abdominal compliance (AC) is associated with the degree of abdominal expansion, the role of AC in pain by pneumoperitoneum is unknown. In this study, we devised a novel index as a surrogate of AC to evaluate the association between AC and postoperative pain in laparoscopic inguinal hernia repair.

MATERIALS AND METHODS

We reviewed 83 patients who underwent elective transabdominal preperitoneal repair from 2019 to 2021 at Heisei Memorial Hospital. Insufflation pressure was set to low pressure (8 mm Hg). The abdominal compliance index [ACI; insufflated intra-abdominal volume (L)/body surface area (m2)] was utilized to evaluate the association between AC and postoperative pain.

RESULTS

ACI was evaluated in 30 patients. Median ACI was 1.53 (1.00 to 2.48) L/m2. Although there was no difference in the average body constitution, the high ACI group (n=15) had significantly higher intra-abdominal volume at 8 mm Hg pressure, compared with the low ACI group (n=15) (3.1 vs. 2.1 L, P<0.0001). The high ACI group had significantly higher pain than the low ACI group on the day of surgery (2.0 vs. 1.0, P=0.006) and the day after (0.8 vs. 0.3, P=0.007). In addition, 46.7% of the patients in the high ACI group experienced pneumoperitoneum-associated pain, whereas patients in the low ACI group experienced incision pain only. Additional analgesics were administered in 53.3% of the high ACI group, compared with 33.3% in the low ACI group.

CONCLUSIONS

AC was suggested to be a vital factor of postoperative pain after laparoscopic inguinal hernia repair. Patients with high AC may be susceptible to higher pain by pneumoperitoneum, even in low-pressure settings.

Suppression of amyloid-β secretion from neurons by cis-9, trans-11-octadecadienoic acid, an isomer of conjugated linoleic acid

Two common conjugated linoleic acids (LAs), cis-9, trans-11 CLA (c9,t11 CLA) and trans-10, cis-12 CLA (t10,c12 CLA), exert various biological activities. However, the effect of CLA on the generation of neurotoxic amyloid-β (Aβ) protein remains unclear. We found that c9,t11 CLA significantly suppressed the generation of Aβ in mouse neurons. CLA treatment did not affect the level of β-site APP-cleaving enzyme 1 (BACE1), a component of active γ-secretase complex presenilin 1 amino-terminal fragment, or Aβ protein precursor (APP) in cultured neurons. BACE1 and γ-secretase activities were not directly affected by c9,t11 CLA. Localization of BACE1 and APP in early endosomes increased in neurons treated with c9,t11 CLA; concomitantly, the localization of both proteins was reduced in late endosomes, the predominant site of APP cleavage by BACE1. The level of CLA-containing phosphatidylcholine (CLA-PC) increased dramatically in neurons incubated with CLA. Incorporation of phospholipids containing c9,t11 CLA, but not t10,c12 CLA, into the membrane may affect the localization of some membrane-associated proteins in intracellular membrane compartments. Thus, in neurons treated with c9,t11 CLA, reduced colocalization of APP with BACE1 in late endosomes may decrease APP cleavage by BACE1 and subsequent Aβ generation. Our findings suggest that accumulation of c9,t11 CLA-PC/LPC in neuronal membranes suppresses production of neurotoxic Aβ in neurons.

Significance of umbilical trocar size and intra-abdominal pressure on postoperative pain after transabdominal preperitoneal repair for inguinal hernia

INTRODUCTION

Laparoscopic inguinal hernia repair is reported to be associated with lower postoperative pain than open repair. However, in the actual clinical setting, some patients experience relatively severe pain. This study aimed to elucidate surgical factors that affect pain after transabdominal preperitoneal (TAPP) repair.

METHODS

We evaluated 199 patients who underwent elective TAPP for inguinal hernia from 2014 to 2019 in Heisei Memorial Hospital. The umbilical trocar size was changed from 12 to 5 mm from October 2017. The pneumoperitoneum intra-abdominal pressure was changed from 10 to 8 mmHg from 2019. Postoperative pain scores and analgesics were compared between patients who were grouped according to trocar size and intra-abdominal pressure, as well as 80 patients who received open repair.

RESULTS

Patients with a 12 mm trocar had significantly higher pain than open repair patients (P < .0001). Patients with a 5 mm umbilical trocar and 8 mm Hg intra-abdominal pressure had significantly lower pain than a 12 mm trocar (P = .025) and did not significantly differ with pain after open repair. Analgesic use significantly decreased in patients using a 5 mm trocar than 12 mm (P = .002).

CONCLUSION

Umbilical trocar size and pneumoperitoneum intra-abdominal pressure were significantly associated with post-TAPP pain. Using a 5 mm umbilical trocar and 8 mm Hg intra-abdominal pressure achieved pain levels as comparatively low as open repair.

New insight into the association between bile infection and clinically relevant pancreatic fistula in patients undergoing pancreatoduodenectomy

BACKGROUND

The association between bacterial infection and clinically relevant postoperative pancreatic fistula (CR-POPF) after pancreatoduodenectomy (PD) has not been fully elucidated.

METHODS

Microbiological data for intraoperative bile culture (BC) and drain culture on postoperative day 4 (DC) were collected. The study population was classified into the following three groups: P1 (positive BC and DC), P2 (positive BC and negative DC), and N (negative BC). A total of 209 patients (P1: 38, P2: 72, and N: 99) who underwent PD between May 2013 and May 2018 met the inclusion criteria of the study.

RESULTS

The rate of CR-POPF was significantly higher in the P1 group (34.2%) than in the P2 (12.5%; P = .007) and N groups (14.1%; P = .008). Between P1 and P2 groups, a significant difference was observed in the proportion of Enterococcus faecalis grown in BC (42.1% vs 4.2%; P < .001). Multivariable logistic regression analysis showed that the presence of E faecalis in bile was independently associated with CR-POPF.

CONCLUSIONS

The detection of both bile and postoperative abdominal fluid infections can be more accurate in predicting CR-POPF. Furthermore, the presence of E faecalis in bile may serve as a novel surrogate marker for CR-POPF.

Effects of Nutrition Therapy in Older Stroke Patients Undergoing Rehabilitation: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically review evidence on the effects of nutrition therapy in older stroke patients undergoing rehabilitation and identify its effectiveness using meta-analysis.

METHODS

PubMed (MEDLINE), EMBASE (via Dialog), Cochrane Central Register of Controlled Trial, World Health Organization International Clinical Trials Registry Platform and Ichu-shi Web were searched for relevant articles. Randomized controlled trials investigating the effects of nutrition therapy compared to control interventions in older stroke patients undergoing rehabilitation were considered eligible. The primary outcome was activities of daily living (ADL), and secondary outcomes were all-cause mortality, infections, pneumonia incidence, disability level, walking ability, fall, stroke recurrence, and quality of life. The risk of bias of each trial was assessed using the Cochrane Collaboration Tool, and the quality of the body of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach.

RESULTS

Eight randomized controlled trials with a total of 5484 participants were included in the meta-analysis. The meta-analysis for ADL showed no significant effects (mean difference, 4.16; 95% confidence interval [CI], -0.88 to 9.20; I2=53%, low-quality evidence). The meta-analyses for secondary outcomes revealed a significant effect of reduced infections (risk ratio, 0.65; 95% CI, 0.51 to 0.84; I2=0%; low-quality evidence), with no significant effects on the other outcomes.

CONCLUSION

Nutrition therapy had no statistically significant effect on ADL. However, it reduced the incidence of infections. More high-quality trials are warranted to clarify the effects of nutrition therapy in older stroke patients undergoing rehabilitation.

Transcriptomic analysis of immunoglobulin novel antigen receptor (IgNAR) heavy chain constant domains of brownbanded bamboo shark (Chiloscyllium punctatum)

Cartilaginous fish are the evolutionarily oldest group of animals which possess antibodies, T cell receptors and major histocompatibility complex (MHC). The immunoglobulin novel antigen receptor (IgNAR) found in cartilaginous fish is a heavy chain homodimer which lacks light chain. The presence of non-canonical cysteine molecules and lack of CDR2 region make it more significant. To synthesize active binding domains based on variable region of IgNAR (VNAR), knowledge on the constant region dynamics play a significant role. The IgNAR exhibit species variations in its primary sequence features; hence, this study was conducted to determine the IgNAR heavy chain constant domain of the brownbanded bamboo shark (Chiloscyllium punctatum). Peripheral blood leukocytes (PBL) isolated from adult bamboo sharks were used to synthesize a cDNA library. A total of four billion residues of two million sequences (average length 218.41 bp) were obtained. Assembled sequences were aligned with published cartilaginous fish IgNAR constant region sequences. Transcriptome analysis revealed two distinct types of IgNAR in the brownbanded bamboo shark. Also, constant-1 domain sequences displayed 13 unique sequences which may reflect the least number of IgNAR gene clusters. The phylogenetic analysis revealed the closest relationship with the nurse shark (Ginglymostoma cirratum) followed by the wobbegong shark (Orectolobus maculatus) which belong to the same order Orectolobiformes. Analysis of the constant domains of the brownbanded bamboo shark IgNAR revealed an evolutionarily conserved nature and this knowledge can be used to design primers for VNAR cloning. Furthermore, knowledge on the structural features in IgNAR constant domains that increase the stability could be useful in the process of stabilizing human immunoglobulins.

Mucocutaneous inflammation in the Ikaros Family Zinc Finger 1-keratin 5-specific transgenic mice

BACKGROUND

Our genomewide association study documented an association between cold medicine-related Stevens-Johnson syndrome/toxic epidermal necrolysis (CM-SJS/TEN) and Ikaros Family Zinc Finger 1 (IKZF1). Few studies examined biological and pathological functions of IKZF1 in mucosal immunity. We hypothesized that IKZF1 contributes to the mucocutaneous inflammation.

METHODS

Human skin and conjunctival tissues were obtained for immunohistological studies. Primary human conjunctival epithelial cells (PHCjECs) and adult human epidermal keratinocytes (HEKa) also used for gene expression analysis. We also generated K5-Ikzf1-EGFP transgenic mice (Ikzf1 Tg) by introducing the Ik1 isoform into cells expressing keratin 5, which is expressed in epithelial tissues such as the epidermis and conjunctiva, and then examined them histologically and investigated gene expression of the epidermis. Moreover, Ikzf1 Tg were induced allergic contact dermatitis.

RESULTS

We found that human epidermis and conjunctival epithelium expressed IKZF1, and in PHCjECs and HEKa, the expression of IKZF1 mRNA was upregulated by stimulation with polyI:C, a TLR3 ligand. In Ikzf1 Tg, we observed dermatitis and mucosal inflammation including the ocular surface. In contact dermatitis model, inflammatory infiltrates in the skin of Ikzf1 Tg were significantly increased compared with wild type. Microarray analysis showed that Lcn2, Adh7, Epgn, Ifi202b, Cdo1, Gpr37, Duoxa1, Tnfrsf4, and Enpp5 genes were significantly upregulated in the epidermis of Ikzf1 Tg compared with wild type.

CONCLUSION

Our findings support the hypothesis that Ikaros might participate in mucocutaneous inflammation.

[Huge Hepatocellular Carcinoma with Portal Vein and Inferior Vena Cava Thrombi Treated with Curative Liver Resection and Perioperative Hepatic Arterial Infusion Chemotherapy - A Case Report]

The prognosis of hepatocellular carcinoma(HCC)with main portal vein(MPV)and/or the inferior vena cava(IVC)tumor thrombi is dismal. The management of HCC with severe tumor thrombus is complicated. In this study, we report a case of HCC with tumor thrombi in the MPV and IVC that was successfullytreated via liver resection and perioperative hepatic arterial infusion chemotherapy(HAI). A 68-year-old man was referred to our institution to treat huge HCC lesion in the right lobe of the liver. Abdominal computed tomography(CT)revealed a tumor(12 cm in diameter)in the right hepatic lobe and tumor thrombi in the MPV and IVC. The patient was initiallytreated with HAI(cisplatin 100mg/body). After 3 courses of HAI, the tumor was dramaticallyreduced in size, and the thrombus in the IVC had disappeared; however, the thrombus in the MPV remained. Therefore, we performed right hepatectomy, wedge resection of the IVC, combined resection of the MPV, and portal vein reconstruction. The histopathological findings of the resected specimen revealed that viable cancer cells were observed onlyin an 8×8mm lesion. Subsequently, HAI was performed as adjuvant therapy for 3 courses. The patient died of other causes 2 years 3 months after surgery. There was no sign of recurrence at the time of death. This case suggested that perioperative HAI and liver resection mayrepresent an effective treatment strategyfor HCC with severe tumor thrombus.

[A Case of Advanced Hepatocellular Carcinoma, Its Disease Progression Could Be Controlled by Multimodal Treatment]

The patient was a 73-year-old man, diagnosed with advanced huge hepatocellular carcinoma with a tumor thrombus extending into the inferior vena cava and extrahepatic metastases. Radiation therapy(50 Gy)was applied for the bone metastases, primary tumor, and tumor thrombus, and the patient received a cisplatin transcatheter arterial infusion(100mg/ body, 5 courses). Sorafenib was administered orally once the local lesion was under control. The tumor showed a partial response according to the RECIST criteria, but the tumor thrombus in the inferior vena cava almost disappeared. The presence of a tumor thrombus in the inferior vena cava must be regarded as an oncologic emergency. Acisplatin transcatheter arterial infusion and radiation therapy may be treatment options for unresectable cases.

The FGF23/KLOTHO Regulatory Network and Its Roles in Human Disorders

The functions of Klotho (KL) are multifaceted and include the regulation of aging and mineral metabolism. It was originally identified as the gene responsible for premature aging-like symptoms in mice and was subsequently shown to function as a coreceptor in the fibroblast growth factor (FGF) 23 signaling pathway. The discovery of KL as a partner for FGF23 led to significant advances in understanding of the molecular mechanisms underlying phosphate and vitamin D metabolism, and simultaneously clarified the pathogenic roles of the FGF23 signaling pathway in human diseases. These novel insights led to the development of new strategies to combat disorders associated with the dysregulated metabolism of phosphate and vitamin D, and clinical trials on the blockade of FGF23 signaling in X-linked hypophosphatemic rickets are ongoing. Molecular and functional insights on KL and FGF23 have been discussed in this review and were extended to how dysregulation of the FGF23/KL axis causes human disorders associated with abnormal mineral metabolism.

Phase I study assessing the feasibility of the triple combination chemotherapy of SOXIRI (S-1/oxaliplatin/irinotecan) in patients with unresectable pancreatic ductal adenocarcinoma

BACKGROUND

The objective of this study was to determine the recommended dose (RD) of a biweekly S-1, oxaliplatin, and irinotecan (SOXIRI) regimen in patients with unresectable pancreatic ductal adenocarcinoma.

METHODS

This phase I study used a traditional "3+3" dose-escalation design, with four dose levels. A dose-escalation schedule consisted of two doses of S-1 (60 and 80 mg/m(2) twice daily) for 2 weeks in alternate-day administration, three doses of irinotecan (125, 150, and 180 mg/m(2)) on day 1, and a single dose of oxaliplatin (85 mg/m(2)) on day 1 of a 2-week cycle. Dose-limiting toxicities (DLTs) were assessed in the first four cycles to determine the maximum tolerated dose. This clinical study was registered at UMIN000014339.

RESULTS

Fifteen patients received this regimen (median, eight cycles; range 4-12). At dose level 3 (S-1, 80 mg/m(2); irinotecan, 150 mg/m(2)), 2/6 patients experienced DLTs of grade 3 fatigue and grade 4 neutropenia. At dose level 4, all three patients experienced DLTs: grade 3 fatigue (n = 1) and grade 4 neutropenia (n = 2). The RD was 80, 85, and 150 mg/m(2) of S-1, oxaliplatin, and irinotecan, respectively. We found the following: response rate, 47 %; disease control rate, 80%; median progression-free survival, 6.7 months; overall survival, 13.4 months.

CONCLUSIONS

The SOXIRI regimen's RD is 80, 85, and 150 mg/m(2) of S-1, oxaliplatin, and irinotecan, respectively.

National Comprehensive Cancer Network Resectability Status for Pancreatic Carcinoma Predicts Overall Survival

BACKGROUND

The aim of this study was to evaluate the validity of preoperative resectability status, as defined by the National Comprehensive Cancer Network (NCCN), from the viewpoint of overall survival.

METHODS

A total of consecutive 704 patients with pancreatic head carcinoma who underwent pancreatoduodenectomy with upfront surgery at seven Japanese hospitals between 2001 and 2012 were evaluated retrospectively. According to the NCCN definition of preoperative resectability status, tumors were divided into resectable tumors without vascular contact (R group), resectable tumors with portal or superior mesenteric vein (PV/SMV) contact of ≦180° (R-PV group), borderline resectable(BR) tumors with PV/SMV contact of >180° (BR-PV group), and BR tumors with arterial contact (BR-A group). The relationship between the NCCN definition of preoperative resectability status and overall survival was analyzed.

RESULTS

Of the 704 patients, 389, 114, 145, and 56 were classified into the R group, the R-PV group, the BR-PV group, and the BR-A group, respectively. Overall survival of the BR-PV and BR-A groups was significantly worse than that of the R group and R-PV groups (P < 0.05), although there was no significant difference in overall survival between the R group and the R-PV group (P = 0.310). Multivariate analysis revealed that PV/SMV contact of >180° (P = 0.008) and arterial contact (P < 0.001) were independent prognostic factors of overall survival.

CONCLUSION

From the viewpoint of overall survival, the NCCN definition of preoperative resectability status was valid.

Three percent diquafosol ophthalmic solution as an additional therapy to existing artificial tears with steroids for dry-eye patients with Sjögren's syndrome

PURPOSE

To investigate the long-term results of 3% diquafosol ophthalmic solution as an alternative therapy to existing ophthalmic solutions, including topical immunosuppression, for the treatment of dry eye in patients with Sjögren's syndrome.

METHODS

This study involved 14 female dry-eye patients (mean age: 62.4 years) with Sjögren's syndrome who insufficiently responded to their current therapy. In all patients, 3% diquafosol ophthalmic solution was administered six times daily for 12 months in substitution for artificial tears and sodium hyaluronate ophthalmic solution. Their use of corticosteroid eye drops remained unchanged from that prior to the treatment with diquafosol sodium. The subjective symptoms assessed, and ocular signs including tear meniscus radius and the tear film breakup time, and ocular-surface epithelial damage score were examined at 1, 2, 3, 4, 5, 6, 9, and 12 months after initiating treatment.

RESULTS

Among the subjective symptoms, significant improvement was obtained in dryness at 2 months post treatment, in eye fatigue at 1, 2, 3, 4, and 12 months post treatment, and in pain at 1, 2, 6, and 12 months post treatment. Difficulty in opening the eye, foreign body sensation, and redness were also significantly ameliorated at various time-points. The tear meniscus radius and the tear film breakup time were significantly improved throughout the observation period, and the corneal epithelial staining scores were significantly decreased at 3 months post treatment.

CONCLUSIONS

In dry-eye patients with Sjögren's syndrome, treatment with 3% diquafosol ophthalmic solution improved both symptoms and signs, and that effectiveness was maintained for 12 months.

Postoperative prognosis of pancreatic cancer with para-aortic lymph node metastasis: a multicenter study on 822 patients

BACKGROUND

The prognosis of pancreatic cancer patients with metastatic para-aortic lymph node (PALN) has been reported to be extremely poor. In general, PALN metastasis has been considered as a contraindication for pancreatic resection. The aim of this study was to reevaluate the postoperative prognostic value of PALN metastasis in pancreatic cancer and to determine the validity of pancreatic surgery.

METHODS

Retrospective multicenter analysis of 882 patients who have undergone curative-intent pancreatic resection with pathological evaluation of PALNs for pancreatic ductal adenocarcinoma between 2001 and 2012 was conducted. Clinicopathological data and outcomes were evaluated with univariate and multivariate analysis.

RESULTS

In total, 102 (12.4 %) patients had positive metastasis in PALN. Patients with metastatic PALN had significantly poorer survival than those without (17 vs. 23 months; p < 0.001). Multivariable analysis of 822 patients identified adjuvant chemotherapy, primary tumor status, regional lymph node metastasis, portal vein invasion, pre- and post-operative serum CA19-9 levels, and tumor grade as independent prognostic factors. In contrast, PALN metastasis did not have a significant prognostic value. Furthermore, the multivariate prognostic analysis in patients with PALN metastasis revealed that adjuvant chemotherapy and the number of metastatic PALN were significantly associated with long-term survival. Lung metastasis as initial recurrence was observed more often in patients with PALN metastasis in comparison with those without.

CONCLUSIONS

Some pancreatic cancer patients with metastatic PALN may survive for longer than expected after pancreatectomy. Adjuvant chemotherapy and the number of metastatic PALN were critical factors for long-term survival of those patients.

Importance of resectability status in neoadjuvant treatment for pancreatic cancer

BACKGROUND

Much attention has been paid to neoadjuvant treatment (NAT) as a new strategy especially for borderline resectable pancreatic cancer (BRPC). However, the optimal indication of NAT remains undetermined.

METHODS

We analyzed 248 patients with pancreatic cancer (PC). One hundred resectable tumors were classified as R group. Sixty-nine tumors with venous involvement were classified as BR-P group, while 31 tumors with arterial involvement were classified as BR-A group. Ninety-nine patients received NAT. Furthermore, 48 unresectable locally advanced PC served as controls (LAPC group). Among them, 11 patients received adjuvant surgery afterwards (Ad-surg group).

RESULTS

The overall median survival time in the R, BR-P and BR-A groups was 45.3, 24.8 and 16.8 months. In the R and BR-P groups, patients treated with NAT had a better prognosis than those without. In contrast, NAT had no impact on prognosis in the BR-A group. Patients treated with NAT in the BR-P, but not BR-A group, had a better prognosis than patients in the LAPC group. Furthermore, patients in the Ad-surg group had a significantly better prognosis than patients in the BR-A group.

CONCLUSIONS

Borderline resectable pancreatic cancer with venous involvement, but without arterial involvement, may be a good indication for NAT. Our data highlight the importance of preoperative resectability assessment to evaluate the indication and efficacy of NAT.

Potential role of surgical resection for pancreatic cancer in the very elderly

BACKGROUND

There is increasing need to evaluate the surgical indication of pancreatic cancer in very elderly patients. However, the available clinical data are limited, and the optimal treatment is still controversial. The aim of this study was to evaluate the benefit of pancreatic resection in pancreatic cancer patients over the age of 80.

METHODS

Between 2005 and 2012, 26 octogenarian patients who received pancreatic resection and 20 who received chemotherapy for pancreatic cancer were retrospectively reviewed. Clinicopathological factors, chemotherapy administration status, and survival were compared. Univariate and multivariate analysis of prognostic factors for survival was performed.

RESULTS

Postoperative major complication rate was 8%, with no mortality. The one-year survival rate and median survival time of the surgery and chemotherapy groups were 50% and 45%, and 12.4 months and 11.7 months, respectively (P = 0.263). Of the 26 resected cases, 6 completed the planned adjuvant chemotherapy treatment course. The median survival time of those 6 completed cases was significantly longer than that of the 20 not completed cases (23.4 versus 10.0 months, P = 0.034). Furthermore, a multivariate analysis of the 26 resected cases showed that distant metastasis (HR 3.206, 95%CI 1.005-10.22, P = 0.049) and completion of the planned adjuvant therapy (HR 4.078, 95%CI 1.162-14.30, P = 0.028) were independent prognostic factors of surgical resection.

CONCLUSIONS

Surgical resection was safe, but not superior to chemotherapy for pancreatic cancer in octogenarians. In the very elderly, only selected patients may benefit from pancreatic resection.

Clinical significance of CD155 expression in human pancreatic cancer

BACKGROUND/AIM

CD155 is expressed in many types of human cells and has diverse functions. We herein evaluated the clinical importance of CD155 in pancreatic cancer.

MATERIALS AND METHODS

We investigated CD155 expression in 134 patients with pancreatic cancer, and evaluated the correlations of CD155 with prognosis, tumor immunity and angiogenesis. Furthermore, CD155 functions were examined.

RESULTS

CD155 expression was abundant in pancreatic cancer tissues. Patients with high CD155 expression had poorer postoperative prognosis than those with low expression. Multivariate analysis indicated that CD155 expression had a significant independent prognostic value. Tumor CD155 expression inversely correlated with the presence of tumor-infiltrating lymphocytes. Furthermore, it significantly positively correlated with vascular endothelial growth factor expression and intra tumoral microvessel density. In addition, silencing of CD155 inhibited proliferation, and induced cell-cycle arrest at G2/M phase in pancreatic cancer cells.

CONCLUSION

CD155 may play a critical role through both immunological and non-immuno logical mechanisms in pancreatic cancer and may be a therapeutic target for this intractable malignancy.

Nectin-4 expression contributes to tumor proliferation, angiogenesis and patient prognosis in human pancreatic cancer

BACKGROUND

Nectin-4 belongs to the nectin family that has diverse physiological and pathological functions in humans. Recent studies have also suggested some roles for Nectin-4 in several human cancers. However, the precise roles and clinical relevance of Nectin-4 in tumors are largely unknown.

METHODS

Nectin-4 expression was investigated in 123 patients with pancreatic cancer by immunohistochemistry. Furthermore, we investigated the association of Nectin-4 in pancreatic cancer with tumor proliferation, angiogenesis and immunity by using immunohistochemistry and siRNA interference method.

RESULTS

Patients with high Nectin-4 expression had poorer postoperative prognosis than those with low expression. Importantly, multivariate analysis indicated that Nectin-4 expression had a significant independent prognostic value in pancreatic cancer (HR = 1.721, 1.085-2.730; P = 0.021). Tumor Nectin-4 expression was significantly correlated with Ki67 expression. In addition, siRNA-mediated gene silencing of Nectin-4 significantly inhibited the cell proliferation in human pancreatic cancer cells, Capan-2 and BxPC-3. Furthermore, Nectin-4 expression was also positively correlated with VEGF expression and intratumoral microvessel density. However, there were no significant correlations of tumor Nectin-4 expression with tumor-infiltrating T cells.

CONCLUSION

Nectin-4 is a significant prognostic predictor, and may play a critical role in pancreatic cancer. Nectin-4 may be novel therapeutic target for pancreatic cancer.

Characterization and antimicrobial susceptibility of motile aeromonads isolated from freshwater ornamental fish showing signs of septicaemia

A total of 74 phenotypically identified presumptive motile Aeromonas isolates recovered from septicaemic freshwater ornamental fish in Sri Lanka were genetically characterized by sequencing of rpoD and gyrB genes. rpoD/gyrB phylogeny confirmed only 53 isolates as Aeromonas, among which A. veronii was the predominant species (79.2%), followed by A. hydrophila (7.5%), A. caviae (5.7%), A. jandaei (1.9%), A. dhakensis (3.8%) and A. entero pelogenes (1.9%). The aeromonads confirmed by sequencing were further subjected to 16S rDNA PCR-RFLP which substantiated sequencing results for 83% of isolates. Fingerprinting of A. enteropelogenes (n = 42) using ERIC-PCR revealed no dominant clones, and the majority were genetically distinct. All isolates were screened by PCR for 7 virulence determinant genes (aer, act, ast, alt, fla, ser, exu) and 2 integrase encoding genes (intI1, intI2). Each isolate contained ≥3 of the virulence genes tested for, with a heterogeneous distribution. Of the isolates, 77% harboured the intI1 gene, while none had intI2. In vitro antimicrobial susceptibility testing showed highest resistances towards tetracycline (58.5%) and erythromycin (54.7%). Our results indicate the diverse range of aeromonads that could potentially be associated with motile aeromonad septicaemia in ornamental fish. This is the first isolation of A. dhakensis from a septicaemic ornamental fish since its original description from the same host.

DPP and DSP are Necessary for Maintaining TGF-β1 Activity in Dentin

Porcine dentin sialophosphoprotein (DSPP) is the most abundant non-collagenous protein in dentin. It is processed by proteases into 3 independent proteins: dentin sialoprotein (DSP), dentin glycoprotein (DGP), and dentin phosphoprotein (DPP). We fractionated DPP and DSP along with TGF-β activity by ion exchange (IE) chromatography from developing pig molars and measured their alkaline phosphatase (ALP)-stimulating activity in human periodontal (HPDL) cells with or without TGF-β receptor inhibitor. We then purified TGF-β-unbound or -bound DPP and DSP by reverse-phase high-performance liquid chromatography (RP-HPLC) using the ALP-HPDL system. The TGF-β isoform bound to DPP and DSP was identified as being TGF-β1 by both ELISA and LC-MS/MS analysis. We incubated carrier-free human recombinant TGF-β1 (CF-hTGF-β1) with TGF-β-unbound DPP or DSP and characterized the binding on IE-HPLC using the ALP-HPDL system. When only CF-hTGF-β1 was incubated, approximately 3.6% of the ALP-stimulating activity remained. DPP and DSP rescued the loss of TGF-β1 activity. Approximately 19% and 10% of the ALP stimulating activities were retained by the binding of TGF-β to DPP and DSP, respectively. The type I collagen infrequently bound to CF-hTGF-β1. We conclude that both DPP and DSP help retain TGF-β1 activity in porcine dentin.

Alignment of crystal orientations of the multi-domain photonic crystals in Parides sesostris wing scales

It is known that the wing scales of the emerald-patched cattleheart butterfly, Parides sesostris, contain gyroid-type photonic crystals, which produce a green structural colour. However, the photonic crystal is not a single crystal that spreads over the entire scale, but it is separated into many small domains with different crystal orientations. As a photonic crystal generally has band gaps at different frequencies depending on the direction of light propagation, it seems mysterious that the scale is observed to be uniformly green under an optical microscope despite the multi-domain structure. In this study, we have carefully investigated the structure of the wing scale and discovered that the crystal orientations of different domains are not perfectly random, but there is a preferred crystal orientation that is aligned along the surface normal of the scale. This finding suggests that there is an additional factor during the developmental process of the microstructure that regulates the crystal orientation.

Structural color of a lycaenid butterfly: analysis of an aperiodic multilayer structure

We investigated the structural color of the green wing of the lycaenid butterfly Chrysozephyrus brillantinus. Electron microscopy revealed that the bottom plate of the cover scale on the wing consists of an alternating air-cuticle multilayer structure. However, the thicknesses of the layers were not constant but greatly differed depending on the layer, unlike the periodic multilayer designs often adopted for artificial laser-reflecting mirrors. The agreement between the experimentally determined and theoretically calculated reflectance spectra led us to conclude that the multilayer interference in the aperiodic system is the primary origin of the structural color. We analyzed optical interference in this aperiodic system using a simple analytical model and found that two spectral peaks arise from constructive interference among different parts of the multilayer structure. We discuss the advantages and disadvantages of the aperiodic system over a periodic one.

Quantification of allergic and irritant patch test reactions using ImageJ

BACKGROUND/AIMS

It is often difficult to differentiate between allergic and irritant patch test reactions by visual inspection. The purpose of this study was to test an image analysis-based method that differentiates between the two reactions by quantifying the degree of erythema at the patch test site.

METHODS

A total of 172 Japanese patients were patch-tested with sodium lauryl sulfate (SLS) and nickel sulfate, followed by digital photography and visual evaluation of the patch test areas by dermatologists at 48 and 72 h. The digital images were converted to erythema index (EI) images by image processing, and changes in ΔEI (the difference in the EI between the patch test site and the adjacent normal skin) values were analyzed.

RESULTS

The ΔEI was significantly increased at 72 h relative to that at 48 h for positive nickel sulfate reactions (P < 0.0001), while no significant difference in the ΔEI was found for SLS reactions.

CONCLUSION

Using image analysis, allergic patch test reactions may be distinguished from irritant reactions by evaluating the change in the degree of erythema at 48 and 72 h.

Turn-over orbital septal flap and levator recession for upper-eyelid retraction secondary to thyroid eye disease

BACKGROUND

A turn-over septal flap has been reported as a spacer for levator lengthening in a single case report. This study reports the preliminary outcomes of this technique in a series of patients with upper-lid retraction (ULR) associated with thyroid eye disease (TED) causing symptomatic exposure keratopathy (EK).

METHODS

Retrospective, multicenter study of 12 eyelids of 10 patients with TED undergoing a transcutaneous levator-lengthening technique using the reflected orbital septum (OS) as a spacer. Change in palpebral aperture (PA) and contour, position of the skin crease (SC), symptoms of EK, and complications were recorded.

RESULTS

The average age was 47.5 years. Two patients were excluded, as their septa were found to be very thin at surgery. At an average of 13 months postoperatively, the PA was reduced by 2.5 mm on average (P<0.001) and was within 1 mm of the contralateral eyelid in 11 cases (92%); the position of the SC was within 1 mm of the desired position in all cases. EK resolved in all cases. Complications included one case of overcorrection and one case of recurrent lateral flare.

CONCLUSIONS

The turn-over orbital septal flap technique may be a viable option as an autogenous spacer for the treatment of ULR in TED. This technique may be possible in cases where the OS has been opened by previous surgery but may not be feasible in patients in whom the septum is very thin.

Significant efficacy of new transcatheter arterial chemoembolization technique for hepatic metastases of pancreatic neuroendocrine tumors

BACKGROUND/AIM

The liver is the most frequent site of metastasis of pancreatic neuroendocrine tumors (PNETs). Moreover, hepatic metastasis is a strong prognostic factor for patients with advanced PNETs and is often difficult to treat and cure.

PATIENTS AND METHODS

We employed our recently developed new transcatheter arterial chemoembolization technique using a fine-powder formulation of cisplatin mixed with degradable starch microspheres (DSM) for the treatment of unresectable hepatic metastases from PNET in five consecutive patients.

RESULTS

A total of 24 sessions of TACE was performed. The responses were complete response in one, partial response in three, and stable disease in one patient. All patients were alive at the time of analysis with a median survival of 36 (3-70) months after the initial treatment of TACE. There were no severe toxicities or adverse effects.

CONCLUSION

This new treatment induced a significant effect on hepatic metastases of PNET. The response rate was very high, which has not been achieved even by recent new agents. Our findings may warrant further prospective studies of this therapy.

Effects of pancrelipase on nonalcoholic fatty liver disease after pancreaticoduodenectomy

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

[Resection of the remnant pancreas for recurrent pancreatic cancer after distal pancreatectomy-a case report]

The standard treatment for metastatic pancreatic cancer is chemotherapy. The effect of surgical resection for localized recurrence in the remnant pancreas after pancreatectomy for pancreatic cancer is unknown, but is reported to have a moderately good outcome in a few reports. We herein report a case of curative resection for recurrence in the remnant pancreas, 24 months after distal pancreatectomy for pancreatic cancer. A 71-year-old man was diagnosed with pancreas tail cancer. Neoadjuvant treatment with chemoradiotherapy[ weekly full-dose gemcitabine(GEM) and radiation therapy 50 Gy/25 Fr] was followed by distal pancreatectomy. Postoperative adjuvant therapy with hepatic arterial infusion of 5-FU and systemic GEM therapy was completed. Twenty-four months after surgery, follow-up computed tomography scan results showed a lesion of 15-mm diameter in the remnant pancreas. Resection of the remnant pancreas was performed. The pathological findings showed moderately differentiated adenocarcinoma, morphologically similar to the primary pancreatic cancer. Six months following surgery, there are no signs of recurrence at present.

Correlation with larval body size of mRNA levels of growth hormone, growth hormone receptor I and insulin-like growth factor I in larval torafugu Takifugu rubripes

The full-length of insulin-like growth factor (IGF) complementary (c)DNAs encoded by igf-I and igf-II from torafugu pufferfish Takifugu rubripes were cloned in the present study. The deduced amino acid sequences of the two genes showed c. 80% identity each with those of Igf-I and Igf-II from other teleosts, respectively. Two growth hormone (GH) receptors, ghr1 and ghr2, were also cloned in silico using the T. rubripes Fugu genome database. The transcripts of T. rubripes igf-I were detected in slow muscle, heart, skin, gill, liver and intestine but not in fast muscle, spleen and testis of adult fish, whereas those of igf-II were found in all tissues examined. Subsequently, the accumulated messenger (m)RNA levels of igf-I and igf-II were investigated in an F(2) population derived from a male of an apparent fast-growing T. rubripes strain and a wild female T. rubripes together with those of other growth-related genes encoding Gh, Ghr1 and Ghr2, and with those of prolactin (Prl) and leptin (Lep) previously reported. The accumulated mRNA levels of igf-I, gh and ghr1 were significantly correlated to growth rate at larval stages in the population, but not for those of igf-II, prl, ghr2 and lep. Although it is unclear whether or not this phenotype is directly related to the heredity of the fast-growing strain, the findings suggest that the expression of igf-I, gh and ghr1 is involved in the regulation of growth rate at larval stages in T. rubripes.

Advanced Ceramics Sintering Using High-Power Millimeter-Wave Radiation

The results of ceramics sintering experiments using high-power millimeter-wave radiation are reported. Sintering of silicon nitride with 5%Al2O3 and 5%Y2O3 was performed in a multi-mode applicator using a 10-kW 28-GHz gyrotron in CW operation. It was found that the silicon nitride samples sintered with 28 GHz radiation at 1650'C for 30 min reached to as high as theoretical density (TD), while the conventionally sintered samples at 1700°C for 60 min resulted in the density as low as 90% TD. Focusing experiments of millimeter-wave radiation from the high-power pulsed 60-GHz gyrotron have been performed using a quasi-optical antenna system (two-dimensional ellipso-parabolic focusing antenna system) to demonstrate the feasibility of the power density of as high as 100 kW/cm2. Typical heating characteristics using the focused beam were made clear for this system. It was found that the densification of yttria-stabilized zirconia (ZrO2-8mol%Y2O3) samples to as high as 97% TD was obtained from the sintering with focused 60 GHz beam in pulse operation with a 10-ms pulse duration at a 0.5Hz repetition. The densification temperature for the zirconia could be lowered by 200°C than that expected conventionally.