Kentaro Inoue

Objective: No ideal training system exists for pancreaticoduodenectomy (PD). We developed an educational system that uses an objective structured assessment of technical skills. Methods: This retrospective observational study was conducted using the data of consecutive trainees and patients who underwent PD from 2007 to 2013 in Kansai Medical University Hospital. The total score on the task checklist (21 parameters) for measuring technical performance during PD by self assessment and instructor assessment was compared between junior (JN) and hepatobiliary pancreatic (HBP) trainees at a university hospital. Surgical outcomes of 303 PDs (2007–2013) were also compared among JN trainees, HBP trainees, and instructors, and the present position of the trainees was investigated. This study was approved by the institutional review board of Kansai Medical University on May 26, 2020. Results: The self-assessment score on the task checklist was significantly higher for the HBP trainees than for the JN trainees on all parts of PD (P < .001). The discrepancy between self-assessment and instructor assessment improved in 3 JN trainees after experience with the first 5 PDs. Although total score curves rose to the right in the JN group, scores in the HBP group were stable, at 70 or higher, which correlated with the instructor assessment. The 90-day and 30-day mortality rates were 1.6% and 0.3%, respectively. Mortality and morbidity after PD did not differ between the JN and HBP trainees or between the instructors and the trainees. Four of 10 trainees became board-certified expert surgeons of the Japanese Society of Hepatobiliary Pancreatic Surgery. Conclusion: These results indicated good construct validity of the task checklist system. This program was safely and effectively implemented in terms of surgical outcomes and final outcomes of trainees becoming board-certified expert surgeons.

Objective: The aim of this study was to compare the scar quality associated with different types of subcuticular suture techniques: running or interrupted. Summary of Background Data: Subcuticular suture is a preferred skin closure method even in gastrointestinal surgery. Two methods for subcuticular suture are used: running or interrupted sutures. Methods: Inclusion criteria were as follows: age ≥ 20 years; American Society of Anesthesiologists performance status 1 to 3; histologically proven adenocarcinoma of the stomach; no evidence of distant metastases or disease considered unresectable; no prior upper abdominal surgery; no uncontrolled infections, diabetes, or cardiac disease; and adequate renal function. Patients were randomly assigned to running subcuticular suture or interrupted subcuticular suture. Scar areas were calculated using a digital photograph calculator at about 7 months after surgery. The observer scar assessment scale (OSAS) was used for scar assessment. Results: Between April 10, 2009, and February 28, 2012, 220 patients were enrolled into this study and 201 patients were evaluated. There was no difference in scar area between the interrupted group and the running group [0.97 cm2 (95% CI: 0.73–1.21) in the interrupted group and 1.17 cm2 (95% CI: 0.91–1.42, P = 0.27) in the running group]. Three observers performed the OSAS, for which no significant difference was detected across the closure groups. Conclusions: There were no significant differences in cosmetic outcomes between running and interrupted subcuticular sutures. The final decision about the choice of method should be made balancing surgeon needs (time-saving with running) and surgeon techniques (running might be difficult).

A woman in her 50s visited our hospital in February 2015 with a complaint of dull abdominal pain in the right lower quadrant. She had a medical history of appendectomy for appendicitis in her 20s. Computed tomography(CT)revealed a tumor 90 mm in diameter near the ileocecum. Elective surgery was planned under the suspicion of gastrointestinal tumor, malignant lymphoma, or ileal cancer. She was emergently hospitalized 1 day earlier than scheduled because of high fever and severe abdominal pain. CT revealed that the tumor had increased to 120 mm in diameter without free air. Her white blood cell count was not elevated, and her symptoms improved readily with medical treatment. Thus, we performed the operation as scheduled. A tumor with a dark red recess on the surface had invaded the transverse colon intraoperatively, and a small amount of purulent ascites was present at the pouch of Douglas. We performed ileocecal resection with partial transverse colectomy. Histopathological examination led to the diagnosis of desmoid tumor in the mesentery of the terminal ileum. The surgical margins were negative for tumor cells. The tumor surface around the recess showed peritonitis, and the ascites showed no bacteria or tumor cells. The patient had been doing well without recurrence after discharge. Some cases of desmoid tumor with peritonitis have been reported, but most were caused by tumor penetration into the intestinal tract. We report herein a rare case of intra-abdominal desmoid tumor with abacterial peritonitis.

The present study was conducted to determine whether active hexose correlated compound (AHCC), a functional food extracted from cultured basidiomycetes, possesses the potential to attenuate adverse events in unresectable pancreas ductal adenocarcinoma (PDAC) patients receiving chemotherapy. Unresectable PDAC patients receiving gemcitabine treatment (GEM) as the first-line chemotherapy were prospectively divided into 2 groups according to AHCC intake (AHCC group, n = 35) or not (control group, n = 40). The patients in the AHCC group ingested 6.0 g of AHCC for 2 mo. Hematological and nonhematological toxicity was compared between the AHCC and control groups. The C-reactive protein (CRP) elevation and albumin decline of the AHCC group were significantly suppressed as compared to the control group during the GEM administration (P = 0.0012, P = 0.0007). Patients in the AHCC group had less frequency of taste disorder caused by GEM (17% vs. 56%, P = 0.0007). Frequency of grade 3 in the modified Glasgow Prognostic Score (mGPS) during chemotherapy was found significantly less in the AHCC group (14%) than the control group (53%, P = 0.0005). AHCC intake can be effective in reducing the adverse events associated with chemotherapy and may contribute to maintaining the QOL of patients with PDAC during GEM administration.

609 Background: The purpose of this study was to characterize histological tumor regression grade (TRG) to colorectal liver metastases (CLM) treated with preoperative chemotherapy followed by liver surgery, and to evaluate whether TRG correlates with radiological response and prognosis. Methods: This study included 30 patients with CLM treated by surgical resection after preoperative chemotherapy with oxaliplatin- or irrinotecan-based regimens with or without molecular target agents. TRG was determined by the amount of fibrosis and necrosis replaced from tumor cells, ranging TRG 0 (0%), 1 (1-24%), 2 (25-50%), 3 (51-99%), and 4 (100%). Results: TRG 0, 1, 2, 3, and 4 were observed in 0%, 6.7%, 10.0%, 66.7%, and 16.6% of the patients, respectively. There were no relations between TRG and regimen, including molecular target agents. As shown in the table, radiological response was not significantly correlated with TRG. Patients with histological major response (TRG 3+4) had better prognosis (MST; TRG 1+2 vs. 3+4: 20.0 vs. 50 months, P= 0.007), and a multivariate analysis identified histological major response as an independent good prognostic factor. Conclusions: In this analysis, histological TRG predicted survival after preoperative chemotherapy and resection for CLM. Preoperative radiological response could not evaluate TRG. [Table: see text]

A 67-year-old man underwent distal gastrectomy via the Billroth Ⅱ method (B-Ⅱ) for a duodenal ulcer. He presented with appetite loss and nausea in May 2014. Gastrointestinal endoscopy revealed wall thickness around gastrojejunostomy and the gastric mucosal fold. Biopsy and re-biopsy revealed a group 2 tumor. Laparotomy for diagnosis was performed because of stenosis and tumor progression. Intraoperative frozen section examination revealed adenocarcinoma in the lymph nodes of the jejunum. Residual gastrectomy with reconstruction using the Roux-en-Y method was performed for residual gastric cancer. Histopathological findings revealed pT4a, pN0, pM1 for the tumor in the lymph nodes of the jejunum, pStage Ⅳ. A distorted gastrojejunostomy site and the presence of anastomotic strictures are important for the rapid diagnosis of residual gastric cancer.

We occasionally require surgical treatment for postoperative adhesion ileus. One patient had adhesion ileus 14 times in 14 years after distal gastrectomy and Billroth-Ⅰreconstruction for gastric cancer. He underwent laparoscopic adhesiolysis for a small bowel obstruction that adhered to the entire surface. Another patient experienced adhesion ileus 7 times in 1.5 years after distal gastrectomy and Billroth-Ⅰreconstruction for gastric cancer. He underwent laparoscopic adhesiolysis for a small bowel obstruction adhering to the scar and the retroperitoneum. After laparoscopic treatment, he underwent an open operation for ischemic colitis but no small bowel obstruction was found. Laparoscopic adhesiolysis was found to be useful in both cases.

Pain is a sensation associated with subjective factors, making it difficult to measure and assess. Currently, there is no widely accepted method of objectively assessing pain, and therefore subjective assessments such as the Visual Analogue Scale (VAS) are generally used. The PainVision system has been developed for the quantitative analysis of pain and comparison of postoperative pain intensity. In this study, we investigated whether postoperative pain could be objectively assessed using this system in digestive tract surgery patients. Pain scores were measured with the VAS, the PainVision system, and the short-form McGill Pain Questionnaire in patients undergoing open or laparoscopic hepatectomy, open or laparoscopic gastrectomy, and laparoscopic cholecystectomy. As measured using the PainVision system, postoperative pain intensity was lower in patients who underwent laparoscopic surgery compared with open hepatectomy. In open hepatectomy patients, pain intensity measured by the PainVision system was significantly lower on postoperative days (POD) 7 and 10 than on POD 1. Preemptive use of nonsteroidal antiinflammatory drugs significantly reduced postoperative pain in open hepatectomy patients. The results showed that PainVision effectively quantifies pain intensity after digestive tract surgery. Objective assessment of postoperative pain may lead to earlier mobility and improved quality of life.