Katsuhisa Hirano

Lumbar hernia following extreme lateral interbody fusion (XLIF) with iliac crest bone harvest is an uncommon but clinically relevant complication. A man in his 70s presented with left flank discomfort and a bulge 3 years after XLIF for lumbar spinal canal stenosis, performed via a route using the left anterior superior iliac spine. CT showed herniation of the descending colon through an abdominal wall defect. Laparoscopic intraperitoneal onlay mesh repair was undertaken with nerve‐sparing fixation. Recovery was uneventful, and no recurrence or postoperative neuropathic pain was observed at 6 months. This case underscores the potential for abdominal wall weakening when XLIF is combined with iliac crest harvest and the value of laparoscopic repair with nerve‐sparing fixation. Meticulous fascial closure and long‐term follow‐up may reduce the risk of delayed lumbar hernia.

Background/Objectives: Appropriate biomarkers are necessary for early diagnosis and multidisciplinary treatment of pancreatic ductal adenocarcinoma (PDAC). In recent years, the clinical utility of circulating tumor cells (CTC) as biomarkers for various can-cers has been reported; however, their detection rate in PDAC remains low, and clinical evidence is not yet established. CTC detection methods with high reliability and per-formance are essential for clarifying the importance of CTC in patients with PDAC. Methods: A total of 5 mL peripheral blood samples were collected from 38 patients newly diagnosed with PDAC and 17 healthy controls. Negatively enriched cells were immunofluorescently stained with EpCAM-phycoerythrin and cell surface vi-mentin-fluorescein isothiocyanate (CSV). Images were automatically captured using an all-in-one fluorescence microscope. Cellular regions were detected from these images, and the average luminance of the cellular regions was calculated. A total of 9086 and 1071 cell images were obtained from patients with PDAC and healthy controls, respec-tively. Results: In the EpCAM assay, a threshold that included 95% of healthy individuals was optimal for distinguishing patients with PDAC from healthy controls, with a sensi-tivity, specificity, and area under the curve of 0.74, 0.76, and 0.84, respectively. At this threshold, the CTC-positivity rate in patients with PDAC was 76.3%. Conversely, the CSV assay failed to demonstrate a valid threshold to distinguish patients with PDAC from healthy controls. No significant differences were found between CTC and clini-copathological features among patients with PDAC. Conclusions: The method using high-resolution image scanning has the potential to identify CTC with greater objectiv-ity by quantifying cell luminance values.

Background/Objectives: Appropriate biomarkers are necessary for early diagnosis and multidisciplinary treatment of pancreatic ductal adenocarcinoma (PDAC). In recent years, the effectiveness of circulating tumor cells (CTCs) as biomarkers for various cancers has been reported; however, their detection rate in PDAC remains low, and sufficient evidence are not yet established. CTC detection methods with high reliability and performance are essential for clarifying the importance of CTCs in patients with PDAC. Methods: A total of 5 mL peripheral blood samples were collected from 38 patients newly diagnosed with PDAC and 17 healthy controls. Negative enriched cells were immunoflu-orescently stained with EpCAM-phycoerythrin and cell surface vimentin-fluorescein isothiocyanate(CSV). Images were automatically captured using an all-in-one fluorescence microscope. Cellular regions were detected from the captured images and the average lu-minance of the cellular regions was calculated. A total of 9086 and 1071 cell images were obtained from patients with PDAC and healthy controls, respectively. Results: In the Ep-CAM assay, a threshold that included 95% of healthy individuals was optimal for distin-guishing patients with PDAC from healthy controls, with a sensitivity, specificity, and AUC of 0.74, 0.76, and 0.84, respectively. At this threshold, the CTC-positivity rate in pa-tients with PDAC was 76.3%. Conversely, the CSV assay failed to demonstrate a valid threshold to distinguish patients with PDAC from healthy controls. No significant differ-ences were found between CTC and clinicopathological features among patients with PDAC. Conclusions: This method using high resolution image scanning has the potential to identify CTCs with greater objectivity by quantifying cell luminance values.

Introduction Pancreatic cancer may invade the colon, resulting in bowel obstruction and requiring the patient to undergo colostomy. Open surgery is often the treatment of choice for patients with colostomy, but we successfully and safely performed a robot-assisted distal pancreatectomy. Case presentation The patient was a 55-year-old woman diagnosed with pancreatic tail cancer invading the left kidney and transverse colon. She underwent a transverse colostomy because of a colonic obstruction associated with colon invasion. She then received gemcitabine plus nab-paclitaxel, followed by modified FOLFIRINOX. After imaging confirmed tumour shrinkage, a robot-assisted distal pancreatectomy, transverse colon resection, and colostomy closure were planned. A partial colon resection, including colostomy, was performed first. As a result, robot-assisted surgery was possible with the usual field of view and port placement. During this procedure, the pancreatic tail, spleen, transverse colon (including invasive pancreatic cancer lesion), left adrenal gland, and part of the left kidney were resected en bloc. Finally, reconstruction of the colon was performed. The patient recovered well postoperatively and was discharged on postoperative day 9 with no complications. The patient has been recurrence-free for 2 months after surgery. Conclusion This case demonstrates that robot-assisted distal pancreatectomy is feasible in selected patients with pancreatic cancer and prior colostomy.

With advancements in multidisciplinary treatments such as chemotherapy and radiation therapy, there have been an increasing number of recent reports regarding surgical interventions for unresectable pancreatic ductal adenocarcinoma with metastasis (UR-M PDAC), known as “conversion surgery”. Olaparib, which is one of the treatment options, has been approved as a maintenance treatment in patients with UR-M PDAC and germline BRCA mutations who achieve disease control after a platinum-based regimen such as modified FOLFIRINOX (mFFX). A 49-year-old male patient was diagnosed with PDAC in the pancreatic body-tail. The 1st staging laparoscopy (SL) revealed hepatic metastases in both lobes and positive peritoneal lavage cytology. A germline BRCA2 mutation was considered, and mFFX was introduced and continued for 8 courses, followed by 8 months of olaparib. The initially elevated levels of duke pancreatic monoclonal antigen type 2 and carcinoembryonic antigen subsequently returned to normal, and CT revealed more than 60% shrinkage of the primary tumor. The 2nd SL revealed the disappearance of multiple hepatic metastases and negative conversion of peritoneal lavage cytology, so we performed chemoradiotherapy with olaparib to ensure an antitumor effect and surgical margin negativity, followed by distal pancreatectomy with celiac axis resection. Histopathological findings revealed R0 resection and a pathological complete response (pCR). Adjuvant olaparib treatment was administered for 10 months starting 2 months after surgery, and the patient has remained alive without recurrence for 2 years after surgery. We report the very rare case of a patient with BRCA-positive PDAC with multiple liver metastases who underwent conversion surgery after treatment with mFFX and olaparib, achieved a pCR, and has remained recurrence-free for 2 years.

Background: Squamous cell carcinoma (SCC) of the breast is a rare form of breast cancer, accounting for approximately 0.1% of all breast cancers. It is known for its rapid tumor growth and poor prognosis with no established treatment. Case presentation: A 56-year-old woman was diagnosed with breast SCC with axillary, supraclavicular and internal thoracic lymph node metastases. She received neoadjuvant chemotherapy (NAC) with dose-dense doxorubicin and cyclophosphamide (AC) followed by dose-dense paclitaxel (PTX). This treatment resulted in a pathological complete response (pCR) after breast-conserving surgery. The patient was then treated with radiotherapy. She remained free of recurrence for three years postoperatively. Conclusions: We report a rare case of breast SCC treated with preoperative dose-dense chemotherapy, resulting in pCR and allowing breast-conserving surgery.

Background: The pectoralis major musculocutaneous flap (PMMF) is a pedicled flap often used as a reconstruction option in head and neck surgery, especially in cases with poor wound healing. However, applying PMMF after esophageal surgery is uncommon. We report here, the case of a successfully repaired refractory anastomotic fistula (RF) after total esophagectomy, by PMMF. Case presentation: A 73-year-old man had a history of hypopharyngolaryngectomy, cervical esophagectomy, and reconstruction using a free jejunal graft for hypopharyngeal carcinosarcoma at the age of 54. He also received conservative treatment for pharyngo-jejunal anastomotic leakage (AL), then postoperative radiation therapy. This time, he was diagnosed with carcinosarcoma in the upper thoracic esophagus; cT3rN0M0, cStageII, according to the Japanese Classification of Esophageal Cancer 12th Edition. As a salvage surgery, thoracoscopic total resection of the esophageal remnant and reconstruction using gastric tube via posterior mediastinal route was performed. The distal side of the jejunal graft was cut and re-anastomosed with the top of the gastric tube. An AL was observed on the 6th postoperative day (POD), and after 2 months of conservative treatment was then diagnosed as RF. The 3/4 circumference of the anterior wall of the gastric tube was ruptured for 6 cm in length, and surgical repair using PMMF was performed on POD71. The edge of the defect was exposed and the PMMF (10 × 5 cm) fed by thoracoacromial vessels was prepared. Then, the skin of the flap and the wedge of the leakage were hand sutured via double layers with the skin of the flap facing the intestinal lumen. Although a minor AL was observed on POD19, it healed with conservative treatment. No complications, such as stenosis, reflux, re-leakage, were observed over 3 years of postoperative follow-up. Conclusions: The PMMF is a useful option for repairing intractable AL after esophagectomy, especially in cases with large defect, as well as difficulties for microvascular anastomosis due to previous operation, radiation, or wound inflammation.

Purpose The efficiency and safety of routine intravenous administration of acetaminophen after highly invasive hepatobiliary pancreatic surgery remain unclear. In particular, there have been no studies focusing on pancreatoduodenectomy. The present study clarified its clinical utility for patients undergoing pancreatoduodenectomy. Methods We retrospectively collected 179 patients who underwent open pancreatoduodenectomy from 2015 to 2020. The analgesic effects and adverse events in patients with scheduled intravenous administration of acetaminophen were evaluated using propensity score matching. Results After 40 patients from each group were selected by propensity score matching, the postoperative liver function tests were not significantly different between the control and acetaminophen groups. No significant differences were found in the self-reported pain intensity score or postoperative nausea and vomiting; however, the rate of pentazocine use and the total number of additional analgesics were significantly lower in the acetaminophen group than in the control group (p = 0.003 and 0.002, respectively). Conclusion The scheduled intravenous administration of acetaminophen did not affect the postoperative liver function and had a good analgesic effect after pancreatoduodenectomy.

The survival rate in congenital diaphragmatic hernia (CDH) with complex heart defects is low. Although the current consensus on the indications for surgical repair of CDH without heart defects has improved surgical outcomes, the surgical indication for CDH with complex heart defects remains unclear. Herein, we report the perioperative management of a patient with univentricular circulation who underwent CDH repair. Thus, patients with CDH complicated by univentricular anatomy may tolerate surgery depending on preserved respiratory function.