Impacts of different pancreatic resection ranges on endocrine function in Suncus murinus

BACKGROUND Surgical intervention involving the pancreas can lead to impaired glucose tolerance and other types of endocrine dysfunction.The scope of pancreatectomy and whether it includes the ventral pancreas are the key factors in the development of postoperative diabetes.The ventral and dorsal pancreases are almost separated in Suncus murinus(S.murinus).AIM To investigate the effects of different extents of pancreatic resection on endocrine function in S.murinus.METHODS Eight-week-old male S.murinus shrews were randomly divided into three experimental groups according to different pancreatic resection ranges as follows:ventral pancreatectomy(VPx)group;partial pancreatectomy(PPx)group;subtotal pancreatectomy(SPx)group;and a sham-operated group.Postprandial serum insulin,glucagon-like peptide-1(GLP-1),pancreatic polypeptide(PP),and somatostatin(SST)levels,as well as food intake,weight,blood glucose,and glucose tolerance were regularly measured for each animal.RESULTS S.murinus treated with PPx and SPx suffered from varying degrees of impaired glucose tolerance,but only a small proportion of the SPx group developed diabetes.Only S.murinus in the SPx group showed a significant decrease in food intake accompanied by severe weight loss,as well as a significant increase in postprandial serum GLP-1 levels.Postprandial serum PP levels decreased in both the VPx and PPx groups,but not in the SPx group.Postprandial serum SST levels decreased in both VPx and PPx groups,but the decrease was marginal.CONCLUSION Severe weight loss after pancreatectomy may be related to loss of appetite caused by compensatory elevation of GLP-1.PP and GLP-1 may play a role in resisting blood glucose imbalance.

A nomogram to preoperatively predict 1-year disease-specific survival in resected pancreatic cancer following neoadjuvant chemoradiation therapy

Objective: This study aimed to develop a nomogram to predict the 1-year survival of patients with pancreatic cancer who underwent pancreatectomy following neoadjuvant treatment with preoperatively detectable clinical parameters. Extended pancreatectomy is necessary to achieve complete tumor removal in borderline resectable and locally advanced pancreatic cancer. However, it increases postoperative morbidity and mortality rates, and should be balanced with potential benefit of long-term survival.Methods: The medical records of patients who underwent pancreatectomy following neoadjuvant treatment from January 2005 to December 2016 at Severance Hospital were retrospectively reviewed. Medical records were collected from five international institutions from Japan and Singapore for external validation.Results: A total of 113 patients were enrolled. The nomogram for predicting 1-year disease-specific survival was created based on 5 clinically detectable preoperative parameters as follows: age(year), symptom(no/yes), tumor size at initial diagnostic stage(cm), preoperative serum carbohydrate antigen(CA) 19-9 level after neoadjuvant treatment(<34/≥34 U/m L), and planned surgery [pancreaticoduodenectomy(PD)(pylorus-preserving PD)/distal pancreatectomy(DP)/total pancreatectomy]. Model performance was assessed for discrimination and calibration.The calibration plot showed good agreement between actual and predicted survival probabilities;the the Greenwood-Nam-D’Agostino(GND) goodness-of-fit test showed that the model was well calibrated(χ~2=8.24,P=0.5099). A total of 84 patients were used for external validation. When correlating actual disease-specific survival and calculated 1-year disease-specific survival, there were significance differences according to the calculated probability of 1-year survival among the three groups(P=0.044).Conclusions: The developed nomogram had quite acceptable accuracy and clinical feasibility in the decision-making process for the management of pancreatic cancer.

Diffusion-weighted imaging might be useful for reactive lymphoid hyperplasia diagnosis of the liver: A case report

BACKGROUND Reactive lymphoid hyperplasia(RLH)of the liver is a rare liver lesion.It is considered difficult to differentiate radiologically from hepatocellular carcinoma,metastatic liver tumor and other pathologies.CASE SUMMARY A 54-year-old woman presented to our hospital with RLH of the liver.The patient had a diagnosis of metastatic carcinoma of the liver from an unknown origin and subsequently underwent partial hepatectomy.However,histopathological analysis revealed RLH.The lesion showed perinodular enhancement in the arterial phase on contrast-enhanced computed tomography and magnetic resonance imaging.On diffusion-weighted imaging(DWI),we encountered linear hyperintensity along the portal tract consecutive to the liver lesion,which is a new characteristic radiologic finding.This finding corresponded to the lymphoid cell infiltration of the portal tract.Furthermore,there was strongly restricted diffusion on the apparent diffusion coefficient map.We used these characteristic radiologic findings to diagnose the lesion as a lymphoproliferative disease.CONCLUSION The linear hyperintensity consecutive to the liver lesion on DWI provided additional valuable diagnostic information.

Evaluation of novel slim biopsy forceps for diagnosis of biliary strictures: Single-institutional study of consecutive 360 cases(with video)

AIM To evaluate the feasibility and reliability of endoscopic transpapillary bile duct biopsy for the diagnosis of biliary strictures.METHODS A total of 360 patients(241 men) who underwent endoscopic retrograde cholangiopancreatography for biliary strictures with biopsy from April 2012 to March 2016 at Tokyo Medical University Hospital were retrospectively reviewed. This study was approved by our Institutional Review Board(No. 3516). Informed consent was obtained from all individual participants included in this study. The biopsy specimens were obtained using a novel slim biopsy forceps(Radial Jaw 4P, Boston Scientific, Boston, MA, United States).RESULTS The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 69.6%, 100%, 100%, 59.1%, and 78.8%, respectively. The sensitivity was 75.6% in bile duct cancer, 64% in pancreatic cancer, 61.1% in gallbladder cancer, and 57.1% in metastasis. In bile duct cancer, a lower sensitivity was observed for perihilar bile duct stricture(68.7%) than for distal bile duct stricture(83.1%). In terms of the stricture lengths of pancreatic cancer, gallbladder cancer, and metastasis, a longer stenosis resulted in a better sensitivity. In particular, there was a significant difference between pancreatic cancer and gallbladder cancer(P < 0.05). One major complication was perforation of the extrahepatic bile duct with bile leakage. CONCLUSION Endoscopic transpapillary biopsy alone using novel slim biopsy forceps is feasible and reliable, but restrictive. Biopsy should be performed in consideration of the stricture level, stricture length, and cancer type.

Computed tomography virtual endoscopy with angiographic imaging for the treatment of type Ⅳ-A choledochal cyst

Type Ⅳ-A choledochal cysts (CCs) are a congenital biliary anomaly which involve dilatation of the extrahepatic and intrahepatic bile ducts. We present the case of a 30-year-old woman with type Ⅳ-A CC, on whom threedimensional computed tomography (3D CT) and virtual endoscopy were performed. 3D CT revealed partial dilatation in the posterior branch of the intrahepatic bile duct and a relative stricture between it and the extrahepatic bile duct. Virtual endoscopy showed that this stricture was membrane-like and separated from the surrounding blood vessels. Based on these image findings, complete cyst resection, bile duct plasty for the stricture, and hepaticojejunostomy were safely performed. To the best of our knowledge, there are no reports of imaging by virtual endoscopy of the biliary tract which show the surrounding blood vessels running along the bile duct.

International consensus statement on robotic pancreatic surgery

The robotic surgical system has been applied to various types of pancreatic surgery. However, controversies exist regarding a variety of factors including the safety, feasibility, efficacy, and cost-effectiveness of robotic surgery. This study aimed to evaluate the current status of robotic pancreatic surgery and put forth experts' consensus and recommendations to promote its development. Based on the WHO Handbook for Guideline Development, a Consensus Steering Group* and a Consensus Development Group were established to determine the topics, prepare evidence-based documents, and generate recommendations. The GRADE Grid method and Delphi vote were used to formulate the recommendations. A total of 19 topics were analyzed. The first 16 recommendations were generated by GRADE using an evidence-based method (EBM) and focused on the safety, feasibility, indication, techniques, certification of the robotic surgeon, and cost-effectiveness of robotic pancreatic surgery. The remaining three recommendations were based on literature review and expert panel opinion due to insufficient EBM results. Since the current amount of;evidence was low/meager as evaluated by the GRADE method, further randomized controlled trials (RCTs) are needed in the future to validate these recommendations.

Safety and feasibility of laparoscopic pancreatoduodenectomy

Laparoscopic pancreaticoduodenectomy(LPD)has been safely performed by experts with favorable surgical outcomes.However,the feasibility of LPD remains controversial.LPD is generally considered a challenging operation that requires advanced laparoscopic techniques.In particular,pancreatic reconstruction can be safely performed by only laparoscopic experts.Thus,guidelines created by LPD experts are valuable in indicating the future direction of LPD.Qin et al.developed practical guidelines regarding the safety and feasibility of LPD with 28 international experts from eight countries(1).To create these guidelines,the first summit on minimally invasive pancreatico-biliary surgery was held in Wuhan,China,to promote the development of LPD.Based on a systematic literature review and expert opinions,16 statements were created by the experts.These statements provide useful guidelines not only for surgical trainees who will attempt LPD but also for specialized surgeons.This expert consensus will contribute to the safe implementation of LPDs in the future.