Publications by authors named "Takashi Kamei"

180 Publications

The anti-angiogenic agent lenvatinib induces tumor vessel normalization and enhances radiosensitivity in hepatocellular tumors.

Med Oncol 2021 Apr 21;38(6):60. Epub 2021 Apr 21.

Department of Medical Physics, Graduate School of Medicine, Tohoku University, 2-1 Seiryo-machi, Aoba-ku, Sendai, 980-8575, Japan.

The evaluation of angiogenesis inhibitors requires the analysis of the precise structure and function of tumor vessels. The anti-angiogenic agents lenvatinib and sorafenib are multi-target tyrosine kinase inhibitors that have been approved for the treatment of hepatocellular carcinoma (HCC). However, the different effects on tumor vasculature between lenvatinib and sorafenib are not well understood. In this study, we analyzed the effects of both drugs on vascular structure and function, including vascular normalization, and investigated whether the normalization had a positive effect on a combination therapy with the drugs and radiation using micro X-ray computed tomography with gold nanoparticles as a contrast agent, as well as immunohistochemical analysis and interstitial fluid pressure (IFP) measurement. In mice subcutaneously transplanted with mouse HCC cells, treatment with lenvatinib or sorafenib for 14 days inhibited tumor growth and reduced the tumor vessel volume density. However, analysis of integrated data on vessel density, rates of pericyte-covering and perfused vessels, tumor hypoxia, and IFP measured 4 days after drug treatment showed that treatment with 3 mg/kg of lenvatinib significantly reduced the microvessel density and normalized tumor vessels compared to treatment with 50 mg/kg of sorafenib. These results showed that lenvatinib induced vascular normalization and improved the intratumoral microenvironment in HCC tumors earlier and more effectively than sorafenib. Moreover, such changes increased the radiosensitivity of tumors and enhanced the effect of lenvatinib and radiation combination therapy, suggesting that this combination therapy is a powerful potential application against HCC.
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http://dx.doi.org/10.1007/s12032-021-01503-zDOI Listing
April 2021

Stomatin‑like protein 2 induces metastasis by regulating the expression of a rate‑limiting enzyme of the hexosamine biosynthetic pathway in pancreatic cancer.

Oncol Rep 2021 Jun 13;45(6). Epub 2021 Apr 13.

Department of Surgery, Tohoku University Graduate School of Medicine, Seiryo‑machi, Aoba‑ku, Sendai 980‑8574, Japan.

Stomatin‑like protein 2 (SLP‑2) is associated with poor prognosis in several types of cancer, including pancreatic cancer (PC); however, the molecular mechanism of its involvement remains elusive. The present study aimed to elucidate the role of this protein in the development of PC. Human PC cell lines AsPC‑1 and PANC‑1 were transfected by a vector expressing SLP‑2 shRNA. Analyses of cell proliferation, migration, invasion, chemosensitivity, and glucose uptake were conducted, while a mouse xenograft model was used to evaluate the functional role of SLP‑2 in PC. Immunohistochemical analysis was retrospectively performed on human tissue samples to compare expression between the primary site (n=279) and the liver metastatic site (n=22). Furthermore, microarray analysis was conducted to identify the genes correlated with SLP‑2. analysis demonstrated that cells in which SLP‑2 was suppressed exhibited reduced cell motility and glucose uptake, while analysis revealed a marked decrease in the number of liver metastases. Immunohistochemistry revealed that SLP‑2 was increased in liver metastatic sites. Microarray analysis indicated that this protein regulated the expression of glutamine‑fructose‑6‑phosphate transaminase 2 (GFPT2), a rate‑limiting enzyme of the hexosamine biosynthesis pathway. SLP‑2 contributed to the malignant character of PC by inducing liver metastasis. Cell motility and glucose uptake may be induced via the hexosamine biosynthesis pathway through the expression of GFPT2. The present study revealed a new mechanism of liver metastasis and indicated that SLP‑2 and its downstream pathway could provide novel therapeutic targets for PC.
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http://dx.doi.org/10.3892/or.2021.8041DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8042670PMC
June 2021

Prognostic value of an inflammation-based nutritional score for patients with initially unresectable pancreatic adenocarcinoma undergoing conversion surgery following chemo-/radiotherapy.

Surg Today 2021 Apr 7. Epub 2021 Apr 7.

Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.

Purpose: To clarify the prognostic value of the preoperative nutrition status of patients undergoing conversion surgery (CS) for initially unresectable pancreatic adenocarcinoma (UR-PA).

Methods: The subjects of this retrospective study were 41 consecutive patients with initially UR-PA treated with chemo-/radiotherapy and subsequent CS between 2007 and 2014, at Tohoku University Hospital. The preoperative Glasgow Prognostic Score (GPS) was 0, conveying normal nutrition, in 25 patients (N group) and 1-2, conveying malnutrition, in 16 patients (M group). The clinicopathological factors influencing overall survival were defined by uni- and multivariate analyses.

Results: The M group had a significantly worse prognosis than the N group (median overall survival (mOS) 9.6 vs 40.7 months, p = 0.001). Multivariate analysis identified a GPS of 1-2 as an independent predictor of worse prognosis [hazard ratio (HR)3.437, p = 0.032], followed by CA19-9 elevation before CS (HR4.089, p = 0.012) and pathological lymph node metastases (HR2.314, p = 0.046). Patients who maintained a favorable nutritional status (GPS 0) during preoperative treatment had a significantly better prognosis, whereas those whose nutritional status deteriorated (elevated to GPS 1-2) had poorer survival (mOS 40.7 vs. 9.7 months, p = 0.003) CONCLUSION: Preoperative malnutrition status (GPS 1-2) is considered an independent predictor of a worse prognosis for patients undergoing CS for initially UR-PA.
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http://dx.doi.org/10.1007/s00595-021-02279-5DOI Listing
April 2021

Increased neutrophil-lymphocyte ratio predicts recurrence in patients with well-differentiated pancreatic neuroendocrine neoplasm based on the 2017 World Health Organization classification.

BMC Surg 2021 Mar 31;21(1):176. Epub 2021 Mar 31.

Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.

Background: The prognostic values of inflammation-based markers in well-differentiated pancreatic neuroendocrine neoplasms, diagnosed according to the new 2017 World Health Organization classification, have remained unclear. Therefore, we assessed the ability to predict the recurrence of such markers after curative resection in patients with these neoplasms.

Methods: Circulating/systemic neutrophil-lymphocyte, monocyte-lymphocyte, platelet-lymphocyte, and platelet-white cell ratios were evaluated in 120 patients who underwent curative resection for well-differentiated pancreatic neuroendocrine neoplasms without synchronous distant metastasis between 2001 and 2018. Recurrence-free-survival and overall survival were compared using Kaplan-Meier analysis and log-rank tests. Univariate or multivariate analyses, using a Cox proportional hazards model, were used to calculate hazard ratios with 95% confidence intervals.

Results: Univariate analysis demonstrated that preoperative neutrophil-lymphocyte ratio, tumor size, European Neuroendocrine Tumor Society TMN classification, 2017 World Health Organization classification, and venous invasion were associated with recurrence. The optimal preoperative neutrophil-lymphocyte ratio cut-off value was 2.62, based on receiver operating characteristic curve analysis. In multivariate analysis, a higher preoperative neutrophil-lymphocyte ratio (HR = 3.49 95% CI 1.05-11.7; P = 0.042) and 2017 World Health Organization classification (HR = 8.81, 95% CI 1.46-168.2; P = 0.015) were independent recurrence predictors.

Conclusions: The circulating/systemic neutrophil-lymphocyte ratio is a useful and convenient preoperative prognostic marker of recurrence in patients with well-differentiated pancreatic neuroendocrine neoplasm based on the 2017 World Health Organization classification.
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http://dx.doi.org/10.1186/s12893-021-01178-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011407PMC
March 2021

Novel candidate factors predicting the effect of S-1 adjuvant chemotherapy of pancreatic cancer.

Sci Rep 2021 Mar 22;11(1):6541. Epub 2021 Mar 22.

Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.

The collagen gel droplet-embedded drug sensitivity test (CD-DST) was revealed to be useful for predicting the effect of S-1 adjuvant chemotherapy for pancreatic ductal adenocarcinoma (PDAC). However, collection of an adequate number of PDAC cells is difficult due to the surrounding fibroblasts. Thus, the aim of this study was to discover novel biomarkers to predict chemosensitivity based on the CD-DST results. Proteomics analysis was performed using liquid chromatography tandem mass spectrometry (LC-MS/MS). Candidate proteins were validated in patients with 5-FU CD-DST results via immunohistochemistry (IHC). The relationships between the candidate proteins and the effect of the adjuvant S-1 were investigated via IHC. Among the 2696 proteins extracted by LC-MS/MS, C1TC and SAHH could accurately predict the CD-DST results. Recurrence-free survival (RFS) was significantly improved in the IHC-positive group compared with the IHC-negative group in both factors. The negative group did not show a significant difference from the group that did not receive S-1. The double-positive group was associated with significantly prolonged RFS compared to the no adjuvant chemotherapy group. C1TC and SAHH have been shown to be useful biomarkers for predicting 5-FU sensitivity as a substitute for the CD-DST in adjuvant chemotherapy for PDAC.
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http://dx.doi.org/10.1038/s41598-021-86099-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985196PMC
March 2021

Comparison of Edoxaban and Warfarin for the Treatment of Cancer-Associated Venous Thromboembolism - A Retrospective Observational Study.

Circ J 2021 Mar 9. Epub 2021 Mar 9.

Department of Surgery, Tohoku University Graduate School of Medicine.

Background: Because anticoagulant drugs for ambulatory patients with cancer-associated venous thromboembolism (CAT) are limited to warfarin and direct oral anticoagulants (DOACs) in Japan, it is important to assess the outcomes of both drugs.Methods and Results:We retrospectively assessed the outcomes of CAT patients who were treated with warfarin or edoxaban between 2011 and 2017. The assessment was limited to the duration of anticoagulant administration. CAT patients who did not receive anticoagulation therapy were also compared with the warfarin and edoxaban groups. We enrolled 111 CAT patients treated with warfarin (n=58, mean age 62.6 years, mean time in therapeutic range [TTR] % 61.1) or edoxaban (n=53, mean age 64.6 years). Although venous thromboembolism (VTE) recurred in 2 warfarin-treated patients, the 2 treatment groups were not significantly different (P=0.18). Bleeding during anticoagulation therapy occurred in 6 warfarin-treated patients (2 with major bleeding) and in 5 edoxaban-treated patients (no major bleeding) (P=1.0). The non-anticoagulation group (n=37) showed a high recurrence rate (P<0.01) compared with the anticoagulant group.

Conclusions: This study showed that warfarin and edoxaban are equally effective in preventing VTE recurrence and bleeding. However, warfarin control in CAT patients presented some difficulties. This study also demonstrated the efficacy of anticoagulant drugs, compared with no anticoagulation, for CAT patients to prevent VTE recurrence.
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http://dx.doi.org/10.1253/circj.CJ-20-0713DOI Listing
March 2021

Surgical resection for liver metastasis and local recurrence of pheochromocytoma 16 years after primary surgery: A case report.

Int J Surg Case Rep 2021 Apr 27;81:105712. Epub 2021 Feb 27.

Department of Surgery, Graduate School of Medicine, Tohoku University, Japan.

Introduction And Importance: Pheochromocytomas arise from the adrenal medulla and are rare. Pheochromocytomas metastasize to bone, lung and liver, and surgery might be the curative treatment. However, few cases are detected when they are resectable lesions because of difficulty in diagnosis and rapid growth. We herein report a patient who underwent resection of liver metastasis and local recurrence of pheochromocytoma.

Case Presentation: A 74-year-old woman visited our hospital for treatment for liver and retroperitoneal tumors. She had undergone left adrenal gland resection for pheochromocytoma 16 years earlier. Eleven years after primary surgery, breast cancer was diagnosed and resected. During the breast cancer follow-up, a liver tumor was identified with computed tomography. Breast cancer recurrence and metastasis were considered, so chemotherapy was administered first. However, the liver tumor gradually enlarged, and another lesion appeared in the retroperitoneum. The tumors were diagnosed as pheochromocytoma recurrence using I-metaiodobenzylguanidine scintigraphy, and she underwent resection of the local recurrence and liver metastasis. She was discharged on postoperative day 25 without complications, and no evidence of recurrence occurred more than 3.5 years postoperatively.

Clinical Discussion: All pheochromocytomas have metastatic potential; however, there are no reliable markers to predict malignancy. Early detection of recurrence by regular imaging and complete resection are important in the treatment. If the recurrence was oligometastasis and tumor growth is slow, surgical resection may be eligible.

Conclusion: A favorable outcome resulted from complete resection for liver metastasis and local recurrence of pheochromocytoma.
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http://dx.doi.org/10.1016/j.ijscr.2021.105712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7941035PMC
April 2021

The area under curve for time-course analysis parameters is associated with abdominal aortic aneurysms and the severity of peripheral artery disease in men.

Int J Cardiol Hypertens 2021 Mar 4;8:100080. Epub 2021 Feb 4.

Department of Internal Medicine and Rehabilitation Science, Graduate School of Medicine, Tohoku University.

Background: Abdominal aortic aneurysm (AAA) and peripheral artery disease (PAD) are associated with vascular endothelial dysfunction. To date, flow-mediated vasodilatation (FMD) and nitroglycerin-mediated vasodilatation (NMD) have been used to evaluate vascular function. Recently, parameters of time-course analysis have been proposed as useful evaluations for arteriosclerotic diseases. In this study, the correlation between the parameters of time-course analysis, to the degree of vascular endothelial damage in AAA and PAD, together with their applicability as a vascular function test, was investigated.

Methods: Brachial artery vasoreactivity was assessed in male patients with AAA (n = 150) and PAD (n = 50). The percentage change in peak diameters (ΔFMD and ΔNMD), the time to diameter change, the time to peak diameter from the diameter change, the blood flow decay time constant, the area under the curve (AUC), the maximum dilation rate and the extended time constant were measured.

Results: Among the groups of aneurysm diameter in AAA, the FMD-AUC was highly different (p = .01), while the ΔFMD was not significantly different (p = .36). Among the Fontaine stages in PAD, the FMD-AUC was inversely associated with severity (p = .01) although the ΔFMD was not significantly different (p = .71). Among the Fontaine stages, the NMD-AUC was also inversely associated with severity (p = .03) although the ΔNMD was not significantly different (p = .11).

Conclusion: This study suggests that FMD-AUC and NMD-AUC are useful for estimating vascular endothelial and vascular smooth muscle dysfunction, serving as supplementary markers for the diagnosis and evaluation of PAD and AAA.
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http://dx.doi.org/10.1016/j.ijchy.2021.100080DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893437PMC
March 2021

Preceding Systemic Chemotherapy for Patients with Pancreatic Ductal Adenocarcinoma with Positive Peritoneal Cytology Provides Survival Benefit Compared with Up-Front Surgery.

Ann Surg Oncol 2021 Feb 20. Epub 2021 Feb 20.

Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.

Background: The significance of surgical resection in pancreatic ductal adenocarcinoma (PDAC) with positive peritoneal cytology (PPC) is controversial. This study aimed to evaluate whether preceding chemotherapy could be beneficial for patients with PDAC with PPC.

Methods: Between 2017 and 2019, 34 consecutive PDAC patients diagnosed with PPC without distant metastasis were retrospectively reviewed. Twenty-three patients did not receive neoadjuvant treatment (NAT) and 11 received NAT. All patients received systemic chemotherapy after PPC was confirmed, and they underwent surgical resection if PPC turned negative. The treatment course, ratio of conversion surgery (CS), and prognosis were evaluated. Moreover, the prognosis of PPC patients who underwent up-front surgery without NAT between 2003 and 2016 was analyzed as a comparative cohort.

Results: The median survival time (MST) of the patients without NAT was 31.4 months. CS was performed in 52.2% of the patients. Patients who underwent CS had better prognoses than those who did not undergo CS (p = 0.005). The CS rate was significantly higher in resectable PDAC (78.5%) than in borderline/unresectable PDAC (11.1%) (p = 0.002). The prognosis of patients with resectable PDAC was improved with preceding chemotherapy compared with up-front surgery (MST 13.0 months; p = 0.016). After NAT, the CS rate was low (27.3%), and the MST was only 14.1 months.

Conclusions: As an initial treatment for PDAC patients with PPC, chemotherapy may lead to a favorable prognosis. Especially, resectable PDAC is associated with a greater chance of improved prognosis. Future studies are required to ascertain whether up-front surgery or preceding chemotherapy should be performed for these patients.
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http://dx.doi.org/10.1245/s10434-021-09718-0DOI Listing
February 2021

Salvage esophagectomy for local recurrent esophageal cancer after definitive chemoradiotherapy followed by photodynamic therapy: A case report.

Int J Surg Case Rep 2021 Mar 3;80:105617. Epub 2021 Feb 3.

Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.

Introduction: Photodynamic therapy (PDT) is performed as a salvage treatment for patients with residual or recurrent esophageal cancer after chemoradiotherapy (CRT). Although PDT is considered less invasive than salvage surgery, it is unclear how deep its effects are and whether it causes damage to adjacent tissues. Herein, we report a case of esophageal cancer treated with PDT followed by esophagectomy. In this case, we evaluated the effect of PDT on adjacent tissues based on surgical and pathological examination.

Presentation Of Case: A 58-year-old man with dysphagia was diagnosed with esophageal squamous cell carcinoma (SqCC; T1N0M0, Stage I) in the upper thoracic esophagus. He underwent definitive CRT with two courses of 5-fluorouracil and cisplatin every 4 weeks with 60 Gy of radiation. Twelve months after CRT, endoscopic examination revealed local recurrence, and PDT using talaporfin sodium was performed. The tumor recurred again 6 months after PDT, and robot-assisted thoracoscopic esophagectomy was performed as a definitive treatment. Tissues around the left side of the esophagus and thoracic duct were tightly adherent with severe fibrosis and were successfully removed by extended resection. Histopathological examinations showed that the esophageal wall and peri-esophageal tissue were replaced by fibrous tissue and this extended even beyond the tumor.

Discussion: The primary tumor was limited to the submucosal layer, and the target for irradiation had some longitudinal margins. Therefore, PDT can cause intense inflammation in tissues adjacent to the tumor.

Conclusions: It is necessary to consider the location when performing salvage esophagectomy after PDT.
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http://dx.doi.org/10.1016/j.ijscr.2021.02.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893415PMC
March 2021

Bleeding from jejunal varices formed at the Roux-en-Y jejunum site caused by the compression of the left renal vein after living donor liver transplantation with renoportal anastomosis.

Surg Case Rep 2021 Feb 6;7(1):43. Epub 2021 Feb 6.

Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, Japan.

Background: Renoportal anastomosis is an option for the portal vein reconstruction of a liver transplantation with grade 4 portal vein thrombosis and a splenorenal shunt. Here, we report the case of gastrointestinal bleeding who underwent living donor liver transplantation (LDLT) with renoportal anastomosis.

Case Presentation: Six-year-old female patient who underwent LDLT with renoportal anastomosis at 1 year of age had severe anemia with normal liver function during the follow-up period. The varices at the Roux-en-Y jejunum were considered the source of bleeding, and the compression of the left renal vein, which is known as a cause of Nutcracker syndrome, seemed to induce venous hypertension through the splenorenal shunt, which might induce the formation of the varices. She underwent percutaneous transhepatic sclerotherapy of the varices, and the anemia improved at her last follow-up, 6 months after sclerotherapy. This is the first reported case of Roux-en-Y jejunal varices bleeding related to the compression of the left renal vein after LDLT was performed with renoportal anastomosis.

Conclusions: Although renoportal anastomosis should be cautiously performed when there are no options for severe portal vein thrombosis, the status of the left renal vein and new collateral formation should be observed carefully during the follow-up period in pediatric cases of renoportal anastomosis.
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http://dx.doi.org/10.1186/s40792-021-01129-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867670PMC
February 2021

A case of esophageal achalasia presenting with empyema and septic shock differentiated from esophageal rupture.

Clin J Gastroenterol 2021 Apr 1;14(2):422-426. Epub 2021 Feb 1.

Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.

The patient was a 44-year-old man with a history of schizophrenia. He had a history of esophageal dysphagia and vomiting and presented with sudden strong epigastric pain. He was taken to a medical emergency center in a state of septic shock. Computed tomography revealed a left thoracic abscess, and esophageal rupture was suspected. He was referred to our department for treatment. Gastrointestinal series and gastrointestinal endoscopy revealed marked esophageal dilation and strong contraction of the lower esophageal sphincter. We, therefore, diagnosed the patient with empyema thoracis secondary to aspiration pneumonia due to esophageal achalasia. Conservative treatment with antibiotics and computed tomography-guided chest drainage was initiated, but the inflammation persisted. Thus, we successfully performed a per-oral endoscopic myotomy to manage achalasia symptoms.
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http://dx.doi.org/10.1007/s12328-021-01349-yDOI Listing
April 2021

Improvement of hepatocyte engraftment by co-transplantation with pancreatic islets in hepatocyte transplantation.

J Tissue Eng Regen Med 2021 Apr 19;15(4):361-374. Epub 2021 Feb 19.

Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.

Because of the fragility of isolated hepatocytes, extremely poor engraftment of transplanted hepatocytes remains a severe issue in hepatocyte transplantation. Therefore, improving hepatocyte engraftment is necessary to establish hepatocyte transplantation as a standard therapy. Since the pancreatic islets are known to have favorable autocrine effects, we hypothesized that the transplanted islets might influence not only the islets but also the nearby hepatocytes, subsequently promoting engraftment. We evaluated the effects of islet co-transplantation using an analbuminemic rat model (in vivo model). Furthermore, we established a mimicking in vitro model to investigate the underlying mechanisms. In an in vivo model, the hepatocyte engraftment was significantly improved only when the islets were co-transplanted to the nearby hepatocytes (p < 0.001). Moreover, the transplanted hepatocytes appeared to penetrate the renal parenchyma together with the co-transplanted islets. In an in vitro model, the viability of cultured hepatocytes was also improved by coculture with pancreatic islets. Of particular interest, the coculture supernatant alone could also exert beneficial effects comparable to islet coculture. Although insulin, VEGF, and GLP-1 were selected as candidate crucial factors using the Bio-Plex system, beneficial effects were partially counteracted by anti-insulin receptor antibodies. In conclusion, this study demonstrated that islet co-transplantation improves hepatocyte engraftment, most likely due to continuously secreted crucial factors, such as insulin, in combination with providing favorable circumstances for hepatocyte engraftment. Further refinements of this approach, especially regarding substitutes for islets, could be a promising strategy for improving the outcomes of hepatocyte transplantation.
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http://dx.doi.org/10.1002/term.3170DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048420PMC
April 2021

[A Case of Sigmoid Colon Cancer with Thrombotic Microangiopathy].

Gan To Kagaku Ryoho 2020 Dec;47(13):2358-2360

Dept. of Surgery, Tohoku University Graduate School of Medicine.

A 50's man was referred to our hospital because of sigmoid colon cancer with multiple liver metastases and para-aortic lymph node metastases. Although blood test showed elevated D-dimer(50 μg/mL), there was no significant thrombus in contrast-enhanced CT scan. Since cancer pain and symptoms of bowel obstruction had continued after endoscopic stent placement, we resected primary lesion. Despite anemia and elevated D-dimer level had persisted after the operation, there were no obvious bleeding source nor thrombus. Continuous intravenous heparin infusion was started for hypercoagulability. Then, D-dimer and CRP levels were promptly decreased. Since schizocyte and giant platelets were observed in peripheral blood smear, he was eventually diagnosed with thrombotic microangiopathy as a paraneoplastic syndrome. However D- dimer and CRP levels were re-elevated, and it seemed to be necessary to control cancer progression. Thus, cetuximab monotherapy was started considering his performance status. After starting cetuximab, fever and CRP level were immediately improved. Cetuximab appeared to be very effective, but he died of acute subdural hematoma. Continuous intravenous heparin infusion was supposed to be effective in the treatment of thrombotic microangiopathy along with the management of cancer.
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December 2020

[A Case of Radically Resected Sigmoid Colon Cancer with Bladder Invasion after Chemotherapy and Weight Loss in an Extremely Obese Patient].

Gan To Kagaku Ryoho 2020 Dec;47(13):2320-2322

Dept. of Surgery, Tohoku University Graduate School of Medicine.

A 30's extremely obese patient(body mass index: BMI 45 kg/m2)was referred to our hospital with a chief complaint of bloody urine and stool. Colonoscopy revealed a sigmoid colon tumor. Barium enema examination revealed stenosis of the sigmoid colon. CT scan showed a tumor in the sigmoid colon, with bladder invasion. The para-aortic lymph node was partially swollen. We considered surgery to be high risk because of the patient's severe obesity. Therefore, we decided to examine the possibility of radical surgery followed by chemotherapy(mFOLFOX6/cetuximab)with weight reduction. Following this, the tumor had shrunk remarkably, and the patient's BMI decreased from 45 kg/m2 to 39 kg/m2. The visceral fat area was reduced from 298 cm2 to 199 cm2 at the umbilical level. We then performed a sigmoid colectomy with partial resection of the bladder. Thus, chemotherapy combined with weight loss enabled us to perform radical surgery safely for a locally advanced sigmoid colon cancer in a patient with severe obesity.
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December 2020

[A Case of Initially Locally Advanced Pancreatic Cancer Curatively Resected after Carbon-Ion Radiotherapy with Gemcitabine].

Gan To Kagaku Ryoho 2020 Dec;47(13):2266-2268

Dept. of Surgery, Tohoku University Graduate School of Medicine.

Background: The neoadjuvant therapy against locally advanced pancreatic cancer(LAPC)have been developed by combining radiation with chemotherapy. We experienced a case of LAPC performed R0 resection and obtained high histopathological effect by carbon-ion radiotherapy with gemcitabine(GEM).

Case Presentation: A 65-year-old male with epigastric and back pain was suspected as pancreas cancer by FDG-PET/CT scan, and was referred to our hospital. CT scan revealed a tumor in pancreatic body with poor contrast effect and with invasion to celiac artery, common hepatic artery and portal vein, and diagnosed as pancreatic adenocarcinoma by endoscopic ultrasound-fine needle aspiration(EUS-FNA). Therefore we diagnosed the tumor as pancreatic body cancer, cT4, cN1a, cM0, cStage Ⅲ, UR-LA. GEM plus nab-paclitaxel(GnP)were administered for 4 months followed by carbon-ion radiotherapy with GEM at other hospital. Distal pancreatectomy with en bloc celiac axis resection(DP-CAR)was performed 3 months after irradiation. High therapeutic effect was obtained histopathologically( Evans grade Ⅲ), and lesions outside the pancreas disappeared except for metastasis to one lymph node (ypT1c, ypN1a, ycM0, ypStage ⅡB), and R0 resection was performed.

Conclusion: Carbon-ion radiotherapy with chemotherapy for LAPC may improve curative resection rate.
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December 2020

[A Successful Case of Pancreaticoduodenectomy after Neoadjuvant Therapy for Pancreatic Head Cancer with Acute Pancreatitis Due to Iatrogenic Injury of the Pancreatic Duct].

Gan To Kagaku Ryoho 2021 Jan;48(1):118-120

Dept. of Surgery, Tohoku University Graduate School of Medicine.

A 64-year-old woman was referred to our hospital for treatment of pancreatic head cancer with acute pancreatitis due to iatrogenic injury of the pancreatic duct during endoscopic retrograde cholangiopancreatography. In addition to a 28 mm pancreatic head tumor, soft tissue shadow and fluid collection surrounding the superior mesenteric artery(SMA)due to pancreatitis were observed in the abdominal CT scan. The tumor was histologically diagnosed as adenocarcinoma by endoscopic ultrasound-guided fine needle aspiration. Neoadjuvant chemotherapy with gemcitabine and S-1 was performed to control the progression of the pancreatic cancer and improve the inflammatory changes for reduction of the operative risk. After 2 courses of neoadjuvant chemotherapy, abdominal CT scan revealed stable disease according to the Response Evaluation Criteria in Solid Tumors and attenuation of the inflammatory changes surrounding the SMA. Then, subtotal stomach- preserving pancreaticoduodenectomy was performed without the difficulty of peeling around the SMA in spite of the old inflammatory changes. Histological examination of the resected specimen showed R0 resection. The patient was discharged 18 days after surgery without any complications and is surviving 9 months postoperatively without any recurrence. Neoadjuvant chemotherapy was helpful for disease control and improvement of the inflammatory changes.
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January 2021

Efficacy of laparoscopic sleeve gastrectomy for patient with morbid obesity and type 1 diabetes mellitus: a case report.

Surg Case Rep 2021 Jan 6;7(1). Epub 2021 Jan 6.

Department of Surgery, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.

Background: Bariatric surgery is effective for the treatment of patients with morbid obesity and type 2 diabetes mellitus (T2DM), for body weight loss and glycemic control. However, in Japan, there has been no previous report of the effectiveness bariatric surgery in a case of morbid obesity associated with acute onset type 1 diabetes mellitus (T1DM), in which pancreatic β-cells were destroyed and endogenous insulin was depleted.

Case Presentation: A 36-year-old woman with morbid obesity and T1DM, diagnosed when she was 6 years, was admitted for bariatric surgery. At her first consultation, she had a body weight of 106.7 kg and a body mass index of 42.2 kg/m. Her HbA1c level was 9.0%, with a required daily insulin dose of 75 units. She underwent laparoscopic sleeve gastrectomy. At 1 year after surgery, her body weight had decreased to 81.0 kg and her body mass index to 32.2 kg/m. In addition, her daily required dose of insulin had decreased to 24 units, with an improvement in her HbA1c level to 7.7%.

Conclusions: Although further evidence needs to be accumulated, including long-term outcomes, laparoscopic sleeve gastrectomy may provide an effective treatment for patients with morbid obesity and T1DM for body weight loss, improvement in HbA1c level, and insulin dose reduction.
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http://dx.doi.org/10.1186/s40792-020-00989-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7788116PMC
January 2021

MicroRNA-593-3p Expression in Peritoneal Lavage Fluid as a Prognostic Marker for Pancreatic Cancer Patients Undergoing Staging Laparoscopy.

Ann Surg Oncol 2021 Apr 3;28(4):2235-2245. Epub 2021 Jan 3.

Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.

Background: Some presumed resectable pancreatic cancer patients harbor radiographically occult metastases that are incidentally identified at the time of abdominal exploration. This study aims to identify novel diagnostic or predictive microRNA (miRNA) markers for subclinical peritoneal dissemination in patients with pancreatic cancer undergoing abdominal exploration.

Methods: Peritoneal lavage fluid samples were harvested from 74 patients with pancreatic cancer at the time of staging laparoscopy. Microarray analysis was performed using peritoneal lavage fluids with positive and negative cytology. Candidate microRNA expression was quantified and validated by droplet-digital PCR assays.

Results: In the miRNA array analysis, miR-593-3p showed significant upregulation in peritoneal lavage fluids with positive cytology. Of the 74 patients validated, peritoneal lavage fluids with positive cytology had significantly higher expression of miR-593-3p than those with negative cytology (P < 0.001). Even in cases with no peritoneal dissemination and negative cytology, multivariate analysis revealed that elevated miR-593-3p expression was significantly correlated with worse overall survival than those with low expression (hazard ratio: 3.474, P = 0.042). Of the 48 patients who underwent pancreatectomy, multivariate analysis also demonstrated that higher expression of miR-593-3p in peritoneal lavage was the only significant poor prognostic marker influencing both overall survival (hazard ratio: 23.38, P = 0.005) and recurrence-free survival (hazard ratio: 5.700, P = 0.002).

Conclusions: Elevated miR-593-3p expression in peritoneal lavage suggests the presence of subclinical micrometastasis even in cases with localized pancreatic cancer, and miR-593-3p could be a useful prognostic predictor for pancreatic cancer patients undergoing staging laparoscopy.
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http://dx.doi.org/10.1245/s10434-020-09440-3DOI Listing
April 2021

Intracholecystic papillary neoplasm arising in the cystic duct and extending into common bile duct: a case report.

Clin J Gastroenterol 2021 Apr 2;14(2):668-677. Epub 2021 Jan 2.

Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.

An 83-year-old man without specific symptoms was referred to our hospital for further evaluation and treatment of apparent double primary tumors of the cystic duct and common bile duct. Computed tomography showed contrast-enhanced solid tumors in the cystic duct and common bile duct. Magnetic resonance imaging showed that the bile duct tumor was isointense on T1-weighted images and had low intensity on T2-weighted images. In addition, the bile duct tumor showed high intensity on diffusion-weighted images. Endoscopic ultrasonography revealed the tumor of the common bile duct and endoscopic retrograde cholangiopancreatography demonstrated a filling defect in the bile duct. The cystic duct was not identified on endoscopic ultrasonography or endoscopic retrograde cholangiopancreatography. Transpapillary biopsy of the bile duct tumor showed adenocarcinoma. The patient was diagnosed with double primary tumors of the cystic duct and the common bile duct and underwent subtotal stomach-preserving pancreaticoduodenectomy. Microscopic examination with molecular profiling of the tumors revealed a high-grade noninvasive intracholecystic papillary neoplasm of the cystic duct extending into the common bile duct and forming a tubulopapillary neoplasm with invasion of the common bile duct.
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http://dx.doi.org/10.1007/s12328-020-01311-4DOI Listing
April 2021

Infected Massive Thrombosed Persistent Sciatic Artery Aneurysm Treated by Small Incision Drainage: A Case Report.

EJVES Vasc Forum 2020 24;49:45-47. Epub 2020 Nov 24.

Department of Surgery, Tohoku University Hospital, Sendai, Japan.

Introduction: Persistent sciatic artery is a rare vascular anomaly. The occurrence of infected persistent sciatic artery aneurysm (PSAA) is extremely rare.

Report: An 84 year old woman who was under observation for a massive thrombosed right PSAA since the age of 74 presented with severe pain in her right lower limb. The patient was diagnosed with the infected PSAA by computed tomography and laboratory test. The condition was treated with antibiotics as well as drainage and removal of the infected thrombus with a small incision. Subsequently, the patient's symptoms improved, and she was discharged ambulatory. Sixteen months after the surgery, her condition remained good, with no evidence of recurrent infection.

Conclusion: Extensive debridement requires a large muscle incision and carries with it a risk of sciatic nerve injury. However, a thrombosed aneurysm has little risk of haemorrhage. Therefore, drainage and removal of the thrombus via a small incision, which is less invasive, was considered effective for this infected thrombosed PSAA.
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http://dx.doi.org/10.1016/j.ejvsvf.2020.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744702PMC
November 2020

Protection of liver sinusoids by intravenous administration of human Muse cells in a rat extra-small partial liver transplantation model.

Am J Transplant 2020 Dec 22. Epub 2020 Dec 22.

Department of Stem Cell Biology and Histology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan.

Small-for-size syndrome (SFSS) has a poor prognosis due to excessive shear stress and sinusoidal microcirculatory disturbances in the acute phase after living-donor liver transplantation (LDLT). Multilineage-differentiating stress enduring (Muse) cells are reparative stem cells found in various tissues and currently under clinical trials. These cells selectively home to damaged sites via the sphingosine-1-phosphate (S1P)-S1P receptor 2 system and repair damaged tissue by pleiotropic effects, including tissue protection and damaged/apoptotic cell replacement by differentiating into tissue-constituent cells. The effects of intravenously administered human bone marrow-Muse cells and -mesenchymal stem cells (MSCs) (4 × 10 ) on liver sinusoidal endothelial cells (LSECs) were examined in a rat SFSS model without immunosuppression. Compared with MSCs, Muse cells intensively homed to the grafted liver, distributed to the sinusoids and vessels, and delivered improved blood chemistry and Ki-67(+) proliferative hepatocytes and -LSECs within 3 days. Tissue clearing and three-dimensional imaging by multiphoton laser confocal microscopy revealed maintenance of the sinusoid continuity, organization, and surface area, as well as decreased sinusoid interruption in the Muse group. Small-interfering RNA-induced knockdown of hepatocyte growth factor and vascular endothelial growth factor-A impaired the protective effect of Muse cells on LSECs. Intravenous injection of Muse cells might be a feasible approach for LDLT with less recipient burden.
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http://dx.doi.org/10.1111/ajt.16461DOI Listing
December 2020

Resection rate curves by location along the small intestine provide perspectives on characteristics of Crohn's disease.

Colorectal Dis 2021 May 30;23(5):1167-1174. Epub 2020 Dec 30.

Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.

Aim: Crohn's disease (CD) can affect any part of the gastrointestinal tract; however, the frequency of CD lesions differs by location. This work aimed to examine resection rates by location to clarify locational characteristics of the small intestine in surgical CD cases.

Method: This was a single-centre retrospective case note review of patients who had undergone resection for CD affecting the small intestine between January 2014 and February 2020. Operative details, including length of the small intestine, location and extent of the resection, identified the pattern of disease. By normalizing these data the resection rate along the length of the intestine was calculated to create resection rate curves.

Results: One hundred and twenty six surgical cases were identified. The resection rate curves could be divided into two types: exponential and bimodal. For primary surgery, this depended on whether or not surgery was limited to an ileocolic resection. At subsequent surgery, a previous ileocaecal resection influenced the pattern of disease. The peaks of the bimodal curve were located at the proximal and distal ileum.

Conclusion: CD patients requiring resection of the small intestine can be divided into terminal ileum type (exponential type) and proximal ileum type (bimodal type). In the future this analytical method may help predict the site of any recurrent disease but also provides a new perspective on the disease.
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http://dx.doi.org/10.1111/codi.15487DOI Listing
May 2021

Effect of enhanced recovery after surgery protocol on recovery after open hepatectomy: a randomized clinical trial.

Ann Surg Treat Res 2020 Dec 26;99(6):320-328. Epub 2020 Nov 26.

Department of Surgery, Tohoku University Graduate School of Medicine, Sendai, Japan.

Purpose: Enhanced recovery after surgery (ERAS) is beneficial to patients undergoing digestive surgery. However, its efficacy in patients undergoing open hepatectomy remains unclear.

Methods: Consecutive patients scheduled for open hepatectomy were randomly assigned to undergo either ERAS or conventional postoperative management. The primary endpoint was the amount of time that elapsed before patients were considered medically fit for discharge (MFD) and length of hospital stay (LOHS). Secondary endpoints included morbidity, mortality, the time to first flatus, defecation, first walk, and freedom from infusion. Perioperative serum nutritional markers, insulin resistance, respiratory quotient (RQ), and resting energy expenditure (REE) were also assessed.

Results: Between August 2014 and March 2017, 57 patients were randomized into 2 groups; ERAS group (n = 29) and conventional management (n = 28). The median MFD was not significantly different between the ERAS and conventional management groups (6.5 7 days; P = 0.381). Recovery from gastrointestinal paresis was significantly quicker in the ERAS group (1.8 2.4 days; P = 0.004). There were no significant differences in serum markers, insulin resistance, RQ, and REE.

Conclusion: This trial did not demonstrate greater efficacy of the ERAS protocol following open hepatectomy in terms of the MFD and LOHS. However, the ERAS protocol was associated with better recovery from postoperative gastrointestinal paresis, suggesting that it is useful for patients undergoing open hepatectomy.
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http://dx.doi.org/10.4174/astr.2020.99.6.320DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704272PMC
December 2020

Cellular Nrf2 Levels Determine Cell Fate during Chemical Carcinogenesis in Esophageal Epithelium.

Mol Cell Biol 2021 01 25;41(2). Epub 2021 Jan 25.

Department of Medical Biochemistry, Tohoku University, Sendai, Japan

Nrf2 is essential for cytoprotection against carcinogens, and through systemic Nrf2 knockout mice, Nrf2-deficient cells were shown to be susceptible to chemical carcinogens and prone to developing cancers. However, the oncogenic potential of Nrf2-deficient epithelial cells surrounded by normal cells in the esophagus could not be assessed by previous models, and the fate of Nrf2-deficient cells in such situations remains elusive. In this study, therefore, we generated mice that harbor almost equal levels of cells with Nrf2 deleted and those with Nrf2 intact in the basal layer of the esophageal epithelium, utilizing inducible Cre-mediated recombination of alleles in adults through moderate use of tamoxifen. In this mouse model, epithelial cells with Nrf2 deleted were maintained with no obvious decrease or phenotypic changes for 12 weeks under unstressed conditions. Upon exposure to the carcinogen 4-nitroquinoline-1-oxide (4NQO), the cells with Nrf2 deleted accumulated DNA damage and selectively disappeared from the epithelium, so almost all 4NQO-induced tumors originated from cells with Nrf2 intact and not from those with Nrf2 deleted. We propose that cells with Nrf2 deleted do not undergo carcinogenesis due to selective elimination upon exposure to 4NQO, indicating that cellular Nrf2 abundance and the epithelial environment determine the cell fate or oncogenic potential of esophageal epithelial cells in 4NQO-induced carcinogenesis.
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http://dx.doi.org/10.1128/MCB.00536-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093497PMC
January 2021

Laparoscopic right hemicolectomy for an ascending colon cancer patient with an implantable left ventricular assist device: a case report.

Surg Case Rep 2020 Nov 9;6(1):282. Epub 2020 Nov 9.

Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryou-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.

Background: Left ventricular assist devices (LVADs) currently play an important role in the treatment of patients with end-stage heart failure who require a bridge to heart transplantation or destination therapy. With the development and improvement of the LVADs, the morbidity and mortality rates are declining and life expectancies increasing, and the number of patients with LVADs requiring non-cardiac surgery is likely to increase. We present the case of a patient with implantable LVAD who underwent laparoscopic right hemicolectomy for ascending colon cancer.

Case Description: The patient was a 66-year-old man who underwent LVAD implantation as a BTT 3 years prior. He suffered from severe anemia at follow-up, and a colonoscopy revealed ascending colon cancer. The LVAD pump was implanted in the epigastrium. The long C-shaped subfascial driveline tunnel was made, and driveline exit site was located on the left lateral abdominal wall. We assessed the positional relationship between the tumor and the driveline using X-ray and three-dimensional computed tomography (3D CT) images. 3D CT image allowed us to easily identify the location of the driveline, and we determined to perform laparoscopic right hemicolectomy. The port sites were decided upon carefully to avoid the driveline injury, and the driveline was marked on the skin before surgery. There were no adhesions in the abdominal cavity, and both the LVAD and the driveline were observable. The trocars were in nearly the same positions as in a standard laparoscopic right hemicolectomy. During the operation, the LVAD and the driveline did not interfere with the trocars. We successfully completed a standard laparoscopic right hemicolectomy despite hemorrhagic tendency. The patient was discharged without any bleeding complications during the postoperative course.

Conclusion: Laparoscopic surgery is feasible and safe for patients with LVADs with intensive preoperative simulation and perioperative prevention of infection.
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http://dx.doi.org/10.1186/s40792-020-01064-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652963PMC
November 2020

GNAS mutation detection in circulating cell-free DNA is a specific predictor for intraductal papillary mucinous neoplasms of the pancreas, especially for intestinal subtype.

Sci Rep 2020 10 20;10(1):17761. Epub 2020 Oct 20.

Department of Surgery, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.

Pancreatic cystic neoplasms (PCNs) are a heterogeneous group with varying risks of malignancy. To explore the clinical utility of liquid biopsy in cyst type classification, we analyzed the GNAS/KRAS mutations in circulating cell-free DNA (cfDNA) obtained from 57 patients with histologically diagnosed PCNs, including 34 with intraductal papillary mucinous neoplasms (IPMNs) and compared the mutant allele prevalence and variant patterns with the paired resected specimens using next-generation sequencing. The positive prevalence of GNAS mutations in cfDNA of patients with IPMN (n = 11, 32%) was significantly higher than that in those with other PCNs (0%, P = 0.002). Conversely, KRAS mutations were detected in cfDNA of only 2 (6%) IPMN patients. The paired-sample comparison revealed highly concordance between the GNAS mutation status of cfDNA and resected IPMN specimens. Similar distributions of GNAS mutation positivity in cfDNA were observed across the different histological grades, whereas IPMNs with intestinal subtype showed a significantly higher prevalence of GNAS mutations than other subtypes (P = 0.030). GNAS mutation positivity in cfDNA was significantly associated with the acellular mucin pool of histological findings in primary IPMN lesions (P = 0.017). Detection of GNAS mutation in cfDNA can serve as a novel biomarker for cyst type classification and differentiation of intestinal subtype IPMN from the other PCNs.
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http://dx.doi.org/10.1038/s41598-020-74868-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576136PMC
October 2020

Effects of re-augmenting maintenance immunosuppression on post-transplant donor-specific HLA antibodies in liver transplantation.

Transpl Immunol 2020 12 10;63:101334. Epub 2020 Sep 10.

Department of Surgery, Tohoku University, 1-1 Seiryo-machi, Aoba-ku, Sendai, Japan.

Background: Donor-specific antibodies (DSAs) have various negative short- and long-term effects after organ transplantation. DSAs are prevalent in patients with insufficient immunosuppression; thus, even patients with stable conditions after liver transplantation should be under optimized immunosuppression. However, the effect of re-augmenting immunosuppression therapy for patients with insufficient immunosuppression remains unclear. In this study, we investigated the long-term changes and the effects of immunosuppression (IS) re-augmentation on the DSA status.

Methods: Two DSA screenings were performed in 67 patients during long-term follow-up after liver transplantation. After the first screening, IS re-augmentation was performed in patients with consent. The effects of IS re-augmentation on the DSA status were analyzed using data of the serial DSA screenings. Negative conversion was defined as DSA positivity with MFI > 1000 converted to MFI < 1000. Improvement of DSA status was defined as either a 50% reduction of MFI or negative conversion.

Results: The median interval between the first and second DSA screening was 50 months. Among 67 patients, 43 were positive for DSAs on the first screening. Among these 43 patients, 30 had minimal to no IS therapy at the time of the first screening. Among the 30 patients, IS re-augmentation was conducted in 19. A comparison between the patients with a re-augmented IS and those with a sustained minimized IS showed that the DSA levels significantly decreased in the former (63% (12/19) vs. 18% (2/11), p = 0.02).

Conclusions: The results of this study indicate that post-liver transplant IS re-augmentation had suppressive effects on the DSA status. However, the clinical significance of DSA-negative conversion and/or mean fluorescence intensity reduction needs to be further investigated through histological evaluation and/or graft survival during longer follow-up periods.
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http://dx.doi.org/10.1016/j.trim.2020.101334DOI Listing
December 2020

[Per-oral endoscopic myotomy for esophageal achalasia following distal gastrectomy].

Nihon Shokakibyo Gakkai Zasshi 2020 ;117(9):796-801

Department of Digestive Surgery, Tohoku University Graduate School of Medicine.

The patient was a male in his 70s with a history of distal gastrectomy and Billroth-I reconstruction. He was suspected of having esophageal achalasia and was started on calcium blockers in X-2 year. The symptoms worsened, and he presented to our hospital in X year. We diagnosed esophageal achalasia (Chicago classification ver. 3.0;type I), and conducted per-oral endoscopic myotomy (POEM). His postoperative course was uneventful with no postoperative symptoms. In cases of esophageal achalasia following distal gastrectomy, it is important to consider adhesions, mobility of the remaining stomach, and preservation of the short gastric artery and vein. Since the Heller-Dor operation can be difficult, POEM may be a reasonable alternative in these cases.
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http://dx.doi.org/10.11405/nisshoshi.117.796DOI Listing
September 2020