Additional Resection of the Pancreas Body Prevents Postoperative Pancreas Fistula in Patients with Portal Annular Pancreas Who Undergo Pancreaticoduodenectomy

Portal annular pancreas (PAP) is a rare variant in which the uncinate process of the pancreas extends to the dorsal surface of the pancreas body and surrounds the portal vein or superior mesenteric vein. Upon pancreaticoduodenectomy (PD), when the pancreas is cut at the neck, two cut surfaces are created. Thus, the cut surface of the pancreas becomes larger than usual and the dorsal cut surface is behind the portal vein, therefore pancreatic fistula after PD has been reported frequently. We planned subtotal stomach-preserving PD in a 45-year-old woman with underlying insulinoma of the pancreas head. When the pancreas head was dissected, the uncinate process was extended and fused to the dorsal surface of the pancreas body. Additional resection of the pancreas body 1 cm distal to the pancreas tail to the left side of the original resection line was performed. The new cut surface became one and pancreaticojejunostomy was performed as usual. No postoperative complications such as pancreatic fistula occurred. Additional resection of the pancreas body may be a standardized procedure in patients with PAP in cases of pancreas cut surface reconstruction

Infrequent RAS mutation is not associated with specific histological phenotype in gliomas

BACKGROUND: Mutations in driver genes such as IDH and BRAF have been identified in gliomas. Meanwhile, dysregulations in the p53, RB1, and MAPK and/or PI3K pathways are involved in the molecular pathogenesis of glioblastoma. RAS family genes activate MAPK through activation of RAF and PI3K to promote cell proliferation. RAS mutations are a well-known driver of mutation in many types of cancers, but knowledge of their significance for glioma is insufficient. The purpose of this study was to reveal the frequency and the clinical phenotype of RAS mutant in gliomas. METHODS: This study analysed RAS mutations and their clinical significance in 242 gliomas that were stored as unfixed or cryopreserved specimens removed at Kyoto University and Osaka National Hospital between May 2006 and October 2017. The hot spots mutation of IDH1/2, H3F3A, HIST1H3B, and TERT promoter and exon 2 and exon 3 of KRAS, HRAS, and NRAS were analysed with Sanger sequencing method, and 1p/19q codeletion was analysed with multiplex ligation-dependent probe amplification. DNA methylation array was performed in some RAS mutant tumours to improve accuracy of diagnosis. RESULTS: RAS mutations were identified in four gliomas with three KRAS mutations and one NRAS mutation in one anaplastic oligodendroglioma, two anaplastic astrocytomas (IDH wild-type in each), and one ganglioglioma. RAS-mutant gliomas were identified with various types of glioma histology. CONCLUSION: RAS mutation appears infrequent, and it is not associated with any specific histological phenotype of glioma

ITS analysis of Clematis plants from East Asia and the botanical origin of Clematidis Radix sold in modern markets

金沢大学医薬保健研究域薬学系漢方生薬 「威霊仙」 はキンポウゲ科のセンニンソウ属植物の地下部に由来する。 近年の生薬市場には多数の原植物に由来する威霊仙が見られるが， 日・中の薬局方では原植物を Clematis hexapetala, C. mandshurica および C. chinensisの 3 種であると規定している。 現在日本， 中国及び韓国市場の威霊仙の原植物を明らかにする目的で， 東アジアに産するセンニンソウ属植物のうち関連する 9 分類群について， 分子生物学的に ITS 領域を検討した。 その結果， ITS 全領域の塩基配列を検討することにより， 9 分類群を区別することができた。 以上の結果から， 現在市場で入手した11サンプルの威霊仙を分子遺伝学的に同定することができた。 すなわち， 日本市場品は 4 サンプルのうち 3 つは C. mandshurica で， 1 つは C. chinensis であった。 中国市場品 4 サンプルのうち 2 つは C. mandshurica で， 他の 2 つは C. brachyura であった。 韓国産 3 サンプルのうち 2 つは C. mandshurica で， 他の 1 つは C. terniflora var. robusta であった。Clematidis Radix (Wei Ling Xian in Chinese and Ireisen in Japanese) is a crude drug used in traditional Chinese medicine and is derived from the underground parts of Clematis plants, which belong to the family Ranunculaceae. The Clematidis Radix sold in modern markets is derived from a variety of botanical origins, whereas the Chinese and Japanese pharmacopoeias state that Clematidis Radix should be produced from Clematis hexapetala, C. mandshurica, or C. chinensis. To clarify the botanical origin of this crude drug, 9 closely related taxa of the genus Clematis growing in East Asia were subjected to molecular biological studies of their internal transcribed spacer (ITS) regions. We found that the ITS region nucleotide sequences of the 9 taxa had diverged. As a result, the 9 taxa could be successfully differentiated by comparing their whole ITS region sequences. Based on this result, 11 Clematidis Radix samples obtained from modern Japanese, Chinese, and Korean markets were genetically identified as follows: Of the samples from Japanese markets, 3 out of 4 were categorized as C. mandshurica, and one as C. chinensis. Among the samples from Chinese markets, 2 out of 4 were identified as C. mandshurica, and the other two as C. brachyura. Meanwhile, of the 3 samples from Korean markets, two were identified as C. mandshurica, and the other as C. terniflora var. robusta. © 2013, Medical and Pharmaceutical Society for WAKAN-YAKU. All rights reserved

Association of inflammatory biomarkers with long-term outcomes after curative surgery for mass-forming intrahepatic cholangiocarcinoma

Purpose Inflammatory biomarkers such as the neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) are reportedly predictive of the long-term outcomes of several cancers. We evaluated their correlations with the post-surgical long-term outcomes of patients with mass-forming (MF) intrahepatic cholangiocarcinoma (ICC). Methods The subjects of this study were 52 patients who underwent hepatic resection for MF-ICC at our hospital. We measured the cutoff values of NLR, LMR and PLR, using receiver operating characteristic curves, and compared the survival rates of patients with high vs. those with low values. We also evaluated a prognostic scoring system based on significant inflammatory biomarkers. Results The cutoff values for NLR, LMR, and PLR were 1.93, 4.78, and 98, respectively. The high-NLR and low-LMR groups had significantly worse prognoses than the low-NLR and high-LMR groups. We designed a scoring system using the inflammation score (IS) based on NLR and LMR values, stratifying patients into three groups with scores of 0, 1, or 2. The IS was significantly correlated with overall survival (OS), with 5-year survival rates by the IS score of 100% for 0, 61% for 1, and 32% for 2 (P = 0.011). The IS was found to be an independent predictor of OS in multivariate analysis. Conclusions Our IS scoring system may predict long-term outcomes after surgery for MF-ICC

Cachexia index as a prognostic predictor after resection of pancreatic ductal adenocarcinoma

Abstract Aim This study was performed to investigate the relationship between the preoperative cachexia index (CXI) and long‐term outcomes in patients who have undergone radical resection of pancreatic ductal adenocarcinoma (PDAC). Methods In total, 144 patients who underwent pancreatic resection for treatment of PDAC were retrospectively analyzed. The relationship between the CXI and the patients' long‐term outcomes after PDAC resection was investigated. The CXI was calculated based on the preoperative skeletal muscle index, serum albumin level, and neutrophil‐to‐lymphocyte ratio. After propensity‐score matching, we compared clinicopathological features and outcomes. Results The multivariate analysis showed that lymph node metastasis (hazard ratio [HR], 1.93; 95% confidence interval [CI], 1.16–3.23; P = 0.0118), R1 resection (HR, 57.20; 95% CI, 9.39–348.30; P < 0.0001), and a low CXI (HR, 2.10; 95% CI, 1.27–3.46; P = 0.0038) were independent and significant predictors of disease‐free survival (DFS) after PDAC resection. Moreover, a low CXI (HR, 3.14; 95% CI, 1.71–5.75; P = 0.0002) was an independent and significant predictor of overall survival (OS) after PDAC resection. After propensity‐score matching, the low CXI group had a significantly worse prognosis than the high CXI group for both DFS and OS. Conclusion The CXI can be a useful prognostic factor for DFS and OS after pancreatic resection for treatment of PDAC

Feasible Isolated Liver Transplantation for a Cirrhotic Patient on Chronic Hemodialysis

End-stage liver and kidney disease (ELKD) is an indication for deceased donor simultaneous liver-kidney transplantation. Although a few cases of living donor liver-kidney transplantation have been reported, the invasiveness remains to be discussed. Living donor liver transplantation (LDLT) is an alternative choice for ELKD, but has never been reported. Here, we report a case of successful LDLT for a patient with ELKD on hemodialysis. The patient was a 63-year-old male and had decompensated hepatitis C cirrhosis with seronegativity for hepatitis C virus. He had non-diabetic end-stage renal failure and had been on hemodialysis for 3 years. He was in good general condition except for hepatic and renal failure. The living donor was his 58-year-old healthy wife. A right lobe graft was transplanted to the recipient under continuous hemodiafiltration (CHDF) and extracorporeal veno-venous bypass. CHDF was continued until postoperative day 4, at which point CHDF was converted to hemodialysis. His posttransplant course was good and he was discharged on postoperative day 36. To the best of our knowledge, this is the first report of LDLT for a patient on chronic hemodialysis. Therefore, being on hemodialysis is not a contraindication for LDLT. LDLT is feasible for a patient with ELKD on hemodialysis