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Background Tranexamic acid (TXA) may reduce intraoperative blood loss, but it has not been investigated in pancreaticoduodenectomy (PD). Methods A pragmatic, multicentre, randomized, blinded, placebo-controlled trial was conducted. Adult patients undergoing planned PD for biliary, duodenal, or pancreatic diseases were randomly assigned to TXA or placebo groups. Patients in the TXA group were administered 1 g TXA before incision, followed by a maintenance infusion of 125 mg/h TXA. Patients in the placebo group were administered the same volume of saline as those in the placebo group. The primary outcome was blood loss during PD. The secondary outcomes included perioperative blood transfusions, operating time, morbidity, and mortality. Results Between September 2019 and May 2021, 218 patients were randomly assigned and underwent surgery (108 in the TXA group and 110 in the placebo group). Mean intraoperative blood loss was 659 ml in the TXA group and 701 ml in the placebo group (mean difference −42 ml, 95 per cent c.i. −191 to 106). Of the 218 patients, 202 received the intervention and underwent PD, and the mean blood loss during PD was 667 ml in the TXA group and 744 ml in the placebo group (mean difference −77 ml, 95 per cent c.i. −226 to 72). The secondary outcomes were comparable between the two groups. Conclusion Perioperative TXA use did not reduce blood loss during PD. Registration number jRCTs041190062 (https://jrct.niph.go.jp).

Nodal metastasis is a leading attributable factor of poor survival in biliary tract cancer (BTC), and adjuvant chemotherapy targeting this high-risk feature has not been attempted to date. This study aimed to test the efficacy of adjuvant S − 1 for patients with node-positive BTC. This single-arm multicenter phase 2 trial enrolled patients who underwent resection for histologically proven node-positive BTC. In this trial, S − 1 was administered at a dose of 80–120 mg/day on 14 days of a tri-weekly cycle for 6 months. The primary end point of the trial was 3-year overall survival (OS), in which the result would be promising if the 90% confidence interval (CI) surpassed a threshold of 30% (alpha error, 0.1; beta error, 0.2). The secondary end points were relapse-free survival (RFS), feasibility, and toxicity. The trial included 50 patients with perihilar (n = 23) or distal (n = 20) cholangiocarcinoma, or gallbladder cancer (n = 7). The median numbers of positive lymph nodes and examined lymph nodes were respectively 2 and 15. The 3-year OS and RFS were respectively 50% (90% CI, 40.9–59.1%) and 32.0% (95% CI, 19.1–44.9%), with median survival times of 34.6 months (95% CI, 19.3–49.8 months) and 18.4 months (95% CI, 11.9–24.9 months). Although hematologic toxicity often occurred, grades 3 and 4 toxicity were rare. The completion rate of the test therapy was 64%, and the median relative dose intensity was 87.5% (interquartile range, 50–100%). Adjuvant chemotherapy with S − 1 may be promising for patients with node-positive BTC.

Neoadjuvant chemotherapy (NAC) alone for locally advanced rectal cancer (LARC) remains an experimental treatment, and the efficacy in terms of long-term outcome has not been fully elucidated. The N-SOG 03 trial examined the safety and efficacy of neoadjuvant CAPOX and bevacizumab (Bev) without radiotherapy in patients with poor-risk LARC. Thirty-two patients with MRI-defined LARC received neoadjuvant CAPOX and Bev followed by curative resection between 2010 and 2011. The overall survival (OS), progression-free survival (PFS), and local-relapse rate (LRR) were calculated using the Kaplan–Meier method, and the risk factors were evaluated by multivariate analysis using the Cox proportional hazard models. This trial is registered with UMIN, number 000003507. In the entire cohort, the 5-year OS was 81.3%. Because of disease progression during chemotherapy, 3 patients ultimately did not undergo curative surgery. As a result, 29 patients underwent R0/1 resection. Among these 29 patients, the 5-year OS, PFS, and LRR were 89.7%, 72.4% and 13.9%, respectively. In multivariate analysis, cT4b tumor was an independent poor prognostic factor for OS and LRR, and ypT4b tumor and absence of N down-staging were independent poor prognostic factors for PFS. Patients with cT4b tumor were not suitable for NAC alone. However, the long-term outcomes of the other patients were satisfactory, and NAC alone might be an option for treatment of LARC. N down-staging was likely to bring favorable PFS, even in patients with cStage III.

Hyperbaric oxygen (HBO) therapy is a controversial treatment for adhesive postoperative small bowel obstruction (ASBO), with only a few retrospective studies reported. The aim of this study was to assess the clinical impact of HBO therapy in the treatment of ASBO. Patients with ASBO were randomly assigned to no-HBO (standard arm) or HBO (intervention arm). Patients of the intervention arm were treated once daily at a pressure of 2.0 atm absolute and received 100% oxygen. The primary endpoint was the success rate of medical treatment. This study was registered at the UMIN Clinical Trial Registry as UMIN000010399. The no-HBO group included 40 patients, and the HBO group included 33 patients. Patient characteristics, time to oral intake, and length of hospital stay were similar between the two groups. No significant differences were noted between the no-HBO and HBO groups in the need for long intestinal tube decompression (20.0 versus 18.2%, respectively, p = 1.000) and the need for operative intervention (10.0 versus 18.2%, respectively, p = 0.332). The overall success rate of medical treatment was 72.5% in the no-HBO group and 78.8% in the HBO group (p = 0.594). In this randomized controlled trial, HBO for ASBO has no additional effect in medical treatment.

Case 1 involved a 54-year-old woman with a complaint of a lump in the left breast since October. A diagnosis of invasive micropapillary carcinoma(IMPC)was made by core needle biopsy. The profile of the carcinoma was as follows: ER(Allred 8=5+3), PgR(Allred 8=5+3), HER2(1+), Ki-67 index 30%. The patient underwent 4 courses of EC(epirubicin 90mg/ m2, cyclophosphamide 600 mg/m2), followed by 4 courses of triweekly docetaxel and nab-paclitaxel chemotherapy. Bp+Ax was underwent in May 2013. Pathologically, no residual tumor was observed. Case 2 involved a 61-year-old woman with the chief complaint of a lump in the right breast, diagnosed as IMPC by core needle biopsy. The profile of the carcinoma was as follows: ER(Allred 8=5+3), PgR(Allred 0=0+0), HER2(1+), Ki-67 index 30%. Pre-operative treatment consisted of letrozole(2.5mg/day)from May 2013 and hormone therapy for 6 months. Bp+SNB was performed in November 2013. Histopathologically, no remnant of IMPC component was observed apart from an 11mm papillo-tubular carcinoma. In spite of the fact that IMPC is considered highly malignant, pre-operative chemotherapy and hormonal therapy may be effective.

The present study reports the case of a 45-year-old pre-menopausal woman treated with 6courses of TAC chemotherapy by the pegfilgrastim for preoperative chemotherapy. The patient visited our hospital in February 2010 with the chief complaint of a mass in the right breast. A 40mm tumor in the outer lower area of the right breast and the axillary lymph nodes was palpable. Pathological findings revealed scirrhous carcinoma with an ER(+), PgR(+), HER2(1+), and Ki-67 80%profile. Pre-operatively, the patient underwent 6courses of triweekly TAC(docetaxel[75mg/m / 2], adriamycin[50mg/m2], cyclo- phosphamide[500mg/m2])chemotherapy. Pegfilgrastim(3.6m g)was subcutaneously injected on the next day of each course. The side effect of 6courses of TAC was stomatitis and low back pain(Grade 2). Relative dose intensity(RDI)was not reduced and there was no occurrence of febrile neutropenia(FN). Partial resection of the tumor was facilitated. Pathologically viable tumor cells still lay scattered in the range of 45 mm, and a ductal carcinoma in situ was seen. However, metastasis to axillary lymph nodes was not observed. Radiation therapy(50 Gy)was performed on the residual breast. There was no recurrence, and now she survival free with tamoxifen(20mg/day)of 8 years four months after operation. TAC with pegfilgrastim therapy could be an effective pre-operative chemotherapy regimen in breast cancer.

The patient was a 66-year-old woman with a history of right breast cancer 20 years prior. Her chief complaint was hematochezia, and she was diagnosed as having rectal cancer. She underwent laparoscopic high anterior resection. We made a diagnosis of moderately differentiated adenocarcinoma, type 2, 25×20 mm, pMP, pN0, Stage I, KRAS being wild-type. Multiple liver metastases were detected 6 months after the surgery. Tumor contacted with grison. The tumor was not completely resected as evidenced by the small liver remnant volume. Conversion therapy was administered, and the patient received 6 courses of FOLFIRI plus cetuximab therapy. Alopecia and grade 1 eruption were observed as adverse effects of the chemotherapy. The tumor size was reduced, and we resected the tumor by performing right lobectomy and partial hepatectomy. At 1 year 3 months after surgery, no recurrence was observed.

A 69-year-old woman underwent total gastrectomy for advanced gastric cancer with pyloric stenosis. She had a good postoperative course and was discharged 2 weeks after surgery. She received adjuvant chemotherapy with S-1 after discharge. One month after the initiation of the adjuvant chemotherapy, she complained of wobbling and weakness of her limbs. She stopped intake of S-1, but the symptoms did not improve. She was admitted to the hospital, but she became unconscious and had headache and blurred vision. We conducted a cerebrospinal fluid examination and made a diagnosis of meningeal carcinomatosis. After we started intrathecal infusion of methotrexate and Ara-C, referring to case reports clinical symptoms, including unconsciousness, headache, and left upper limb paralysis, improved and the CEA level in cerebrospinal fluid decreased.

Background: The utilization of laparoscopic surgery for groin hernias is rapidly increasing in Japan even though a consensus for the use of the laparoscopic over the open approaches to surgery for emergent cases has yet to be determined. Therefore, we retrospectively examined patient outcomes from both open and laparoscopic surgeries.Methods: Emergent surgery for a strangulated groin hernia was performed on 63 patients at our hospital from January 2013 to December 2017. All laparoscopic surgeries were performed using the transabdominal preperitoneal repair (TAPP) approach. The choice of whether to perform an open approach (open) or laparoscopic surgery with the TAPP approach was made by doctors who were familiar with both surgical techniques.Results: There were 49 patients in the open group and 14 patients in the TAPP group. The median operation time (min) was 78 in the open group and 127 in the TAPP group. The median intraoperative blood loss (ml) was 21.0 in the open group and 3.0 in the TAPP group. There were 12 patients (24.5%) in the open group and 1 patient (7.1%) in the TAPP group who had postoperative complications. Surgical site infection did not occur in the TAPP group.Conclusions: TAPP is a useful technique in emergent surgery for incarcerated hernias.

The first patient was a 62-year-old woman who was referred to our hospital with the complaint of a left breast tumor. She was diagnosed with invasive ductal carcinoma(T1N0M0, stage I). The tumor was ER-positive, PgR-negative, and HER2- negative. She was treated with toremifene, letrozole, and anastrozole as neoadjuvant hormone therapy for 4 months, but the tumor increased in size. The clinical response was judged as progressive disease, and a left partial mastectomy and axillary lymph node dissection were performed. Chemotherapy and radiotherapy were performed after surgery. The second patient was a 68-year-old woman who was referred to our hospital with the complaint of a right breast tumor. She was diagnosed as invasive ductal carcinoma(T1N0M0, stage I). The tumor was ER-positive, PgR-negative, and HER2-negative. She was treated with letrozole as neoadjuvant hormone therapy for 4 months, but the tumor increased in size. The clinical response was judged as progressive disease, and a right partial mastectomy and axillary lymph node dissection were performed. Chemotherapy and radiotherapy were performed after surgery. Although the evidence is still insufficient, with neoadjuvant hormone therapy for hormone-sensitive breast cancer, improved tumor shrinkage and breast conservation have been reported. We experienced two cases in which the tumor increased in size during neoadjuvant hormone therapy; however, even though these cases showed no apparent effect, chemotherapy may be effective in future cases.