Content - IASGO 2021

NOVEMBER 20-22, 2021

Content Saturday, November 20, 2021

Immunotherapy on Digestive Malignancy Session 1Immunotherapy on Digestive Malignancy Session 2Immunotherapy on Digestive Malignancy Session 3Update: Endoscopic Procedures for GI & HPB Disease Session 1Update: Endoscopic Procedures for GI & HPB Disease Session 2Hepatitis Management for Oncologic Patients Update of Diagnostic Image and Intervention Therapy for Abdominal MalignancyUpdate of Radiotherapy & Proton Therapy for Abdominal MalignancyNET Session 1NET Session 2NET Session 3ERAS-IASGO Joint Symposium 1ERAS-IASGO Joint Symposium 2ERAS-IASGO Joint Symposium 3ICS (Taiwan Section)-IASGO Joint Symposium 1ICS (Taiwan Section)-IASGO Joint Symposium 2Sarcoma and GIST Session 1 (Update Knowledge What Surgeons Need to Know) Sarcoma and GIST Session 2 (Zai Lab-Sponsored Session)Metabolic and Bariatric Surgery Session 1Metabolic and Bariatric Surgery Session 2Metabolic and Bariatric Surgery Session 3AI and Surgical Oncology Session 1AI and Surgical Oncology Session 2

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Sunday, November 21, 2021

Keynote Speech GI Session 2KM Chen Memorial Lecture GI 3GI Session 4Esophagus Session 1Esophagus Session 2Liver Session 1Liver Session 2Liver Session 3Liver Session 4Liver Session 5Liver Session 6GI Session 1Hernia SessionBiliary Session 1Biliary Session 2Biliary Session 3Biliary Session 4Pancreas Session 1Pancreas Session 2Pancreas Session 3Pancreas Session 4Pancreas Session 5Pancreas Session 6MIS Session 1MIS Session 2MIS Session 3MIS Session 4MIS Session 5MIS Session 6

Colorectal Session 1Colorectal Session 3Nutrition Session 1Nutrition Session 2Thyroid & Parathyroid Session 1Thyroid & Parathyroid Session 2Thyroid & Parathyroid Session 3Thyroid & Parathyroid Session 4Thyroid & Parathyroid Session 5Thyroid & Parathyroid Session 6Oncology Nursing Session 1Oncology Nursing Session 2Oncology Nursing Session 3Perioperative Nursing Session 1Perioperative Nursing Session 2Perioperative Nursing Session 3Free Paper - GI & PancreasFree Paper – LiverFree Paper – BiliaryFree Paper – Others

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Monday, November 22, 2021

GI Session 5GI Session 6Liver Session 7Liver Session 8TSSG & JSGS Joint MeetingPancreas Session 7Pancreas Session 8Pancreas Session 9MIS Session 7MIS Session 8Others SessionTelemedicine and Telecare Session 1Telemedicine and Telecare Session 2

E-Poster Session

E-Poster Session

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Introduction to Immunotherapy

Tom Wei-Wu Chen

National Taiwan University Hospital Immunotherapy, or more specifically, has transformed the treatment paradigm of cancer patients. PD-1 and CTLA-4 antibodies have been approved by regulatory agencies around the world for various cancer types including melanoma, renal cell carcinoma, hepatocellular carcinoma, gastric, and esophageal cancers, etc. The lecture will provide a short introduction about the mechanism of adaptive immunity, the combinations of immune checkpoint inhibitors and with other anti-angiogenic agents, and, lastly, the biomarkers of immune checkpoint inhibitors.

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Immuotherapy for Esophageal Cancer

Jhe-Cyuan Guo

National Taiwan University Cancer Center, Taiwan

Email: [email protected]

Immunotherapy especially immune checkpoint inhibitors (ICIs) has changed the therapeutic landscape of many cancer types. Esophageal cancer (EC) includes two major histologic subtypes, esophageal adenocarcinoma and esophageal squamous cell carcinoma (ESCC) which are different disease entities with different geographic distributaions, risk factors and even genetic alterations. Anti-programmed cell death protein 1 (PD-1)-based ICIs has become an indispensable treatment modality for ESCC. Anti-PD-1 monoclonal antibodies outperform chemotherapy as second-line systemic therapy for recurrent or metastatic ESCC. Anti-PD-1 monoclonal antibodies plus chemotherapy compared with chemotherapy alone exhibit better survivals and response rate as fisrt-lint systemic therapy for recurrent ESCC. Nivolumab (an anti-PD-1 antibody) compreed with placebo also improved disease-free survival as adjuvant therapy for patients with locoregional EC treated with neoadjuvant chemoradiotherapy followed by esophagectomy. Anti-PD-1 monoclonal antibody has incoporated into the therapeutic landscape of EC in adjuvant and recurrent or metastatic settings. Keywords: esophageal cancer, immunotherapy, PD-1.

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Immune Checkpoint Inhibitors for Gastric Cancer

Li-Yuan Bai Since the introduction of the first immune checkpoint inhibitor ipilimumab in 2011, there have been more than 3000 clinical trials to evaluate T cell modulation, and most of them are anticancer trials. The initial and most impressive data comes from 20% of patients with melanoma having complete remission after checkpoint inhibitor. But how are immune checkpoint inhibitors for gastric cancer? Immune checkpoint inhibitors have been used extensively in gastric cancer trials with diverse results. Even immune checkpoint inhibitors show benefit for some patients with advanced gastric cancer, can we identify the population who will get the benefit most from it? Till now, MSI, TMB, PD-L 1 expression and EBV are all potential biomarker for immune checkpoint inhibitor treatment in patients with gastric cancer. In this meeting, I will present the current clinical trial data and discuss the issue of biomarkers for using immune checkpoint inhibitors.

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Immunotherapy for Metastatic Colorectal Cancer: Beyond a Needle in a Haystack

Yi-Hsin Liang

Department of Oncology, National Taiwan University Hospital, Taiwan (R.O.C)

Recent years, the role of immune checkpoint therapies, such as PD-1 inhibitors, have expanded their application in colorectal cancer (CRC). While PD-1 inhibitors have been approved for MSI-H indications, many ongoing trials are exploring various treatment algorithms for all subsets of CRC patients. In this session, different combination modalities with immune checkpoint inhibitors will be discussed ranging from MSI-H to MSS CRC. In the phase 2 CheckMate 142 trial, patients with MSI-H/dMMR mCRC and no prior treatment for metastatic disease received nivolumab 3 mg/kg every 2 weeks + low-dose ipilimumab 1 mg/kg every 6 weeks until disease progression or discontinuation. This combination provided robust and durable clinical benefit and was well tolerated as 1L therapy for MSI-H/dMMR mCRC with an overall response rate of 64%, disease control rate of 84% for more than 12 weeks; meanwhile, both PFS and OS were not reached. Last but not least, a phase II study of ipilimumab and nivolumab with radiation in MSS metastatic colorectal adenocarcinoma will be discussed. In this study, 40 MSS mCRC patients were enrolled undergone treatment consisted of ipilimumab 1mg/kg every 6 weeks, nivolumab 240 mg every 2 weeks and 3 fractions of 8 Gy of RT at cycle 2 every other day. DCR was 25% (10/40) with a 10% (4/40) ORR by ITT. Median duration of disease control was 2.4 months. Median overall survival for patients with CR/PR/SD was 15.8 months demonstrating durable activity of dual blockade of CTL-A and PD-1 with RT in MSS mCRC patients.

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Immunotherapy for Surgical Oncologists: Adjuvant Setting

Chiao-En Wu

Chang Gung Memorial Hospital, Taiwan


Immunotherapy have largely improved the survivals in various cancers. Adjuvant immunotherapy

aims to decrease recurrence and increase overall survival. Based on the successful studies of

immunotherapy in advanced cancer, some studies of immunotherapy have moved to adjuvant setting.

In this talk, I will review the current advance of adjuvant immunotherapy particularly in digestive

malignancy. The most important study is that adjuvant nivolumab significantly improved disease-

free survival in resected esophageal or gastroesophageal junction cancer following neoadjuvant

chemoradiotherapy (CheckMate 577). Other studies of potential immunotherapy is ongoing.

Keywords: immunotherapy, adjuvant, digestive malignancy

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Immunotherapy for Surgical Oncologists: Future Perspective

Jiun-I Lai Department of Oncology, Taipei Veterans General Hospital

[email protected] Immunotherapy has revolutionized the treatment landscape for advanced and metastatic cancers. From melanoma to lung cancer to a plethora of other cancer types, immunotherapy has become an indispensible treatment option in the majority of cancers. The role of immunotherapy in early cancers, including neoadjuvant or adjuvant setting, is currently still under active development. In this presentation, I will discuss the recent updates and breakthroughs on immunotherapy in adjuvant and neoadjuvant setting. I will also hightlight the important considerations and concepts in adjuvant and neoadjuvant immunotherapy and related mechanisms in cancer biology and biomarker development. Keywords: immunotherapy, adjuvant, neoadjuvant

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Update of EUS Intervention for Luminal Anastomoses

Yu-Ting Kuo

Division of Endoscopy, Department of Integrated Diagnostics & Therapeutics

National Taiwan University Hospital, Taipei, Taiwan

Recently, there have been significant advancements in endoscopic ultrasound-guided

gastroenterostomy (EUS-GE) is now a reality. The described procedures have been

made possible with novel devices that can reduce the difficulties of the procedures and

potentially reducing the risk of adverse events. EUS-GE composes of a number of

different procedures for different indications. EUS-GE can be performed for benign or

unresectable malignant gastric outlet obstruction, EUS-guided afferent limb obstruction

can be performed for malignant afferent limb obstruction, and EUS-guided gastro-

gastrostomy can be performed for performance of ERCP after Roux-en Y gastric bypass

(EDGE).

EUS-GE for benign or malignant gastric outlet obstructions has been described in

several studies. When compared with duodenal stenting, the procedure was shown to

be associated with less symptom recurrence and reinterventions. When compared with

laparoscopic gastrojejunostomy, the technical and clinical success were similar but

adverse events were significantly more in the laparoscopic gastrojejunostomy group.

For afferent limb obstruction, EUS-guided drainage has been showed to be associated

with 100% technical success and needed fewer reinterventions than endoluminal

stenting. In EDGE, the procedure was shown to be successful in allowing performance

of ERCP through the stent via the excluded stomach. When compared with

enteroscopy-guided ERCP, the technical success rate was significantly higher, and the

total procedure time was significantly shorter. The post-procedure median length of

hospitalization was also shorter. Therefore, EUS-guided anastomosis between two

gastrointestinal organs is a promising approach and a safe and effective therapeutic

option to resolve several mentioned clinical conditions.

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Current Intraductal Management with Cholangioscopy

Yi-Chun Chiu

Kaohsiung Chang-Gung Memorial Hospital, Taiwan Email: [email protected]

Cholangioscopy is a noninvasive endoscopic method used for both direct visual diagnostic evaluation and simultaneous therapeutic intervention of the bile ducts. Peroral cholangioscopy overcomes some of the limitations of endoscopic retrograde cholangiopancreatography (ERCP). Early cholangioscopes had several limitations: they were very fragile and could break up; required two endoscopists; had only a two-way steering mechanism, which severely limited negotiation of ducts; and lacked working channels and irrigation ports. Thus, in the absence of more modern endoscopic technologies, this procedure was restricted to a few specialized centers worldwide for very specific indications. However, the Spyglass cholangioscopes have overcome many of the limitations posed by these earlier cholangioscopes. Indeed, the Spyglass cholangiopancreatoscopy showed promising results in a multicenter international study for diagnostic and therapeutic applications during endoscopic procedures in the pancreaticobiliary system. Studies have evaluated clinical efficacy of peroral cholangioscopy in characterizing benign versus malignant natures of biliary strictures, diagnosing intraductal tumors, better defining unknown biliary pathologies, and treating biliary and pancreatic stones. This topic will review the recent advances in intraductal management with cholangioscopy performed during ERCP using currently available instruments. Keywords: Peroral cholangioscopy; SpyGlass; Intraductal management

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POEF (POEM+F): Per-oral Endoscopic Fundoplication - Pure NOTES Partial Fundoplication

Haruhiro Inoue

Chief and Professor, Digestive Diseases Center, Showa University Koto Toyosu

Hospital, Tokyo, Japan POEF (Per-oral endoscopic fundoplication) is a NOTES partial fundoplication. Through anterior submucosal tunnel, flexible endoscope can access to abdominal cavity. Under monitoring pediatric scope placed in the stomach, anterior gastric wall is sutured using endoscopic suturing device as a distal anchor. Right crus of diaphragm is sutured as a proximal anchor. Two stitches are completed using V-lock. Last three years 45 consecutive patients received POEF. Technical success rate was 100%. improvement of composite score was demonstrated by 24hr pH-impedance monitoring. In this lecture actual procedural details will be shared.

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Endoscopic Suturing and Stapling Devices & Their Applications

Amit Maydeo

Baldota Institute of Digestive Sciences (BIDS), Global hospital, Mumbai, India

Email: [email protected] The speciality of Interventional GI Endoscopy has grown exponentially over the past 6 decades. Beginning with foreign body removal, today interventional GI endoscopy has entered the era of flexible endoscopic surgery. In 2021, procedures like endoscopic dissection and resection (EMR, ESD and EFTR) have become quite common and newer modalities like endotherapy of gastroesophageal reflux disease (GERD) as well as obesity are evolving. There is therefore a need for having a robust endoscopic suturing system which can be applied for a variety of purposes like closing iatrogenic GI perforations, closing defects caused by EMR, ESD and EFTR, fix implants like metallic stents, close outlets after a previous bariatric surgery or remodel the OG junction and stomach in patients having GERD or obesity. Traditionally, closing defects endoscopically could be achieved only by using through the scope clips along with endoloops. However, this can be quite a cumbersome technique and the robustness of the closure was questionable. In 2021 we have a variety of endoscopic suturing and stapling techniques which can be applied easily. The most time-tested technique is that of the overstitch system from Apollo endosurgery. Since its first introduction in 2005, this device has undergone many changes and we have the latest generation device which can be used with the double and single channel endoscope. The most common use of this device is to reduce the stomach size with a procedure called as endoscopic sleeve gastroplasty (ESG). The device can also be used to reduce a dilated GJ anastomosis after a bypass procedure and used very effectively to close full thickness defects caused after EMR or ESD. The second device which is a stapling device is the GERDx system which can be used very effectively to remodel the OG junction in patients having PPI dependent GERD. The latest and easiest device to use is the X-Tack system also from Apollo Endosurgery where in simple helix tacks are used along with a prolene suture by which we can effectively close defects created by EMR, ESD or EFTR. The future of endoscopic suturing is however going to be actual intra-corporeal suturing using the flexible robotic multi-armed endoscope.

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Endohepatology

Jiann-Hwa Chen

Taipei Tzu Chi hospital, Taiwan Email: [email protected]

Lesions such as hepatocellular carcinoma (HCC) or other entities at the caudate lobe were located at the deep site of liver, which was not visualized well by transabdominal ultrasound, and there were intervening veins that would have made it not only difficult but also hazardous to attempt percutaneous ablative treatment due to the long trajectory. Endoscopic ultrasonography (EUS) has emerged as a highly sophisticated interventional modality. EUS guided therapy provide the best solution to treat the caudate lobe lesion, i.e., in close proximity to the stomach, which made it easily accessible by EUS. EUS have been developed for the interventional purpose in addition to the pancreatic disease. EUS-guided liver biopsy or ethanol injection, owing to its less invasiveness, appears to be a new innovative option for lesions that is difficult to treat by local percutaneous treatment.

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Prevention and Management of HBV Reactivation for Oncologic Patients

Chun-Jen Liu

Hepatitis Research Center and Department of Internal Medicine,

National Taiwan University College of Medicine and Hospital, Taipei, Taiwan Chronic hepatitis B virus (HBV) infection is endemic in the Asian-Pacific region, and reactivation of HBV post-cancer chemotherapy has become an emerging clinical challenge. Patients with detectable serum HBV DNA before chemotherapy and those receiving intensive chemotherapy are particularly at a risk of HBV reactivation. Most patients with HBV reactivation are positive for hepatitis B surface antigen (HBsAg) and are, therefore, easily identified by recommended serological screening before chemotherapy. However, a small, but significant proportion of subjects who have apparently recovered from HBV infection as reflected by HBsAg negativity and hepatitis B core antibody positivity in HBV endemic areas may also experience reactivation when host immunity is severely compromised by cancer chemotherapy. Recent studies suggest that HBV reactivation can occur in oncology patients receiving immune check point inhibitors or tyrosine kinase inhibitors. APASL 2021 international guidance suggests that serum alanine aminotransferase, HBsAg, and HBV DNA should be monitored for oncology patients. Liver fibrosis status should also be evaluated before the start of immunosuppressive therapy. Risk of reactivation can be stratified and antiviral prophylaxis should be administered for patients at moderate or high risk of reactivation. For patients with advanced fibrosis or cirrhosis, antiviral prophylaxis should be given for patients even at low risk of HBV reactivation. The prophylactic use of nucleos(t)ide analogs before chemotherapy and its continuation until reconstitution of host immunity remain the mainstay of effective prevention of hepatitis B reactivation in this special clinical entity.

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Diagnosis and Management of Nonalcoholic Steatohepatitis in Cancer Patients

Hung-Chih Yang

National Taiwan University College of Medicine and Hospital, Taiwan

Email: [email protected] Nonalcoholic fatty liver disesase (NAFLD)/Nonalcoholic steatohepatitis (NASH) is increasingly prevalent worldwide, and becomes a global important issue of public health. NAFLD results from fat accumulation in liver, and a portion of patients with NAFLD develop hepatic inflammation, leading to NASH. NASH is closely associated with obesity and metablic syndrome, which have been recognized as critical factors contributing to the development of cancer. Thus, NASH is often observed in cancer patients. Additionally, some anti-cancer drugs, like estrogen inhibitor tamoxifen used for treating breast cancer, is reported to enhance fat accumulation in liver, further promoting the development of NASH. Recently, NASH has been found to attenuate the host immunity against cancer, so early diagnosis and management of NASH is crucial in cancer patients. However, diagnosis of NASH is no easy thing. Abnormal liver function is frequeently encountered in cancer patients, and several common etiologies of hepatitis need to be differentiated, incluidng viral hepatitis, drug-induced liver injury, and immune-mediated hepatitis. Although NFALD can be conveniently determined by ultrasonography, definite diagnosis of NASH requires liver biopsy because elevation of alanine transaminase (ALT) in patients swith NAFLD is not always a reliable marker. Liver biopsy remains the gold-standard diagnostic method for NASH, but non-invasive approaches or surrogate biomarkers for easily dignosing NASH have gained great attraction and are more practical due to the convenience and safety concerns. Nevertheless, non-invasive methods still cannot replace liver biopsy to confirm the diagnosis of NASH at present. Timely management of NASH in cancer patients is also very important. Severe NASH with high ALT may prevent patients from receiving adequate anti-cancer treatment or interupt the therapeutic schedules, compromizing the response to treatment. However, there is so far no approved pharmacological treatment for NASH. Lifestyle change involveing increase of the physical activity and diet modification and body weight reduction remain the major measures to treat NASH. In this talk, we will discuss the impact of NASH on the short-term treatment response and long-term prognosis, and the importantce for timely diagnosis and management of NASH in cancer patients. Keywords: NAFLD, NASH, cancer patients

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Diagnosis of Pancreatic Cancer: Radiological Imaging and AI

Po-Ting Chen

Department of Medical Imaging, National Taiwan University Hospital, Taiwan Email: [email protected]

Outline

● Common imaging modality for pancreatic cancer diagnosis ● Artificial intelligence study for pancreatic cancer in CT images

○ Radiomics with machine learning ○ Deep learning

Radiomic Features at CT Can Distinguish Pancreatic Cancer from Noncancerous Pancreas Background and Purpose: To identify distinguishing CT radiomic features of pancreatic ductal adenocarcinoma (PDAC) and to investigate whether radiomic analysis with machine learning can distinguish between patients who have PDAC and those who do not. Materials and Methods: This retrospective study included contrast material–enhanced CT images in 436 patients with PDAC and 479 healthy controls from 2012 to 2018 from Taiwan that were randomly divided for training and testing. Another 100 patients with PDAC (enriched for small PDACs) and 100 controls from Taiwan were identified for testing (from 2004 to 2011). An additional 182 patients with PDAC and 82 healthy controls from the United States were randomly divided for training and testing. Images were processed into patches. An XGBoost (https://xgboost.ai/) model was trained to classify patches as cancerous or noncancerous. Patients were classified as either having or not having PDAC on the basis of the proportion of patches classified as cancerous. For both patch-based and patient-based classification, the models were characterized as either a local model (trained on Taiwanese data only) or a generalized model (trained on both Taiwanese and U.S. data). Sensitivity, specificity, and accuracy were calculated for patch- and patient-based analysis for the models. Results: The median tumor size was 2.8 cm (interquartile range, 2.0–4.0 cm) in the 536 Taiwanese patients with PDAC (mean age, 65 years 6 12 [standard deviation]; 289 men). Compared with normal pancreas, PDACs had lower values for radiomic features reflecting intensity and higher values for radiomic features reflecting heterogeneity. The performance metrics for the developed generalized model when tested on the Taiwanese and U.S. test data sets, respectively, were as follows: sensitivity, 94.7% (177 of 187) and 80.6% (29 of 36); specificity, 95.4% (187 of 196) and 100% (16 of 16); accuracy, 95.0% (364 of 383) and 86.5% (45 of 52); and area under the curve, 0.98 and 0.91. Conclusion: Radiomic analysis with machine learning enabled accurate detection of PDAC at CT and could identify patients with PDAC. Deep learning to distinguish pancreatic cancer tissue from non-cancerous pancreatic tissue: a retrospective study with cross-racial external validation Background and Purpose: The diagnostic performance of CT for pancreatic cancer is interpreter-dependent, and approximately 40% of tumours smaller than 2 cm evade detection. Convolutional

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neural networks (CNNs) have shown promise in image analysis, but the networks' potential for pancreatic cancer detection and diagnosis is unclear. We aimed to investigate whether CNN could distinguish individuals with and without pancreatic cancer on CT, compared with radiologist interpretation. Materials and Methods: In this retrospective, diagnostic study, contrast-enhanced CT images of 370 patients with pancreatic cancer and 320 controls from a Taiwanese centre were manually labelled and randomly divided for training and validation (295 patients with pancreatic cancer and 256 controls) and testing (75 patients with pancreatic cancer and 64 controls; local test set 1). Images were preprocessed into patches, and a CNN was trained to classify patches as cancerous or non-cancerous. Individuals were classified as with or without pancreatic cancer on the basis of the proportion of patches diagnosed as cancerous by the CNN, using a cutoff determined using the training and validation set. The CNN was further tested with another local test set (101 patients with pancreatic cancers and 88 controls; local test set 2) and a US dataset (281 pancreatic cancers and 82 controls). Radiologist reports of pancreatic cancer images in the local test sets were retrieved for comparison. Results: Between Jan 1, 2006, and Dec 31, 2018, we obtained CT images. In local test set 1, CNN-based analysis had a sensitivity of 0·973, specificity of 1·000, and accuracy of 0·986 (area under the curve [AUC] 0·997 (95% CI 0·992–1·000). In local test set 2, CNN-based analysis had a sensitivity of 0·990, specificity of 0·989, and accuracy of 0·989 (AUC 0·999 [0·998–1·000]). In the US test set, CNN-based analysis had a sensitivity of 0·790, specificity of 0·976, and accuracy of 0·832 (AUC 0·920 [0·891–0·948)]. CNN-based analysis achieved higher sensitivity than radiologists did (0·983 vs 0·929, difference 0·054 [95% CI 0·011–0·098]; p=0·014) in the two local test sets combined. CNN missed three (1·7%) of 176 pancreatic cancers (1·1–1·2 cm). Radiologists missed 12 (7%) of 168 pancreatic cancers (1·0–3·3 cm), of which 11 (92%) were correctly classified using CNN. The sensitivity of CNN for tumours smaller than 2 cm was 92·1% in the local test sets and 63·1% in the US test set. Conclusion: CNN could accurately distinguish pancreatic cancer on CT, with acceptable generalisability to images of patients from various races and ethnicities. CNN could supplement radiologist interpretation.

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Image-Guided Radiotherapy in Pancreatic and Hepatobiliary Cancer: MR, PET and Conebeam-CT

Thomas B. Brunner, Ahmed Gawish

Department of Radiotherapy, University of Magdeburg, Germany

Email: [email protected] Background and Purpose: Image guided radiotherapy (IGRT) is crucial in upper abdominal radiotherapy where sensitive organs at risk are often in close proximity to the tumor. The aim is to define the roles of conebeam CT, MR and PET for liver, the biliary tree and the pancreas. Materials and Methods: After definition of IGRT and analysis of the specific setting in the upper abdomen the three imaging modalities are analysed according to IGRT in the narrower sense of radiation sessions and the broader sense including diagnostic work up and radiation therapy planning imaging. Results: Radiotherapy of upper abdominal malignancies is dominated by stereotactic body radiotherapy (SBRT) especially for hepatobiliary cancer. In this situation the necessity for accurate and precise therapy is highest due to narrow margins between the tumour and the planning volume and thus a very challenging example for IGRT. kV-CBCT is the mainstay of IGRT and standard in modern radiotherapy and surrogate structures for the tumor have to be utilized (fiducial markers, lipiodol, whole liver, surgical clips, stents). MR-LINACs are available from two companies and these define a new gold standard of perifractional IGRT in upper abdominal malignancies. This is due to the excellent soft tissue contrast visualizing the position of the tumour and of the organs at risk for setup und for continuous imaging during the actual radiation treatment. 4D-planning imaging most often is realized as CT, but 4D-PET/CT and cine-MRI are also excellent options for respiratory motion managment. Conclusion: IGRT has dramatically improved over the past two decades and allows to apply radiotherapy with ablatvie doses in the pancreas and the hepatobiliary tract. Keywords: IGRT, SBRT, pancreatic cancer, liver cancer, MR-LINAC, PET, MR, CBCT

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Update of Radiotherapy and Particle Therapy for Pancreatic Cancer

Chiao-Ling Tsai

National Taiwan University Hospital, Taiwan Email: [email protected]

Pancreatic cancer is one of the most lethal malignancies in gastrointestinal entities. Surgery is the only chance for a cure; however, only a minority of patients can be offered this option at diagnosis. After resection, almost 80% of patients develop tumor recurrence with 5-year survival rates of less than 30%. This high recurrence rate has led to the introduction of neoadjuvant and adjuvant therapy. The strategies of neo-adjuvant and adjuvant treatment include chemo- and/or radiotherapy before/after surgery. In this part, we will review current algorithms for pancreatic cancer management. Discussing issues and controversies which were related to neoadjuvant/adjuvant radiotherapy. A brief introduction of particle therapy and SBRT (stereotactic body radiotherapy) and their role in this disease. Keywords: pancreatic cancer, radiotherapy.

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Recent Advances of Proton and Particle Therapy for Rectal Cancer

Che-Yu Hsu

Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital Email: [email protected]

Rectal cancer requires multidisciplinary care, and preoperative chemoradiation with 5-fluorouracil-(5-FU)-based treatment followed by total mesorectal excision is the standard of care for locally advanced rectal cancer with good loco-regional outcome. Intensity modulated radiation therapy (IMRT) or volumetric modulated arc therapy (VMAT) holds a prominent role to deliver the radiation to tumors and aviod the critical organ exposure. Proper dosimetric constraints of IMRT or VMAT limits the radiation dosage to small bowel, bladde, and bone marrow, and may reduce the toxicities, such as diarrhea, dysuria, and neutorpenia. Particle therapy (PT) is known as a highly conformal radiation technique providing better dosimetric advantages over conventional radiotherapy by allowing significant dose reduction for organs at risk. The present session will review the role of PT in rectal cancer. Comparison of IMRT or VMAT with pencil beam scanning (PBS) PT in the neoadjuvant for newly diagnosed rectal cancer and re-irradiation for recurrent casese will be adressed. Key words: rectal cancer, proton therapy, particle therapy

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Epidemiology of Neuroendocrine Tumors (NETs)

Hui-Jen Tsai

National Institute of Cancer Research, National Health Research Institutes, Taiwan Email: [email protected]

Neuroendocrine tumors (NETs) are neoplasms originating from neuroendocrine cells located throughout the body, most commonly in lung and gastroentero-pancreas (GEP). The incidence of NETs in US has been increased from 1.09 per 100,000 in 1973 to 6.98 per 100,000 in 2012. The incidence of NETs in Taiwan has also been increased from 0.24 per 100,000 in 1996 to 3.16 per 100,000 in 2015. Although the incidecen of NETs varies among different countries, the increasing trend in recent decades is similar worldwide. There are heterogeneity in common primary sites of NETs among different races and countries. Lung is a common primary site of NETs for most countries and races. However, small intestine, including appendix, is a common site of NETs in European countries, such as Norway and the Netherlands, US and Australia but less common in Asia. Rectal NETs are more common in Asia, Asian in US, and American Black but less common in Caucasian, such as American White and European. The increased incidence of NETs, particularly localized and grade 1 NETs, may attributed to multiple factors, including improved and enhanced diagnosis tool, increased awareness in clinical practice, and introduction of 2010 WHO clasification for NETs. The survival of NETs has also been improved, including metastatic disease, attributed to early diagnosis and introduction of various novel agents, such as somatostatin analogues, small molecular targeted agents, and peptide receptor radionucleotide therapy, for the treatment of advanced NETs. The survivals of NETs among different primary sites varies, which may attribute from the proportion of stage and grade. Therefore, how to improve the early diagnosis of NETs is important. In addition, why different races have their prevalent site of NETs is always concerned and need further investigation. Keywords: epidemiology, neuroendocrien tumors, incidence, survival

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Diagnosis and Classification of GEP-NET

Chien-Feng Li

Department of Medical Research, Chi Mei Medical Center

National Institute of Cancer Research, National Health Research Institutes Email: [email protected]

Surgery is the mainstay of early-stage gastroenteropancreatic neuroendocrine tumors (GEP-NET); chemo-/targeted therapy and experimental therapies remain the therapeutic cornerstone in unresectable and metastatic GEP-NET. Recent studies further disclosed the biological and immune landscapes of GEP-NET leading to the development of potential biomarkers carrying prognostic and/or therapeutic relevance. Emerging integration of molecular profiling datasets has led to the identification of distinct molecular features of GEP-NET with diverse clinical behaviors and potential sensitivity to various therapies. It has also led to the disclosure of frequently altered genes and proteins that could lead to perturbation of intracellular signaling pathways. In this talk, we will briefly summarize the morphological and genomic biomarkers that may predict the nature course of and/or response to various therapeutics with examples of ‘personalized treatment’ aiming to improve outcomes in GEP-NET. Keywords: GEP-NET

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Effective Cytoreduction of Numerous Neuroendocrine Tumor Liver Metastases

James R. Howe

Surgical Oncology and Endocrine Surgery, University of Iowa College of Medicine, United States [email protected]

Background and Purpose: Surgical cytoreduction of neuroendocrine tumor liver metastases (NETLMs) is one of many options for treating metastatic disease. Materials and Methods: The rationale and methods for performing will be reviewed. Results: Cytoreduction of NETLMs can improve symptoms and survival in patients when 70% cytoreduction can be achieved. Conclusion: Surgical cytoreduction of NETLMs should be considered in the management of patients with Stage IV NETs. Keywords: Neuroendocrine tumors; cytoreduction; hepatic debulking

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Real-World Practice in GEP-NET Management and PRRT: Future Treatment Scope

Rodney Hicks

Co-Chair of NET Service (ENETS Centre of Excellence), the Peter MacCallum Cancer

Centre and Head, Molecular Imaging and Targeted Therapeutics Laboratory, the University of Melbourne, Australia

Email: [email protected] Neuroendocrine neoplasia (NEN) primarily arises in the gut and ancillary organs and is covered by the general term gastro-entero-pancreatic neuroendocrine tumour (GEP-NET). Although once thought to be rare, the incidence of GEP-NET is increasing throughout the world and because over 50% present with metastatic disease and generally progress relatively slowly, they can be associated with significant impairment in quality of life as well as causing premature death. A high proportion of GEP-NET express the somatostatin receptor (SSTR), which represents both a diagnostic and therapeutic target. Peptide receptor radionuclide therapy (PRRT) with Lu-177 DOTA-octreotate is part of an established theranostic paradigm with an increasing body of evidence demonstrating its efficacy in appropriately-selected patients. Therapeutic goals can include control of symptoms related to secretion of various biologically-active compounds, including serotonin and various gut and pancreatic hormones, or control of progressive disease. The former aspiration is more typical of lower grade, well-differentiated disease whereas oncological control becomes more important as grade increases. Increasing grade may, however, be associated with reduction in SSTR expression and render patients unsuitable for this treatment. The NETTER-1 trial confirmed the efficacy observed in multiple prior institutional trials but was narrow in its eligibility criteria and used a fixed treatment protocol. Reflecting the heterogeneity that exists in GEP-NET, the Peter MacCallum Cancer Centre adapts the administered activity, the interval between treatments, the radionuclide used and use in combination with other oncological therapies based on molecular imaging phenotyping, disease burden and clinical manifestations of disease. These and other novel therapeutic approaches will be discussed.

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Updates of NETs 2021 in Nuclear Medicine Management – PRRT in Taiwan

Shih-Hsin Chen

Keelung Chang Gung Memorial Hospital, Taiwan


Back in 2011, when Prof. Hwang returned from the International Collaboration on Neuroendocrine Tumor in Vienna, he asked the nuclear medicine department to develop Gallium-68 somatostatin analog positron emission tomography. Two years later, the first patient was scanned. A manuscript describing the characteristics of our first batch of patients was accepted for publication in 2017. 4 years later, the last piece of the Theranostics paradigm – the treatment agent Lutathera – was finally introduced into Taiwan. In this talk, I will follow the journey of developing the theranostics model in Taiwan, with emphasis on the set up of the treatment facility and patient referral. Keywords: Ga-68 DOTATOC, FDG, PET, Lu-177 DOTATATE , PRRT, neuroendocrine tumor

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ERAS Enhanced Recovery After Surgery Needed More Than Ever Before

Olle Ljungqvist

Örebro University & Karolinska Institutet, Sweden ERAS is the abbreviation for Enhanced Recovery After Surgery – and this lecture gives a short insight to the history and the basic concepts of ERAS. ERAS is a new way of caring for the surgical patient that was imitated by a group of surgeons in northern Europe early this century 1. The concept was inspired by the Fast Track ideas employing a multi modal approach to enhance recovery after surgery. ERAS took these ideas further to address the entire patients journey using the available literature to identify and employ every care item that could enhance the recovery after major surgery. These care elements were assembled in an evidence based care program2 that proved to have major impact by improving outcomes substantially3. Because the program is multi modal it alos involves all disciplines engaged in the care of the patient. In 2010 the ERAS Society was formed with the aims to develop perioperative care by research and education, but also to implement ERAS principles globally (www.erassociety.org). ERAS Society Implementation programs are now in place in more than 250 units in more than 25 countries around the world and growing. ERAS has been shown to reduce complications by up tom 50%, enhance recovery to allow discharge in days instead of weeks, and to be associated with long term survival in cancer surgery and for these reasons ERAS can play an important role to manage the backlog of surgeries from the COVID19 pandemic that exists in many countries.4 For more information and tips on new and important research in ERAS please go the ERAS Society website.

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A Newcomer’s Perspectives of ERAS

Kyoichi Takaori

President, Nagahama City Hospital, Shiga, Japan, Visiting Professor, Asahi University

Enhanced Recovery After Surgery (ERAS) is a global platform for quality improvement in the field of perioperative care. Implementation of ERAS Society guidelines is a significant step forward to improve the clinical outcomes in a number of surgical specialties and to provide patients with numerous benefits. For example, ERAS protocols ensure the opportunities for improved outcomes by means of addressing frailty, optimizing nutrition, prehabilitation, correction of preoperative anemia and so on. Besides, it has been reported that ERAS is associated with cost savings for both patients and healthcare providers. These advantages are strong motivation for newcomers to join the ERAS Society and adopt the ERAS protocol. Moreover, the COVID-19 pandemic caused serious changes in patient care including perioperative management, resulting in strong demand for the ERAS-based practice. In the present session, a newcomer’s perspective of ERAS is to be presented and discussed with experts.

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Global View of ERAS in Taiwan

Shu-Lin Guo

Chairman, Taiwan Chapter, ERAS society, Taiwan


Background and Purpose: This presentation focuses on ERAS development in Taiwan. Materials and Methods: none. Results: The TW NHI was well-known around worldwide because of low cost and high citizen satisfication. However, we can find several problems to interrupt the healthcare quality and lead to HPCs burnout. Hence, it is necessary to change the current system and refocus individual professionalism. Enhanced recovery after surgery (ERAS) is a multimodal evidence-based approaches patient-centered care with supporting with multidisciplanary team. More and more HPCs awared this trend and provide their best efforts in ERAS implementation. Therefore, Taiwan Chapter, ERAS soceity has been established in July 2019. With the collaboration of different medical soceities, hopitals and patient groups, ERAS has been a hot issue in periperative care and attracted more HCPs joining this practices. We demostrate the best model of value-based practices which raise the better quailty with reasonable cost. That is the best chance to break the limitation and optimize the patient safety. Based on the society platform, implementaion expericne can be shared between ERAS teams and ERAS certificated hospitals. Conclusion: ERAS has a big step in Taiwan and attracts HCPs attention. More and more hospitals will be able to provide ERAS care in major surgeries. That will lead to 3 wins within patients, HCPs, and hosptals. Keywords: Enhanced recvoery after surgery, perioperative care, evidence-based medicine.bundle care, multidiscplanry team

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Anaesthetic Care in ERAS

Vera Lim

Tan Tock Seng Hospital, Singapore Email: [email protected]

Teams in healthcare are often good at functioning in their silos but coordination among them is poor. Enhanced Recovery After Surgery (ERAS) addresses this through change methodology combined with evidence-based surgery-specific guidelines. The anaesthetist is a vital team member in the multidisciplinary ERAS team, working in tandem with all on the team in achieving postoperative functional outcomes and return of physiological and psychological well-being for the perioperative patient. Anaesthetic care in ERAS mainly involves preoperative optimisation, intraoperative standardised workflows and postoperative multimodal analgesia. Prehabilitation is preoperative physiotherapy, psychological support through education and shared decision making and pathophysiology optimisation. Time may be required for prehabilitation to facilitate optimal recovery. Intraoperatively, standardised anaesthetic techniques with postoperative nausea, vomiting and temperature management strategies are utilised. Multimodal, opioid-sparing analgesia strategies are vital in balancing side effects with functional outcomes. There is evidence that anaesthetic techniques can influence oncological outcomes. Anaesthetic agents, regional anaesthesia techniques, lignocaine, dexamethasone, opioids, beta-blockers and non-steroidal anti-inflammatory agents have all been demonstrated in in vivo studies to influence cancer cells. For example, propofol has been shown to predominantly decrease tumour cell proliferation and invasion across a broad spectrum of cancer types in vivo. However, there is also evidence that propofol can increase migration and proliferation of breast cancer cell lines. On the other hand, volatile anaesthetic agents have consistently been shown to increase tumour growth, migration, and invasion in a broad range of cancer cell lines. Strong clinical evidence for recommendations in anaesthetic technique in oncological outcomes is still lacking. Fluid management is an integral part of intraoperative anaesthetic practice. The principles are to maintain euvolaemia and avoid hyperchloraemia. In summary, anaesthetic care is a part of the larger ERAS team goal of improving recovery of the perioperative patient, while minimising complications and returning the patient to their preoperative physiological and psychological state.

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Patient-Center Care of ERAS

Alison Yi-Ting Chang

Taichung Veterans General Hospital, Taiwan


Background and Purpose The key concept about ERAS program is starting patient engagement way before the admission and using multi-disciplinary collaboration throughout peri-operative phases under the evidence-based guideline that eventually achieves better outcomes. I would like to share my experience of ERAS program implantation in Taichung Veterans General Hospital, talk about obstacles that we met; how we deal with it, how we work with other professional faculty as a team, and the patient outcome.

“Fight for the things that you care about, but do it in a way that will lead others to join you”

Ruth Bader Ginsburg, justice of the US Supreme Court

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Perioperative Nutrient Care

Marianna S. Sioson

The Medical City Hospital, Philippines


Surgery is a procedure many patients fear and dread. Although life-saving and necessary in many instances, surgery induces inflammation which complicates wound healing and recovery. What Enhanced Recovery After Surgery® (ERAS) protocols attempt to do is to offer multimodal, multidisciplinary strategies to attenuate this inflammatory stress response. One such strategy is to manage the patient’s nutritional needs in the perioperative period. Malnutrition, as well as concomittant sarcopenia, may be present and must be identified before surgery is done. Furthermore, if malnutrition continues to persist in the postoperative period, patients have more clinical complications and stay longer in the hospital. Studies have shown that perioperative malnturition also increases hospital costs. Guidelines from the European Society for Clinical Nutrition and Metabolism (ESPEN) and the ERAS® Society state specific evidence-based nutrition-focused recommendations that surgery teams should implement in practice to improve clinical and functional status of patients upon discharge.

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ERAS and Early Nutrition for Pancreaticoduodenectomy

Julie Perinel

Edouard Herriot University Hospital, HCL, UCBL1 [email protected]

Pancreatic surgery is associated with a significant morbidity and prolonged length of hospital stay (LOS). In 2012, the Enhanced Recovery After Surgery (ERAS) study group published the first guidelines to implement ERAS program in patients undergoing pancreaticoduodenectomy (PD). These guidelines, updated in 2019, included 27 evidence-based recommendations but also a proper and structured audit system to provide feedback and to report the compliance. Systematic review and meta-analysis reported improved postoperative outcomes in ERAS group, with shorter LOS, lower incidence of delayed gastric emptying and overall complications without increasing readmission rates or mortality. ERAS program represents also a financial issue and is associated with significant cost savings. However, considering the majority of non-randomized studies and the substantial heterogeneity between the studies, more large-scale randomized studies with standardized ERAS program are still needed. Implementation of the ERAS program is a challenging process requiring the commitment of a multidisciplinary team. Compliance is a key element to assess the success of ERAS implementation and also to improve postoperative outcomes. Keywords : enhanced recovery program, ERAS, pancreatic surgery, pancreaticoduodenectomy, compliance

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Single-Incision Laparoscopic Cholecystectomy for Acute Cholecystitis

Chao-Wen Pan

Zuoying Branch of Kaohsiung Armed Forces General Hospital

[email protected] Laparoscopic cholecystectomy is the gold standard treatment for acute cholecystitis due to its minimal invasiveness. Pursue less invasiveness, less pain, and faster return to daily activity is the dream of all surgeon and then single-incision laparoscopic surgery has become the treatment option for acute cholecystitis. However, the safety and feasibility have become the main concern of this treatment. In our study, we included 79 patients with acute cholecystitis receiving single-incision laparoscopic cholecystectomy. We would discuss about the operation time, pain score, and the complications in single-incision laparoscopic cholecystectomy.

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Techniques of Reduced-Port Surgery for Miscellaneous Liver Anatomical Resection

Jian-Wei Huang

Department of Surgery, Kaohsiung Municipal Siao-Gang Hospital, Kaohsiung, Taiwan

[email protected]

Background and Purpose: Minimal invasive surgery has become the most popular technique in all kinds of surgery. Recently, not only easy partial hepatectomy, but advanced major liver surgery under laparoscopic method were published worldwide. Reduced-ports concept has been discussed to make minimal invasive surgery better due to increasing cosmetic outcome and decreasing wound pain. Generally, more than 5 ports laparoscopic liver surgery is acceptable by most surgeons. Here we share our experiences in how to create a better operative field in only 3 ports for laparoscopic major liver resection. Methods: From October 2014 till now, more than 200 patients received laparoscopic liver resection. One surgeon and one camera technician were enough in our operation. We got used to using three ports in most cases for achieving better outcome by reduced port surgery. We used tractable structure such as round ligament and gallbladder when doing hilar pedicle approaching. Straight needle holding was also a good tool for counter-traction in any direction to create a better operative field with limited assistance. Elastic band fixed on the specimen was another gentle and continuing holding way for tumor excision. Intracorporeal Pringle maneuver by Huang’s loop also makes the surgery more comfortable via inflow control. Triangulation manipulation was always the concern when inserting 3 trocar ports. Harmonic scalpel or Thunderbeat scalpel was used rather than CUSA. Bipolar coagulation was also helpful when dealing with raw surface oozing. We hope it will help the young staff have an alternative surgical choice in the world of reduced port laparoscopic anatomic hepatectomy. Conclusion: There are lots of preparations in laparoscopic liver resection before parenchymal transection. For beginners, don’t be too rash when doing liver partition. Enough pre-operative skills always make the surgery more comfortable and safe. When encountering bleeding, never forget Pringle maneuver and gentle coagulation helping you to stop bleeding. In the end, the technique of suture can hardly be overemphasized. Therefore, reduced port surgery may be acceptable widely in the future. Keywords: Reduced port liver surgery, Huang’s loop

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Reduced-Port Laparoscopic Right Hepatectomy: Tips and Tricks

Wen-Lung Su

Department of Surgery, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan

[email protected]

Background and Purpose: According to the recommendations for laparoscopic liver resection from the second international consensus conference in Morioka in 2014, a minor resection is one in which 2 or fewer Couinaud segments are removed. A major resection is one in which 3 or more segments are removed. In actuality, most laparoscopic minor resections reported in the literatures are left lateral sectionectomies or resections of segments 2, 3, 4b, 5, and 6, that is, mainly the anterior and inferior segments. Laparoscopic left lateral sectionectomy is the standard of care. Materials and Methods: From October 2014 to September 2021, total 96 patients received laparoscopic liver resection. Twenty-six cases (27%) received laparoscopic right hepatectomy. One surgeon with one a surgical technician was enough for our operation. Three (85%) to four trocars with Pfannenstiel (62%) or umbilical extended wound were used in our surgery. Huang’s loop for Pringle maneuver during parenchymal transection had become our standard procedure in inflow hilar control. Extraglissonean approach were started to be used for control of right Glissonean pedicle in the later 14 cases. Results: Among 26 cases of laparoscopic right hepatectomy, conversion to open surgery happened in 2 cases (7.7%) because of uncontrollable bleeding. Specimen weight is 796.13 ± 454.19 g, specimen size 17.09 ± 4.25 cm, tumor size 6.08 ± 4.40 cm, operation time 348.79 ± 120.15 minutes, blood loss 572.92 ± 613.45 ml, post-operative length of stay 11.13 ± 9.73 days, and overall length of stay 12.83 ± 10.06 days. Long term recurrent rate, disease free survival and overall survival had not been calculated due to short follow-up period. Conclusion: Laparoscopic surgery is feasible in major liver resection. It improved cosmetics and surgical wound pain. Patients can go back to work and normal daily of life as soon as possible if they receive this kind of minimally invasive surgery. Keywords: laparoscopic hepatectomy, right hepatectomy, reduced port surgery

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Laparoscopic Hepatectomy for Difficult Segments（Sg 1,7,8）

Chee Chien Yong

Kaohsiung Chang Gung Memorial Hospital, Taiwan Email: [email protected]

Background and Purpose: Difficult segments for laparoscopic hepatectomy was Sg 1,7,8 are challenging and higher in difficult score.

Materials and Methods: Surgical indication and strategy for overcome difficultly in laparoscopic approached was reviewed in single surgeon 10 years case series.

Results: At the past 10 years, author accumulated 427 laparoscopic hepatectomy and 21.5% of case in difficult segments. 81% of case was malignant and majority was hepatoma. 55% of case of underwent anatomical resection. and minor complication was 10.1% and major complication was 3.2% .

Conclusion: In selective patient, laparoscopic hepatectomy in difficult segments can safety performed in experience surgeon with no inferior outcome

Keywords: Minimal invasive surgery, liver resection, hepatoma.

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Single-Incision Laparoscopic Pancreaticoduodenectomy: Ways to Overcome

Shu-Hung Chuang

1. Division of General and Digestive Surgery, Department of Surgery, Kaohsiung Medical

University Hospital, Kaohsiung, Taiwan 2. School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan


Single-incision laparoscopic surgery (SILS), or laparoendoscopic single-site (LESS) surgery, has been introduced to diminish incision number and surgical trauma in 1992. While single-incision laparoscopic cholecystectomy (SILC) is the most frequently performed SILS, its application on major hepatopancreatobiliary (HPB) surgery has a slow progress due to instrumental and technical limitations. Besides, cost and safety are two additional major concerns. While SILC and single-incision laparoscopic common bile duct exploration (SILCBD) became our standard of care over the past decade, we developed more advanced SILS for malignant HPB diseases such as major liver resection, bile duct resection with hepaticojejunostomy, distal pancreatectomy and pancreaticoduodenectomy in recent years. Strictly following the principles of surgical oncology and standard multi-port laparoscopy is crucial to patient safety and prognosis. We herein report our preliminary experience of single-incision laparoscopic pancreaticoduodenectomy (SILPD). To the best of our knowledge, this is the first reported case series of SILPD in the world. Keywords: Hepatopancreatobiliary, laparoendoscopic single-site surgery, pancreaticoduodenectomy, single-incision laparoscopic surgery.

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Long Term Outcomes of NOSE Surgery of Left Colon Cancer

Joaquim Costa Pereira

Hospital de Braga, Portugal

Email: [email protected] Background and Purpose: NOSE (Natural Orifice Specimen Extraction) surgery of left colon cancer. Long Term Outcomes Materials and Methods: Evaluate the long term outcomes on patients with left colon cancer, in patients operated with NOSE surgery vs classis laparoscopic surgery. Sudied 66 pts (39 classic laparoscopi vs 27 NOSE). Survival evaluated with Kaplan-Mayer curves. Mi.nimum follow-up time of 5 years Results: There was not found any diference in overall survival and disease free survival between the two techniques. Conclusion: NOSE surgery of left colon is a safe technique with better short term outcomes than classic laparoscopy NOSE surgery of left colon has similar long term outcomes as classic laparoscopy Keywords: NOSES, Left colon cáncer, colorectal laparoscopy.

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What’s new in GIST:Evidence from the optimal treatment for GIST in Taiwan and the world

Chun-Nan Yeh

Department of Surgery, Chang Gung Memorial Hospital and University, Taiwan

Abstract For two decades, the understanding of gastrointestinal stromal tumors (GISTs), which are the most common mesenchymal tumors of the GI tract, has been proven to be a paradigm for developing targeted therapy. Due to a more precise definition through the use of pathological classification and molecular techniques, coupled with the advancement of clinical practice, especially the development of targeted therapy, there is now a much better insight into its treatment. In 2020, the ripretinib and avapritinib have been the eye-catchers in the GIST field. The recent arrival of avapritinib and ripretinib to the GIST arena has aimed to further improve on precision kinase inhibition and address tumor heterogeneity in imatinib-resistant GIST. The two main clinical challenges for the forthcoming years entail tumor eradication in patients with early-stage GIST, and maximization of tumor response in late-stage disease. To succeed, we will need to better understand the mechanisms behind adaptation to KIT inhibition and apoptosis evasion, tumor evolution after successive lines of treatment, and to explore clinically novel creative therapeutic strategies, with the overarching goal to tackle the intrinsic oncogenic complexity while minimizing adverse events. First, genetic test is strongly recommended when GIST patients using TKI. Apart from that, GIST has proven to be a paradigmatic model to study oncogene addiction, and to identify structural and functional mechanisms for drug resistance and response. Remarkably, the GIST field has been shaken once more: in 2020, ripretinib and avapritinib come into play by continuing to exploit GIST oncogenic dependencies to KIT and PDGFRA receptor tyrosine kinases (RTK). I hope the presentation regarding “What’s new in GIST” can help enhancing the quality of diagnosis, treatment, and care of patients with GIST in Taiwan.

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Gastrointestinal Stromal Tumors: Guidelines and Perspectives 2021

Jean-Yves Blay, Mehdi Brahmi, Armelle Dufresne

Centre Leon Berard, Lyon, France [email protected]

Background and Purpose: The objectives of the presentation is to present the state of the art and current questions on the management of GIST. Materials and Methods: A review of published literature was conducted. Results: Gastrointestinal stromal tumors (GIST) have an incidence of ~1.2 per 105 individuals per years worldwide. About 80% of GIST harbor different molecular changes, predominantly mutually exclusive activating KIT or PDGFRA mutations. Other rare molecular subtypes also exist. Localized GIST are curable and surgery is the mainstay of treatment for these tumors. Risk factors for relapse after optimal surgery include primary tumor size, mitotic index, bowel primary sites and rupture during surgery. Patients with GIST with KIT or PDGFRA mutations sensitive to imatinib that are at high risk of relapse have improved survival with 3-year adjuvant imatinib treatment. In advanced disease, median overall survival has improved from 18 months to >70 months since the introduction of tyrosine kinase inhibitors (TKI). The role of surgery in the advanced setting remains unclear. Resistance to TKI results from a clonal selection of cells equipped with resistance mutations of KIT or PDGFRA when they are the primary drivers. Advanced resistant GIST respond to second-line sunitinib and third-line regorafenib, as well as to the new inhibitors Ripretinib, avapritinib and also pazopanib and cabozantinib,. Rare molecular forms of GIST with aberrations involving NF1, SDH, BRAF or NTRK generally show primary resistance to standard TKIs, but respond to specific inhibitors when available (eg NTRKi) Conclusion: GIST are paradigmatIc models of targeted therapy in solid tumors . Cure rate has significantly progressed in the last years. Ripretinib and other new targeted therapies are now available to treatment molecular subsets resistant to the first generation of therapies. Keywords: GIST, targeted therapy, KIT, PDGFRA, imatinib, sunitinib, regorafenib, Ripretinib, avapritinib

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Bariatric & Metabolic Surgery in Taiwan

Wei-Jei Lee

Depart of Surg, Min-Sheng General Hospital, National Taiwan University, Taiwan

Obesity and type 2 diabetes(T2D) are of the common chronic, debilitating diseases in Taiwan now. Bariatric/metabolic surgical approaches not only are successful in achieving and maintaining long-term weight loss in severe obese patients, but also achieving pronounced metabolic effects, especially remission of type 2 diabetes. This review is aimed to summarize the development of metabolic surgery in Taiwan. The development in Taiwan can be classified into 4 major periods.

1) The Open VBG Period (1981-1997): Professor Kai-Mo Chen successfully performed the first open vertical banded gastroplasty (VBG) in Asia at 1981. However, the case number is limited in the following 15 years. The booing of bariatric surgery in Asia started after the development of laparoscopic surgery.

2) Laparoscopic Surgery Period (1998-2007): We performed the first LVBG at 1998, then laparoscopic RYGB at 2000 and MGB at 2001. Laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (LSG) were then developed at 2002 and 2005, separately. In this period, the main themes were the development of laparoscopic techniques for bariatric/metabolic surgery and many new procedures.

3) From Bariatric Surgery to Metabolic Surgery (2008-2017): Since we published the first landmark paper of using surgery to treat T2D in patients with BMI < 35 Kg/m2, bariatric surgery was transformed into metabolic surgery for the treatment of T2D. Many novel metabolic surgeries were and evaluated. . For T2D treatment, we designed a Diabetes Surgical Score, ABCD score which is a simple system for predicting the success of surgical therapy for T2D. This score help in patient selection and procedure choice, and also help in clinical research.

4) Individualized Treatment (2018 - ): Bariatric/Metabolic surgery is a very safe procedure now in Taiwan. Using detailed presurgical evaluation and proper patient selection system, we can designe the best treatment strategy for our patients

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Sleeve gastrectomy in low income countries. The exemple of Senegal

Ousmane Ka

Faculty of Medicine. Cheikh Anta DIOP University of Dakar.

Teaching Hospital of A. Le Dantec, Avenue Pasteur, CP 3001, Dakar. Senegal [email protected]

Background and Purpose: In Senegal, the practice of obesity surgery is very recent. The objective of this study is to report the results of our first experience of bariatric surgery in Senegal. Material and Methods: We did at the Clinique de la Madeleine in Dakar, a prospective study in 28 patients undergoing surgery for obesity. The study included patients who had sleeve gastrectomy by laparoscopy. A total of 21 patients were included. We evaluated at one year, weight loss, diabetes control, high blood pressure, dyslipidemia and patient satisfaction. Results: They were 2 men and 19 women (sex ratio: 0.1). The mean age was 36 years (range: 26 years-54 years). Body mass index, BMI, was 44.3 kg / m2 (range: 41 kg / m2 - 49.3 kg / m2). Five patients were treated for arterial hypertension), 19 for knees arthrosis, 8 for low back pain and 2 for primary infertility. Five (5) patients had type II diabetes and were treated with oral antidiabetics. Hypercholesterolemia was found in 5 patients, hypertriglyceridemia in 3 patients and metabolic syndrome in 5 patients. Abdominal ultrasound had eliminated biliary lithiasis in all patients and had recovered hepatic steatosis in all patients. In peroperative time, one patient presented barotrauma to intubation with a left pneumothorax requiring exsufflation and postponement of the procedure. One patient presented an early stenosis of the gastric sleeve. The mean weight loss was 49.5 kg (39 kg-65 kg), type II diabetes and high blood pressure were controlled in 5 patients by the diet alone; Dyslipidemia was corrected in 8 patients. Twenty one (21) patients were satisfied. Morbidity was 2/19 and mortality was zero. Conclusion(s): The preliminary results of our study are encouraging and motivate us to develop bariatric surgery in Senegal. Keyword(s): morbib obesity sleeve gastrectomy low income countries.

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Greater Chinese Metabolic and Bariatric Surgery Database (GC-MBD): Development and current status of a national data registry

Peng Zhang

Capital Medical University Beijing Friendship Hospital, Beijing, China

[email protected]

Background and Purpose: Establishment of a national data registry system and its application in quality improvement and clinical research. Materials and Methods: A national database named as Greater Chinese Metabolic and Bariatric Surgery Database (GC-BMD) was created and upgraded with comprehensive functions. Results: GC-BMD went online in 2018, and now is the oficial data registry of Chinese College of Metabolic and Bariatric Surgeons, an academic organization of National Commission of Health. The clinical data of more than 10 thousands patients were included and analyzed. In addition, a few quality improvement projects and clinical research projects were conducted based upon the registry. Conclusion: A national registry is a big investment which demands time, money, dedication and passion. However, once it is established, it becomes a powerful tool for evidence collection, research and quality improvement . Keywords: Metabolic and bariatric surgery, National registry, Quality improvement, Clinical research

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Predictors of Outcomes After Bariatric Surgery

Po-Jen Yang

National Taiwan University Hospital, Taiwan


Obesity is a global epidemic health problem nowadays, and bariatric surgery is the only effective

treatment for severe obesity. Bariatic surgery not only reduces body weight but also improves

obesity related disorders, such as type 2 diabetes, dislipidemia, and obstructive sleep apnea.

However, not all of the patients will significantly reduce body weight and improve metabolic

disorders after surgery. Besides, some of the pateints would have postoperative long-term weight

regain and relapse of the metabolic disorders. Therefore, it is clinically important to identify the risk

factors of poor weight loss, weight regain, and remission and relapse of metabolic disorders. We

will present our studies about the predictors of the outcome of body weight and type 2 diabetes after

bariatric surgery. Eary intervention to the patients with high risks would be helpful to improve the

outcomes after bariatric surgery.

Keywords: Bariatric surgery; Predictor; Relapse; Remission; Type 2 diabetes; Weight loss; Weight

regain

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Anti-inflammatory Diet Post Bariatric Surgery

Pei-Fen Lee

Taipei Medical University Hospital, Taiwan

[email protected]

Patients post bariatric surgery eat much less in quantity to achieve weight loss and therefore improves the pro-inflammatory condition of obesity and its related comobidities. However, studies showed that the bariatric patients would have eating behavior changed post surgery to eat more snacks and sweets than whole foods, and also have inadequate micornutrients and fiber intake but excessive fat intake. The poor diet quality post bariatric surgery would even worsen the pro-inflammatory condition, or even weight regain. Therefore, an anti-inflammatory diet is necessary for the bariatric patients. Many studies as well as the 2019 Canada food guide show that a plant-based diet which is higher in vegetables, fruits, legumes and nuts, and lower in dairies, eggs, poultry, red and processed meats, is showed to reduce all and cardiovascular motarlity, and also it is a high fiber and low fat diet pattern. Therefore, a plant-based diet is believed to improve diet quality and pro-inflammatory condition of the bariatric population. Keywords: obesity, bariatric surgery, eating behavior, diet, anti-inflammatroy, Canada food guide, plant-based

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Barrett Esophagitis After Sleeve Gastrectomy

Yosuke Seki, Kazunori Kasama

Weight Loss and Metabolic Surgery Center, Yotsuya Medical Cube, Tokyo, Japan Email: [email protected]

Despite the increasing popularity of sleeve gastrectomy (SG) owing to its excellent outcome regarding excess weight loss and improvement in comorbidities, the procedure is still associated with some serious consequences such as gastroesophageal reflux disease (GERD). Recently, a meta-analysis attempted to answer the critical question whether SG exposes the distal esophagus to severe reflux. It concluded that 19% of patients experienced worsening of GERD symptoms and 23% developed new-onset GERD with an alarming incidence of Barrett’s esophagus (BE) reaching 8%. This goes in agreement with a recent multicenter study that employed systematic endoscopy for 5 years after SG and found the prevalence of BE, which is a precancerous condition of esophageal adenocarcinoma, to be 18.8% with an increase in the prevalence of GERD symptoms from 22 to 76% after SG. One of the biggest problems is the difficulty of predicting which patient is more liable to develop new-onset GERD or worsening of already existing GERD after SG. Although several technical modifications such as concomitant hiatal hernia repair, anti-reflux gastroplasty, limited fundoplication have been proposed, the results are not fully satisfactory. On the other hand, Roux-en-Y gastric bypass (RYGB) has been associated with appropriate GERD control in both short- and long-term studies. Besides, a recent systematic review and meta-analysis showed that RYGB leads to significant improvement of both short- and long-segment BE after surgery in terms of regression and resolution of the associated GERD. Overall, at this moment, sleeve gastrectomy would not be recommended as the best procedure of choice for patients with severe obesity and pre-existing GERD. Keywords: sleeve gastrectomy; Barrett esophagus; gastroesophageal reflux disease

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Body Contouring in Massive Weight Reduction

Wei Tang Li, Hsiung-Fei Chien, Weu Wang

Taipei Medical University Hospital Email: [email protected]

Obesity is a global health problem in industrialized countries. In United States, almost 40% of adults and 19% of youths have obesity. Form 2016 to 2019, more than 50% of men and more than 35% of women with overweight in Taiwan. The increased prevalence of successful bariatric surgery procedures over the past two decades has resulted in a variety of body contour deformities in the massive weight loss patient. The excessive skin is also associated with fungal infections, itching, and a lower Body-Q score. Therefore, the demand for body contouring surgery following massive weight reduction is increasing. Body contouring surgery has a role not only in a cosmetic adjustment to bariatric surgery but also in reversing the functional and psychological abnormalities that result from the excessive skin after massive weight loss. The surgeon and the patient should have a detailed discussion about the information to recovery and possible complications of the planned procedure. Despite significant weight loss, many of these patients still fall within the morbidly obese or overweight range, and have associated medical issues that must be ascertained. Multidisciplinary teamwork ensures better healthcare outcome.

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Application of AI to Mentoring Systems for Surgical Procedures

Mano Soshi

BonBon inc, Japan Email: [email protected]

Background and Purpose: The application of AI to surgery tends to be the automation of surgery, intraoperative guidance, and preoperative planning, not for surgical education. But AI can be helpful for educating surgeons. Materials and Methods: we surveyed young surgeons for learning environments and started Online video-based surgical education courses. Results: In the survey, of 30 young surgeons (PGY4-10), 70% of participants don't feel satisfied with the training environment. 60% of participants need more feedback on their surgeries and procedures. Second, 80% of participants want video-based feedbacks on their surgeries. Through online video-based educational program, we found it possible to develop AI based on expert feedback data on surgical videos uploaded by young surgeons. Conclusion: Summary of the overall findings and the importance of the study. 1. Young surgeons need more feedback on their surgeries. And video-based education can be efficient。 2. Education on young surgeons can be education on surgical AI through video-based feedback programs. Keywords: A tool to help indexers and search engines find relevant papers. Surgical AI, video-based feedback, medical AI

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Is It the Prime Time to Implement Artificial Intelligence in Colonoscopy Practice?

Han-Mo Chiu

National Taiwan University Hospital


Colorectal cancer (CRC) is currently one of the most prevalent malignancies worldwide and screening has been demonstrated effective in reducing CRC and its related deaths. Detecting and resecting neoplastic lesions during colonoscopy can reduce the incidence of colorectal cancer (CRC) and several studies have demonstrated that adenoma detection rate of the endoscopits were inversely associated with the risk of post-colonoscopy CRC. The cutting-edge artificial intelligence technologies are emerging in clinical medicine and it can help the endoscopists to detect polyps during colonoscopy. In this presentation, the following issues will be addressed: 1. Introduction of colonoscopy quality indicators 2. Why adenoma detection rate is important 3. Review of the current clinical evidences on AI-assisted colonoscopy in enhancing adenoma

detection 4. Unmet need ad future perspectives of AI-assisted colonoscopy

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Detection of Pancreatic Cancer with Artificial Intelligence

Wei-Chih Liao



Background and Purpose: The diagnostic performance of CT for pancreatic cancer (PC) is interpreter-dependent, and the sensitivity for tumors smaller than 2 cm is modest. Whether convolutional neural networks (CNNs) can differentiate between PC and normal pancreas is unclear. Materials and Methods: In this retrospective diagnostic study, contrast-enhanced CT images of 370 patients with pancreatic cancer and 320 controls from a Taiwanese center were manually labelled and randomly divided for training and validation (295 patients with pancreatic cancer and 256 controls) and testing (75 patients with pancreatic cancer and 64 controls; local test set 1). Images were preprocessed into patches, and a CNN was trained to classify patches as cancerous or non-cancerous. Individuals were classified as with or without pancreatic cancer on the basis of the proportion of patches diagnosed as cancerous by the CNN, using a cutoff determined using the training and validation set. The CNN was further tested with another local test set (101 patients with pancreatic cancers and 88 controls; local test set 2) and a US dataset (281 pancreatic cancers and 82 controls). Radiologist reports of pancreatic cancer images in the local test sets were retrieved for comparison. Results: Between Jan 1, 2006, and Dec 31, 2018, we obtained CT images. In local test set 1, CNN-based analysis had a sensitivity of 0·973, specificity of 1·000, and accuracy of 0·986 (area under the curve [AUC] 0·997 (95% CI 0·992–1·000). In local test set 2, CNN-based analysis had a sensitivity of 0·990, specificity of 0·989, and accuracy of 0·989 (AUC 0·999 [0·998–1·000]). In the US test set, CNN-based analysis had a sensitivity of 0·790, specificity of 0·976, and accuracy of 0·832 (AUC 0·920 [0·891–0·948)]. CNN-based analysis achieved higher sensitivity than radiologists did (0·983 vs 0·929, difference 0·054 [95% CI 0·011–0·098]; p=0·014) in the two local test sets combined. CNN missed three (1·7%) of 176 pancreatic cancers (1·1–1·2 cm). Radiologists missed 12 (7%) of 168 pancreatic cancers (1·0–3·3 cm), of which 11 (92%) were correctly classified using CNN. The sensitivity of CNN for tumors smaller than 2 cm was 92·1% in the local test sets and 63·1% in the US test set. Conclusion: CNN could accurately distinguish pancreatic cancer on CT, with acceptable generalizability to images of patients from various races and ethnicities. CNN could supplement radiologist interpretation. Keywords: pancreatic cancer, artificial intelligence, convolutional neural network.

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AI-Surgical Wounds Assessment System (AI-SWAS) and Wound Infection Assessment

Hao-Chih Tai1, Jui-Tse Hsu2, Te-Wei Ho2,Sy-Yen Kuo3, Feipei Lai2

1Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei,

Taiwan, 2Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, 3Department of Electrical Engineering, National Taiwan University

Email: [email protected] Background and Purpose: Numerous patients suffer from chronic wounds. The wound assessment remains a tedious and challenging work for the medical personnel. With the help of the hand-held mobile devices, there is high demand for the development of a series of algorithms and related methods for wound assessment. Materials and Methods: This research proposed an automated way to perform (1) wound image segmentation and (2) wound infection assessment. The first part describes an edge-based self-adaptive threshold detection image segmentation method to exclude nonwounded areas from the original images. The second part describes a wound infection assessment method based on machine learning approach. In this method, the extraction of feature points from the suture area and an optimal clustering method based on unimodal Rosin threshold algorithm that divides feature points into clusters are introduced. These clusters are then merged into several regions of interest (ROIs), each of which is regarded as a suture site. Notably, a support vector machine (SVM) can automatically interpret infections on these detected suture site. Results: For (1) wound image segmentation, boundary-based evaluation were applied on 100 images with gold standard set up by three physicians. Overall, it achieves 76.44% true positive rate and 89.04% accuracy value. For (2) wound infection assessment, the results from a retrospective study using confirmed wound pictures from three physicians for the following four symptoms are presented: (1) Swelling, (2) Granulation, (3) Infection, and (4) Tissue Necrosis. Through cross-validation of 134 wound images, for anomaly detection, our classifiers achieved 87.31% accuracy value; for symptom assessment, our classifiers achieved 83.58% accuracy value. Conclusion: This augmentation mechanism has been demonstrated reliable enough to reduce the need for face-to-face diagnoses. To facilitate the use of this method and analytical framework, an automatic wound interpretation app and an accompanying website were developed. Keywords: AI-Surgical Wounds Assessment System, AI-SWAS, Chronic Wound Assessment

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Ethical AI and Bias in Surgery

Dr. David C. Chang

Massachusetts General Hospital, Harvard Medical School, USA


While AI holds great promise, we should also be aware of potential risks of AI. Ethical problems and biases of AI can occur when there is incomplete data, or when the data is flawed, or when there is flawed interpretation of the data. Transparency of AI after development is also a problema. Users should evaluate posible biases in algorithm and data when evaluating AI for use. The long-term solution will only come when more physicians and Physician scientists get involved in the development of AI, to make sure medical ethics are considered in the process. Keywords: Ethics in AI, algorithmic bias

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Should Latin America's Surgery Develop Artificial Intelligence Processes in the Context of COVID-19?

Luis Ruso Martinez

Hospital Maciel.Department of Surgery School of Medicine. University of Republic (UdeLar).Montevideo. Uruguay. Mail: [email protected]

The possibilities of incorporating new technologies in Latin America, for the development of highly complex and precision surgical procedures, are variables even within the countries themselves and with populations that have very different possibilities of accessibility to care and resolution of surgical pathologies. The term AI is commonly used when a machine imitates cognitive functions that humans associate with other human minds, such as learning and solving problems. Our paradigm is that these AI devices can provide answers to the unsolved problems of surgery. But these appliance, still depend on the human been to generate processes that are currently: expensive, limited accessibility with outcomes and a cost-benefit calculation not yet established for Latin America; but whose incorporation is essential to continue with the transformation of surgery through new technologies. Latin America is highly affected by the COVID-19 pandemic, suffering a decline in external demand with fall the income, which raised the cost of health care at the expense of a significant part of public budgets, which represents an onerous burden for the finances of the countries. On the other hand, the Covid.19 pandemic has dramatically reduced surgeries around the world, demanding an immediate and expensive surgery rescheduling strategy. This is a great economic and surgical challenge that will be increased if promoting it through the use of AI processes, to avoid the delay in the development of surgical technologies that improve the quality of care, by increasing processes of more diagnostic precision and safe procedures and for the training of surgeons currently based on simulation and the acquisition on line the skills. Conclusions: Assay are needed to assess the feasibility and cost-benefit of the application of advanced technologies for surgery, in the current epidemiological and economic situation in Latin America, linked to Covid. 19. Keyword(s): Surgery, Artificial intelligence, Latin American, covid.19.

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Delta, a World-Class Corporate Citizen Fostering a Greener and Healthier Tomorrow

Bruce C.H. Cheng

Delta Group, Taiwan

Bullet Points: Opening remarks by Bruce Cheng, Delta’s Founder & Honorary Chairman

Delta’s stature as a global leader in switching power supplies and DC brushless fans. A uniquely broad spectrum of innovative and energy-saving products and solutions. Delta’s 29 green buildings worldwide - Living foundations of eco-friendlier and healthier cities. Delta’s cutting-edge healthcare solutions against COVID-19 and beyond. The world’s first 8K projector technology by Delta inspiring endeavors for environmental

protection. Extract of the 8K-resolution environmental documentary film “Life in the Coral Reefs”

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Image-Guidance for Gastric Cancer Surgery

Woo Jin Hyung

Yonsei University College of Medicine, Republic of Korea


Recent advances in imaging technology have led to changes in surgery in various ways. The interests in imaging technology are leading to the research of how to use imaging information in the imaging studies for surgery, such as CT, MRI, and US of the surgical patient. There is a lot of other information in those imaging studies as well as disease diagnostic information, although they were not well explored yet. Most of this information is not readily utilizable for clinical application. Moreover, it is impossible to identify what to use. However, with the recent advancement of AI technology such as computer vision, those imaging studies can be transformed into a form that can be used practically or discover new information previously unavailable. Various technologies are being developed for better surgery with the concept of preoperative planning and intraoperative guidance by using information extracted from imaging studies. New imaging information is mainly used in the form of a virtual model. The developments of VR/AR technologies in the surgical field are primarily stimulated due to an increase in laparoscopic or robotic surgery, which is an image-based surgery. As gastric cancer surgery gradually shifts from open to laparoscopic or robotic surgery, new attempts are being made through applying the aforementioned technology. In this presentation, I would like to introduce technologies related to preoperative planning, the use of intraoperative vascular navigation by reconstructing preoperative diagnostic images into a three-dimensional model in robotic gastric cancer surgery.

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Biomarkers in Gastrointestinal Cancers

Renata Dobrila-Dintinjana

Clinical Hospital Center Rijeka, School of Medicine Rijeka, Croatia Email: [email protected]

Gastrointestinal (GI) cancer is a major cause of morbidity and mortality worldwide. Novel diagnostic approaches allow scientists to examine and evaluate each individual’s genetic and epigenetic information in order to analyze disease susceptibility and tailor proper treatment for each patient. Besides the diagnosis, the main task of pathologic evaluation is the prediction of the clinical course to facilitate an adequate therapeutic approach. Especially for personalized medicine, biomarkers are of increasing importance. The impact of the immune contexture, which is defined as type, functional orientation, density, and location of adaptive immune cells within distinct tumor, according to the studies, support the implementation of the consensus that immunoscore is a a new component of a TNM-Immune classification of Cancer. Immunotherapies can be divided into concepts that enhance the immune system and strategies that normalize or restore the immune response to cancer. Normalizing or restoring concepts can be realized by application of antibodies against the programmed death receptor 1 (PD-1) or its ligand (PD-L1). The most investigated prognostic immunologic marker is the occurrence of infiltration of a tumor by immune cells. Despite the currently high importance of tumor-infiltrating lymphocytes, (expecially in CRC), other immune cells could also be shown to be prognostic . The topic of predictive biomarkers in immunotherapy today can be restricted to anti-PD-1 and anti-PD-L1 therapies. Immunotherapy (checkpoint inhibitors) is already approved by the FDA in all solid dMMR tumors since it is shown that deficient mismatch repair (dMMR) is predictive for treatment response, regardless of tumor origin (dMMR tumors are responders to a immunotherapy). Pembrolizumab (anti PD-1) studies also indicate that the high number of somatic mutations (a feature of dMMR tumors) were associated with prolonged progression-free survival . Tumor mutational burden (nearly 3% CRCs with pMMR) as well as POLE (polymerase epsilon ) gene mutations (1% of CRCs) also have value as predictive biomarkers for PD-1 inhibitor therapy. We can conclude that there are many more biomarkers under investigation, some of which may become relevant. There is huge and urgent need for more investigational studies to confirm the more appropriate biomarkers for clinical use.

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Pathology of Gastrointestinal Lymphomas and Diagnostic Challenges in a Resource Limited Centre

Babatunde M Duduyemi

Department of Pathology, University of Sierra Leone Teaching Hospital Complex & College

of Medicine and Allied Health Sciences, Freetown, Sierra Leone Email: [email protected]; [email protected]

Introduction: Lymphoma is a term describing malignant lesions arising primarily from lymphocytes and forming discrete tissue masses. They are classified broadly into Hodgkins lymphoma (HL) and Non-Hodgkins lymphoma (NHL). Gastrointestinal (GI) lymphomas are the commonest extranodal form, mostly NHL, and mainly of B cell origin. This review sets out to highlight the pathology of GI lymphomas and the challenges in the diagnosis and management. Material and Method: GI specimens of suspected of lymphoma in our centre over 9 years were reviewed from surgical daybook of our department. The H&E slides were reviewed for confirmation and results presented in tables and figures. A report of a challenging case of 40 year old woman with GI mass who was thought to have soft tissue sarcoma but with better ancillary investigation (IHC) had anaplastic large B cell lymphoma was highlighted. Results: The age range of our cases is 1st to 9th decade of life with male to female ratio of 2:1. Of the 106 samples of suspected lymphomas received, 39 cases were NHL with Burkitt lymphoma constituting 53.8% (n=21/39), Diffuse large B cell lymphoma 43.6% (n=17/39) and Maltoma 2.6% (n=1/39). A case of anaplastic B cell lymphoma in the small intestine was associated with HIV and one case in the stomach (maltoma) was associated with H pylori by urea breath test and histology. Conclusion: GI lymphomas are generally rare in our centre and when they occur, are NHL with Burkitt lymphoma being most common especially in children. We are faced with challenges of inability to do IHC and molecular markers which are obligatory in proper diagnosis and management of GI lymphomas. Keywords: GI lymphoma, IHC, challenges, resource limited centre

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Pave the Way for International Communications -in memory of Prof Kai-Mo Chen-

Po-Huang Lee

Department of Surgery,National Taiwan University Hospital,Taipei,Taiwan


Background and Purpose: Introducing Prof. Kai-Mo Chen, the pioneer of gastrointestinal surgery in Taiwan Conclusion: Prof. Chen was born on Aug. 29, 1929 and he passed away on Dec. 6, 2019 at the age of 90. He graduated from College of Medicine, National Taiwan University and completed his surgical residency training in NTUH after he finished medical school. In 1965, he was sent to Duke University to pursue further education in medicine. He was supposed to develop the kidney transplantation program in NTUH; however, the plan was put to a halt after his classmate, Prof. C. J. Lee, successfully completed the first kidney transplantation in Asia on May 27, 1968. After retiring in 1996, he became the director of Cathay General Hospital,one of big healthcare group in Taiwan . Since 2002 he was appointed as senior advisor of the Office of President in Taiwan. Prof. Chen is Prof T. Y. Lin’s closest student. They are close not only on personal level, but also on professional level that they cooperate in liver research. As we all know, Prof. T. Y. Lin is famous for his achievements in liver surgery; however, he is also a pioneer in cardiothoracic surgery and esophagus surgery in Taiwan. Although his career did not go as planned in transplantation surgery, he actually contributed plenty on the development of liver surgery because of his long term cooperation with Prof. Lin and close interest in transplantation surgery. He published his first paper in Surgery in 1960 when he was a senior resident and this initiated him to further study in liver surgery. Because of his experiences in liver dissection, he became the best candidate in performing liver bipartition on conjoined twins. He later shifted his focus on gastrointestinal surgery, especially morbid obesity. In 1981, he successfully completed the first gastric partition surgery for treatment of morbid obesity in Taiwan. His serial experience in surgery for morbid obesity was published in 1998. Losing the leading role in clinical transplantation surgery is a regrettable matter for him. In 1984, Prof. K. M. Chen became the Chairman of Department of Surgery in NTUH and immediately he decided to develop liver transplantation program in NTUH. The liver transplantation program in NTUH was initiated and pushed forward by him that he devoted countless hours and close attention to the team. The team has overcome and completed many difficult medical cases that they not only are able to undertake tough tasks alone, but also capable of training surgical doctors abroad. In Dec. 1992, Prof. T. Y. Lin’s 80th birthday, his students founded Dr. T Y Lin’s Hepatocellular Carcinoma Research Foundation and elected Prof. Chen as the board chairman. At that time, it was difficult for young doctors to attend conferences abroad not only because of financial reasons but also political reasons in Taiwan. Establishing the foundation made up for the shortcoming. The foundation invites many international leading specialists to Taiwan to exchange their expertise that contributed a great deal in improving and elevating the medical quality in Taiwan. We were honored to have invited Prof. Masatoshi Makuuchi to Taiwan the year after the foundation was established. In fact, Prof. Chen can speak fluent Japanese that through these occasions he got acquainted with many Japanese colleagues. In 1994, Prof. N.J.Lygidakis accepted Prof. Chen’s invitation. He gave a speech on multidisciplinary management of hepatocellular carcinoma. They have continued their friendship ever since. Prof. Chen founded Taiwan Surgical Society of Gastroenterology in 1987. This society is founded to establish medical system and doctors’ subspecialty training. In 2015, he received lifetime

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achievement award from the society for his contribution to the development of gastrointestinal surgery in Taiwan. International Association of Surgeons,Gastroenterologists and Oncologists(IASGO) was founded in 1988 by Prof Lygidakis and has held continued medical education in Taiwan for four times. We would like to thank Prof. Makuuchi and Prof. Kyoichi Takaori for encouraging doctors in Taiwan to participate in IASGO events. We look forward to further connections between Taiwan and the international society through events with IASGO. We are more integrated to the international community through exchanging valuable knowledge with experts worldwide. Through unreserved exchange of expertise, we learn and also have ability to care and understand one another. Although Prof Lygidakis and Prof Chen have left us, I believe under the efforts of their wise successors, the spirits of IASGO will persist and pass on to the future generations.

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Real World Gastrectomy in Japan and New Treatment Guidelines for Gastric Cancer

Takeshi Sano

Cancer Institute Hospital, Tokyo, Japan


Backgrounds: [A] Detailed real-world data of the major surgery including distal and total gastectomies have been accumulating in the National Clinical Database in Japan since 2011. [B] The Japanese Gastric Cancer Associasion (JGCA) published the 6th edition of treatment guidelines (GL) in 2021. Results: [A] Until 2019, the numbers of distal and total gastrectomies steadily decreased by 3 – 5% every year, while the proportions of postoperative complications gradually increased. More than half of distal gastrectomy were performed with laparoscopy in 2019. The decrease of operations is partly explained by the rapid increase of endoscopic resection for early cancer, and the increase of complication rates is partly due to rapid aging of operated patients and may possibly be due to increase of poorly trained laparoscopic surgery. [B] The first edition of JGCA GL published in 2001 was based on consensus, rather than evidence, obtained in the nationwide registry and 69 biannual meetings. It was a thin book written in the textbook style without clinical questions. The style was continued till the 5th edition, but for the 6th edition, the JGCA GL committee decided to introduce the evidence-based style and formed a systematic review team consisting of 122 specialized members. After enormous amount of time for systematic review and assessement, 32 clinical questions and recommendation statements have been added to the traditional textbook descriptions. In the surgery section, approach and lymphadenectomy extent for esophagogastric junction tumors (both adenocarcinoma and squamous cell carcinoma) are proposed based on the results of a prospective clinical study conducted by JGCA and Japan Esophageal Society. An English version has been prepared and will appear in Gastric Cancer in 2022. Conclusion: Treatment for gastric cancer is rapidly diversifying. The number of gastrectomy is steadily decreasing, being partly replaced by endoscopic resection especially for aged patients. JGCA guidelines changed the style to provide recommendations based on scientific evidence derived through comprehensive systematic review. Surgeons should continually review their own role in multidisciplinary, diversified treatments for gastric cancer. Keywords: gastric cancer, guidelines, National Clinical Database

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New Hope in Metastasis-Stage of Esophageal Cancer Treatment: Real-World Experience Sharing

I-Chen Wu

Kaohsiung Medical University Hospital, Taiwan

Email: [email protected] The incidence of esophageal cancer, mainly squamous cell carcinoma (SCC), increased rapidly in the past few decades in Asian countries, including Taiwan. Patients with metastatic esophageal cancer usually receive palliative chemotherapy and/or radiotherapy with limited responses. In recent years, phase III trials on first-line therapy using immune checkpoint inhibitors, targeting programmed death-1 (PD-1; eg. nivolumab, pembrolizumab), PD-ligand 1 (PD-L1) or CTLA-4 in metastatic esophageal cancer showed promising results. Pembrolizumab plus PF (cisplatin and 5-FU) has been approved by FDA as the first line treatment for esophageal cancer and Siewert type I gastroesophageal junction cancer with a better response in esophageal SCC and PD-L1 combined positive score (CPS) ≥ 10 subgroups (Keynote 590). According to the results of Checkmate 648 released in June, 2021, nivolumab plus PF and ipilimumab plus nivolumab can also be considered as first line therapy for esophageal SCC. Both nivo + PF and dual IO were effective in prolonging survival for all comer and PD-L1 TPS ≥ 1% group. However, quite a few patients were non-responders to dual IO therapy and the progression free survival was not significant. Our experience is that responders to dual IO therapy can have rapid symptom improvement and long recurrence free survival. However, there is still no reliable biomarker, including PD-L1 to predict the response. Moreover, there was variable progression after end of IO treatment. Further study is needed to determine the policy of discontinuation and rechallenge of IO. There were no new safety concerns, but physicians should be careful about possible side effects including interstitial lung disease, colitis and endocrinopathy. Keywords: Immunotherapy, metastatic esophageal cancer, squamous cell carcinoma, PD-L1

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Robot-Assisted Transmediastinal Esophagectomy

Yasuyuki Seto

The University of Tokyo Hospital, Japan Email: [email protected]

Background and Purpose: Surgical treatment is still main stream for esophageal cancer. In radical esophagectomy, three fields’ lymph node dissection, cervical, mediastinal, and abdominal regions, is standard procedure. Frequent complications after radical esophagectomy are well known. Japanese nation-wide database (National Clinical Database) shows that 1/2 patients underwent the esophagectomy by MIE (minimally invasive esophagectomy), while the conventional open procedures were done among 1/2 patients. Big data based on NCD showed that MIE failed to decrease the post-operative pneumonia. The prevention of post-operative complications, especially pneumonia, is most important issue yet. Material and Methods: With the aim of achieving lymph node dissection equivalent to the conventional procedure (open or VATS) and decreasing the development of post-operative pulmonary complications simultaneously, we developed the novel procedure, non-transthoracic radical esophagectomy by using da Vinci. It is the combination of transhiatal robotic manipulation for the middle and lower mediastinum and a video-assisted (mediastinoscopic) transcervical procedure for the upper mediastinum. Results: That procedure has been performed in 211 cases with esophageal cancer, to date. Among them, the postoperative pneumonia occurred in 16 cases (7.6%) and the number of harvested mediastinal lymph nodes was equal to the conventional open surgery. Furthermore, the QOLs after surgery were observed to be better as compared to the conventional groups. Conclusion(s): Robot-assisted transmediastinal esophagectomy offers a new radical procedure for esophageal cancer. Keyword(s): esophageal cancer, robot, minimally invasive esophagectomy, pneumonia

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Minimally Invasive Surgical Approaches for Treating Esophageal Cancer

Jang-Ming Lee

Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital


Minimally invasive esophagectomy has gradually accepted as an active treatment option for

surgery of esophageal cancer. However, there is no consensus about how to perform the

procedures in the thoracic and abdominal phase including anastomosis in the neck (McKeown)or

chest (Ivor Lewis), VATS or robotic assisted esophagectomy. With the maturation of single-port

surgical procedure in thoracic surgery, the single-port MIE has been introduced for treating

esophageal cancer. Although the preliminary reports have demonstrated the feasibility of single-

port surgical technique applied in MIE, the evidence about the clinical value of single-port

technique requires to be evaluated in the future. In the current presentation, we evaluate the

feasibility and clinical value of single-port MIE and our experience how to facilitate the surgical

procedure in single-port MIE both in the thoracic and abdominal phases.

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Surgical treatment of the cervical esôfago-visceral anastomotic stenosis

Valter Nilton Felix*

*MD, PhD Nucleus of General and Specialized Surgery – Sao Paulo – Brazil and FMUSP Email: [email protected]

Abstract Background and Purpose: Few patients with strictures at the cervical esophagogastric anastomosis require operative revision, when conservative resources run out. Materials and Methods: 22 patients were operated, 18 undergoing esophagectomy for benign diseases (long peptic stenosis - 2; caustic stenosis of the esophagus - 10; end stage achalasia – 6) and 4 for cancer, these after ruling out the possibility of malignant recurrence by PET- CT. There were six retrosternal esophagocoloplasties and sixteen esophagogastroplasties, using a gastric tube through the esophageal bed, all with cervical anastomosis (12 hand-sewn and 10 stapled). The laryngeal recurrent nerve was identified as early as possible and the technique included a careful dissection of the anastomotic place, a minor esophageal displacement to preserve vascularization and a sufficient release of the transposed viscera enough to allow tension-free anastomosis, after resection of the stenotic area. Results: Only one patient developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. All the other had uneventful recoveries after operations and restored complete oral intake on the 15th postoperative day, remaining without dysphagia over a mean follow-up of two years. Conclusion: Only the depletion of endoscopic resources will indicate surgical treatment of stricture, but a well-conducted operation can provide excellent results and an important upgrade in the quality of life of patients. Keywords: cervical esophago-visceral anastomosis; refractory stricture; surgical treatment Anastomotic leak Esophagectomy is performed for a wide spectrum of conditions but mostly for carcinoma. Improvement of perioperative management and surgical techniques has resulted in a steady decrease in postoperative mortality, but their quality of life may be very much influenced by the quality of their esophageal anastomosis. In fact, the incidence of anastomotic leaks varies widely and has been reported up to 53%1. Local and systemic factors can influence the process of wound healing and hence influencing the incidence of anastomotic complications, in particular leakage. Esophagectomy followed by reconstruction requires extensive dissection as well as an extensive mobilization, bringing viscera from a distant remote position to perform an anastomosis outside of the protective peritoneal cavity, under influence of many systemic factors, increasing the chances for an uneventful healing: malnutrition, hypotension, hypoxemia, neoadjuvant therapies, diabetes, cardiovascular diseases, respiratory insufficiency, excessive smoking and drinking habits. Subtotal esophagectomy with cervical anastomosis (McKewon) is the standard type of operation for cancer of the esophagus in many centers. Restoration of continuity is performed by using either stomach or colon. Jejunum is rarely used because the technical difficulty to prepare a loop sufficiently long to reach the neck for anastomosis.

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The colon, especially the transverse and left colon, have a rather consistent vascular anatomy based on arcades connecting left, middle and right colic artery. However, the majority of surgeons do prefer to use stomach to restore continuity because of the relative simplicity of the operation and the need for only one anastomosis, although the entire vascularization depends solely on the right gastroepiploic artery and vein. Approximately 60% of the gastric tube is supplied by this vessel and another 20% more proximally by the connections between right and left gastroepiploic vessels. Finally, the most cranial 20% is vascularized through a dense submucosal and microvascular network and the anastomosis is mostly made at this level, at the gastric fundus2. For these reasons there is advocated to resect the proximal 4–6 cm of the fundus in case of doubtful macroscopic vascularity2. On the other hand, to improve vascularization of the gastric fundus, gastric conditioning by laparoscopic partial gastric devascularization at the time of e.g., laparoscopic cancer staging has been proposed3 while some authors argue that a better blood supply can be obtained when using the whole stomach4. Nederlof et al5 reported 174 patients with esophageal cancer submitted to esophagectomy. Ninety‐three patients were randomized to hand-sewn (HS) (n = 44) or semi-mechanical (SM) (n = 49) anastomosis. Anastomotic leak occurred in 9 of 44 patients (20%) in the HS group and 12 of 49 patients (24%) in the SM group (absolute difference 4%, 95% CI −13% to +21%; p = .804). There was no significant difference in dysphagia at one year postoperatively (HS 25% vs. SM 20%; p = .628), nor in median hospital stay (17 days in the HS group, 13 days in the SM group), morbidity (82% vs. 73%, p = .460) or mortality (0% vs. 4%, p = .175) between the groups. The leakage rate when using stapled anastomosis versus hand-sewn anastomosis was similar in my Service, around 12%. As to the hand-sewn anastomosis, many technical details, e.g., running versus interrupted sutures, absorbable or nonabsorbable, one- or two-layer sutures, knots within or outside the lumen, have been debated, without evidence of significant difference among all. Delayed gastric emptying is associated with a higher incidence of anastomotic leak6. Postoperative gastric decompression by performing a pyloroplasty or pyloromyotomy is therefore considered a mandatory procedure by us and many surgeons. As to the route of reconstruction it is commonly believed that the posterior mediastinal route is superior to the retrosternal route because of the shorter distance of the visceral transposition decreasing consequently the incidence of anastomotic leaks. As to the site of the anastomosis, Blewett et al.7 compared in a retrospective study intrathoracic and cervical anastomosis. Leaks occurred in 5% (1/19) of the cervical anastomosis and in 16% of the patients with an intrathoracic anastomosis. These data, although indicating a trend, were not significant. The clinical presentation of the anastomotic leak and consequently the therapeutic attitude is largely determined by the site (thoracic versus cervical). Little specific treatment, a delay of oral intake, especially solids, for few days until enteral nutrition through nasoenteric tube and broad-spectrum antibiotherapy can be sufficient for closure of cervical anastomosis leak; in case of abscess formation in the neck, bedside opening and drainage of the cervical incision must be performed; as to thoracic anastomosis, some patients may develop an intrathoracic fluid collection, requiring CT-guided drainage. Dilatation of a leaking anastomosis may favorably influence healing because relative narrowing by local inflammation and spasm may contribute to obstruction distal to an esophageal leak and adversely affect spontaneous closure. In more severe cases there will be a substantial defect at the site of the anastomosis which together with the present mediastinitis will preclude a repair of the anastomotic dehiscence. In such a situation a takedown of the anastomosis with temporary esophagostomy and feeding jejunostomy may be the only valid option. Once the leak has dried up or has disappeared on X-ray contrast study, oral diet can

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be resumed. Finally in case of necrosis of the proximal part of the conduit, a resection of the necrotic part, debridement of the mediastinum, esophagostomy and feeding jejunostomy is the treatment of choice8. Anastomotic stricture After anastomotic leaks, the incidence of anastomotic stenosis is relatively high between 10 and 56%9. However, the introduction of PPI and Rigiflex balloon or Savary dilatation constitute key factors in the treatment of anastomotic stricture. Early postoperative endoscopy, between days 3 and 5 and dilatation, when necessary, seems to result in a decreased need for multiple dilatation, but the presence of dehiscence involving more than 50% of the anastomotic circumference seems the most important factor in predicting development of anastomotic stricture. In a large group of patients (n = 269) who had undergone transhiatal esophagectomy with gastric tube interposition, Honkoop et al10 examined surgical and nonsurgical risk factors for the development of benign strictures at the cervical anastomosis. During follow-up, 114 patients (42%) had a benign anastomotic stricture. Only a history of cardiac disease (p = 0.03), postoperative leakage at the anastomosis (p = 0.002), and a stapled rather than a hand-sewn anastomosis (p = 0.04) were found to be independent risk factors for the development of a stricture. However, Nederlof et al5 compared hand-sewn and semi-mechanical anastomosis after esophagectomy for cancer and there was no significant difference in stricture rate (HS 25% vs. 19% in SM, p = .46). Park et al.11 applied balloon dilation under fluoroscopic guidance. The mean follow-up period was 37 months (range 1–159 months). Overall clinical success was achieved in 153 patients (99%) after a single (n = 78) or multiple (n = 75) balloon dilations, but during follow-up, recurrence of the stricture requiring repeated dilation was seen in 77 of 155 patients (50%). Esophageal rupture (mostly intramural rupture) occurred in 22 of 155 patients (14%). In multivariate analysis, early development of stricture within 10 weeks after surgery (p = 0.002) and McKeown esophagectomy (p = 0.002) were independently related to recurrence after initial balloon dilation. In the treatment of benign stenosis, Honkoop et al10 referred that endoscopic bougie dilation of anastomotic strictures was successful in 78% of patients after a median of three dilation sessions (range 1 to 28) and 19% of patients had died before normal swallowing had been achieved. In two of 519 (0.4%) dilation sessions a major complication occurred. Long-term follow-up is important to gauge the functional status following transhiatal esophagectomy and a cervical esophagogastric anastomosis. The presence and degree of dysphagia must be assessed at each postoperative visit based on patient symptoms. None or mild dysphagia often do not require treatment, but moderate symptoms indicate occasional dilation and severe dysphagia requires regular dilation. As a rule, passage of a 46 Fr or larger size dilator through the anastomosis is a prerequisite for achieving comfortable swallowing. Maloney bougienage can be performed without fluoroscopic or endoscopic assistance. Typically, at the initial dilation, three dilators of increasing size, 36-, 40-, and then 46-Fr caliber, are passed with the patient sitting upright and the neck slightly flexed. If a patient develops an anastomotic stricture following either an esophagocolic or an intrathoracic esophagogastric anastomosis, dilation may be performed with endoscopic and/or fluoroscopic guidance. For patients in whom resistance to passage of the dilators is encountered, or cervical dysphagia recurs within few days or weeks of the initial anastomotic dilation, a more aggressive program must be undertaken with esophageal dilation being performed over 2 to 3 weeks. This aggressive program of dilation seeks to allow long-term comfortable swallowing with little or no need for subsequent dilation. A refractory anastomotic scar may respond dramatically to direct endoscopic injection of steroids combined with esophageal dilation, initially described for the treatment of corrosive esophageal strictures and anastomotic stricture following tracheoesophageal fistula repair12. A four-quadrant 0.5

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mL intralesional injections of triamcinolone acetonide (40 mg/mL diluted 1:1 with saline solution) is performed immediately preceding esophageal dilation. The administration of mitomycin C (MMC), an antiproliferative agent, for treatment of recurrent anastomotic strictures has also been reported in small series, but this procedure requires direct visualization of the anastomosis to administer a MMC-soaked pledget against exposed mucosa immediately following anastomotic dilation13. Alternative techniques including endoscopic electrocautery incision14 have been reported. In general, patients requiring five or more dilatations are those of worst prognosis. Endoscopic incision is an alternativemethod for refractory esophageal strictures; however, little is known about its long-term efficacy. Tan & Liu15 described 13 patients underwent the procedure in a total of 27 sessions to maintain lumen patency, and 7 patients needed retreatment. The symptoms relieved in all the cases, and the median dysphagia score decreased from 4 to 1 during a median follow-up of 24 months and the median diameter of stricture was enlarged from 4 mm to 12 mm. This technique obviously needs a more consistent study. In patients found to have a malignant stricture of the cervical esophagogastric anastomosis, the local recurrence is almost invariably associated with transmural invasion that is surgically incurable. Chemotherapy and definitive radiation are generally indicated since operative management is generally contraindicated. Schipper et al16 reported their retrospective series of 27 patients undergoing reoperation for locally recurrent esophageal cancer, and 4 of them who underwent resection were found to have microscopic residual disease (R1). There are few other options available for palliation of dysphagia occurring in patients with a malignant stricture of the cervical esophagogastric anastomosis. Stent placement at this location has been felt to be relatively contraindicated, particularly due to patient discomfort following placement of such devices which necessitates positioning the proximal portion of the stent across the upper esophageal sphincter into the hypopharynx. If stent position is more distal, then there is a greater risk for stent migration17. Surgical treatment of strictures Few patients with strictures at the cervical esophagogastric anastomosis require operative revision, when conservative resources run out, something that was observed many years ago18. When this is necessary, a partial upper sternal split or manubrium resection to facilitate exposure is beneficial. The laryngeal recurrent nerve must be identified as early as possible and the technique includes a careful dissection of the anastomotic place, a minor esophageal displacement to preserve vascularization and a sufficient release of the transposed viscera enough to allow tension-free anastomosis, after resection of the stenotic area. Thus, 22 patients were operated, 18 undergoing esophagectomy for benign diseases (long peptic stenosis - 2; caustic stenosis of the esophagus - 10; end stage achalasia – 6) and 4 for cancer, these after ruling out the possibility of malignant recurrence by PET- CT. There were six retrosternal esophagocoloplasties and sixteen esophagogastroplasties, using a gastric tube through the esophageal bed, all with cervical anastomosis (12 hand-sewn and 10 stapled). In only two cases, right videothoracoscopy was necessary to complete the release of the upper part of the gastric tube. The length of resection was on average 2.5 cm (2-3.5), of fibrotic conduit, and the new hand-sewn anastomosis was performed in two-layer interrupted sutures of 3.0 vycril. A nasoenteric tube was passed for enteral feeding and oral liquid intake was successfully attempted on the 7th postoperative day in 21 patients, after a radiological study proving the integrity of the anastomosis. Only one patient developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. All the other had uneventful

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recoveries after operations and restored complete oral intake on the 15th postoperative day, remaining without dysphagia over a mean follow-up of two years. Conclusion Without question, the prevention of an anastomotic leak is the key to a successful functional outcome of a cervical esophagogastric anastomosis. A wide hand-sewn anastomosis or a side-to-side stapled cervical esophagogastric anastomosis can provide a low anastomotic leak rate, but also a dramatic reduction in the need for late postoperative anastomotic dilatations if it occurs. In the patient who experiences a cervical esophageal anastomotic leak, the neck wound must be opened widely at the bedside; irrigation of the wound is accomplished by having the patient swallow water and nutrition is maintained with jejunostomy tube feedings. The wound must be packed lightly with saline-moistened gauze, which is changed at least two to three times daily or more frequently as needed. At each dressing change, the patient should swallow sips of water and any cervical drainage from the wound is aspirated with a bedside suction device. The wound is then repacked gently with a saline-moistened gauze. Healing of the cervical esophagogastric anastomotic leak is assessed by observing the relative amount of swallowed water that issues from the neck wound at the time of the dressing change. As the amount decreases and most of the drainage while swallowing can be prevented by gentle pressure on the skin directly over the anastomosis, the patient is permitted to resume oral intake, initially, of clear liquids. Early passage of 30-, 36-, and 46-Fr Maloney tapered esophageal dilators within one week of drainage is performed to maintain a satisfactory lumen and prevent the late development of a stenosis. Such an anastomotic fistula generally diminishes greatly in output or heals completely within 7 to 10 days of external drainage. It is not necessary that the cervical wound and fistula be healed completely before resumption of an oral diet is permitted. If adequate dilation of the anastomosis to a 46-Fr size has been achieved, most of the swallowed food will enter the intrathoracic viscera preferentially, and little will leak from the neck wound. Continued mediastinal soilage is suspected if persistent purulent drainage from the neck is observed or if the characteristic odor of necrotic stomach is present. A dilute barium esophagogram should be obtained or repeated to determine whether undrained mediastinal extravasation of contrast is present. Upper endoscopy can be performed to evaluate mucosal viability of the intrathoracic stomach and to estimate the extent of anastomotic disruption. Direct visualization of the gastric conduit through the opened cervical incision can confirm the occurrence of gastric tip necrosis. A chest computed tomography can help determine whether there is persistent mediastinal soilage that might require more extensive transcervical or even transthoracic drainage. After all the initial measures and recovery of oral feeding, the patient should be kept in an outpatient follow-up and dysphagia will indicate the presence of stricture and the need for further dilations. Only the depletion of endoscopic resources will indicate surgical treatment of stricture, but a well-conducted operation can provide excellent results and an important upgrade in the quality of life of patients. References

1. Lerut T, Coosemans W, De Leyn P, Van Raemdonck D, Nafteux P, Moons J: Optimizing treatment of carcinoma of the esophagus and gastroesophageal junction. Surg Oncol Clin North Am 2001; 10:863–884

2. Liebermann-Meffert DM, Meier R, Siewert JR. Vascular anatomy of the gastric tube used for esophageal reconstruction. Ann Thorac Surg 1992; 54:1110–1115

3. Urschel JD. Esophagogastric anastomotic leaks: The importance of gastric ischemia and therapeutic applications of gastric conditioning. J Invest Surg 1998; 11:245–250

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4. Collard JM, Tinton N, Mailaise J et al. Esophageal replacement: Gastric tube or whole stomach? Ann Thorac Surg 1995; 60:261–267

5. Nederlof N, Tilanus HW, Vringer T et al. A single blinded randomized controlled trial comparing semi‐mechanical with hand‐sewn cervical anastomosis after esophagectomy for cancer (SHARE‐study). J Surg Oncol 2020; 122:1616–1623

6. Fok M, Cheng SWK, Wong J. Pyloroplasty versus no drainage in gastric replacement of the esophagus. Am J Surg 1991; 162:447–452

7. Blewett CJ, Miller JD, Young JE et al. Anastomotic leaks after esophagectomyfor esophageal cancer comparison ofthoracic and cervical anastomoses. Ann ThoracCardiovasc Surg 2001; 7:75–78

8. Whooley BP, Law S, Murthy SC et al. Analysis of reduced death and complicationrates after esophageal resection. AnnSurg 2001; 3:338–344

9. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomoticleak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000; 119:277–288

10. Honkoop P, Siersema PD, Tilanus HW et al. Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy: risk factors and management. J Thorac Cardiovasc Surg 1996; 111:1141-1148

11. Park JY, Song JHY, Kim H et al. Benign anastomotic strictures after esophagectomy: long-term effectiveness of balloon dilation and factors affecting recurrence in 155 patients. AJR 2012; 198: 1208–1213

12. Holder TM, Ashcraft KW, Leape L. The treatment of patients with esophageal strictures by local steroid injections. J Pediatr Surg 1969; 4:646- 653

13. Annino DJ Jr, Goguen LA. Mitomycin c for the treatment of pharyngoesophageal stricture after total laryngopharyngectomy and microvascular free tissue reconstruction. Laryngoscope 2003; 113:1499-1502

14. Hordijk ML, Siersema PD, Tilanus HW, et al. Electrocautery therapy for refractory anastomotic strictures of the esophagus. Gastrointest Endosc 2006; 63:157-163

15. Tan Y, Liu D. Endoscopic incision for the treatment of refractory esophageal anastomotic strictures: outcomes of 13 cases with a minimum follow-up of 12 months. Rev Esp Enferm Dig (Madrid) 2016; 108: 196-200

16. Schipper PH, Cassivi SD, Deschamps C et al. Locally recurrent esophageal carcinoma: when is re-resection indicated? Ann Thorac Surg 2005; 80: 1001-1006

17. Shim CS. Esophageal stenting in unusual situations. Endoscopy 2003; 35: S14-S18 18. Orringer MB. Partial median sternotomy: anterior approach to the upper thoracic esophagus. J

Thorac Cardiovasc Surg 1984; 87:124-129

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Quality of Life after Esophagectomy

Sheraz R. Markar

1. Nuffield Department of Surgery, University of Oxford, UK; 2. Department of Molecular Medicine

& Surgery, Karolinska Institutet, Sweden Email: [email protected]

There is a paucity of data concerning quality of life after esophagectomy. With very little data considering the interplay with long-term symptoms, functional status and psychological well-being. Through this talk, I will discuss previous and ongoing research that is specifically focused on survivorship challenges in long-term survivors following esophageal cancer treatment. The LAsting Symptoms after Esophageal Resection (LASER) was a multi-center European cohort study including just under 900 long-term survivors. Through this study, we were able to identify the most prevalent and important symptoms and the interplay between them in impacting quality of life after esophagectomy. Utilising national registry data from the UK and Sweden, we have also been able to study the relationship between psychological well-being of patients and how this interacts with symptoms, quality of life and survival in these postoperative patients. Finally, from meta-analysis, randomized controlled trial (MIRO trial) and population based cohort study, we have shown minimally invasive surgical techniques fail to improve long-term quality of life. Survivorship is a complex term encompassing a range of factors that together affect a patients’ quality of life after esophagectomy. Future research must generate multi-component interventions to reflect these range of factors, with the aim of improve quality of life in long-term survivors. Keywords: esophagectomy; quality of life; esophageal cáncer

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Esophageal Squamous Cell Carcinoma and Prognosis in Taiwan

Bing-Yen Wang

Division of Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, Taiwan


Background and Purpose: The prognosis of esophageal squamous cell carcinoma is poor. In order to find out appropriate treatment for each group of patients, we aim to examine the prognostic factors influencing survival for esophageal cancer patients in Taiwan. Materials and Methods: Data were obtained from the Taiwan Society of Cancer Registry. The Taiwan Cancer Registry was implemented in 1979. After the Cancer Control Act was promulgated in 2003, the completeness (97%) and data quality of the cancer registry database have been excellent. The Taiwan Cancer Registry is organized and funded by the Ministry of Health and Welfare of Taiwan. To monitor the cancer care patterns and evaluate the cancer treatment outcomes, the central cancer registry has been reformed since 2002. The overall number of clinic-pathologic variables extended from 20 to 114 in 2011. The Taiwan Cancer Registry has run smoothly for over 30 years. The database of the Taiwan Cancer Registry was used to retrieve records for patients with ESCC. The Taiwan Cancer Registry was linked to National Health Insurance of Taiwan and Taiwanese death certificates. We only included patients with pathologic diagnoses in the database. Results: There were 18741 esophageal squamous cell carcinoma patients analyzed between 2008 and 2016 in this retrospective review. The impact of the clinicopathologic factors on overall survival was assessed. The following clinic-pathologic factors were included to analyses: age, sex, tumor location, tumor length, histologic grade, clinical T, clinical N, clinical M, clinical stage, and all therapeutic methods within 3 months after diagnosis. The 5-year survival rate was 16.8%, with a median survival of 343 days. The distribution of patients by their clinical stage is as follows: stage 0 (n = 162; 1.1%); stage I (n = 964; 6.7%); stage II (n = 2392; 16.6%); stage III (n = 6636; 46.1%); and stage IV (n = 3661; 25.4%). In the multivariate analysis, age, sex, tumor location, tumor length, clinical T, clinical N, clinical M, and treatment remained independent prognostic factors. Conclusion: Our data indicated that age, sex, tumor location, tumor length, clinical T, clinical N, clinical M, and treatment remained independent prognostic factors. Patients who could receive surgery had significantly better outcomes.

Keywords: Esophageal squamous cell carcinoma

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The Novel Treatment Strategies for Hepatocellular Carcinoma

Minoru Tanabe

Department of Hepatobiliary and Pancreatic Surgery, Tokyo Medical and Dental University


HCC remains a global health challenge and is the most common form of liver cancer. Various treatment modalities have been developed; however, the prognosis is not good enouph. Among the many treatment options for HCC, systemic chemotherapy has made remarkable progress in recent years. In addition to sorafenib, lenvatinib and atezolizmab plus vebacizmab has been currently introduced as a first line treatment. Besides these agents, several immunocheckpoint inhibitors, tyrosine kinase inhibitors, and anti-VEGF antibody have been approved by FDA. As a result, systemic chemotherapy for advanced HCC has entered a new era. In the first half of my talk, I will summarize advances in systemic chemotherapy for HCC. In the second part, I will present our current surgical trials for advanced HCC. Thirteen patients with unresectable HCC were enrolled and treated with lenvatinib. The patients who responded well to lenvatinib treatment underwent surgical resection afterward. There is a strong positive correlation between the tumor response to lenvatinib and the AFP-decrease rate. Objective response rete was 38.5%. Surgery was performed in 7 of 13 cases, and R0 resection was achieved in 5 cases. There were no operative mortality and no cases of complications of CD classification grade IIIA or higher. The resection group had significantly longer survival (median OS = 22 months) than non-resection group (median OS = 17 months) (P=0.031). In addition to lenvatinib, newly developed agents may have the potential to improve surgical outcomes for advanced hepatocellular carcinoma. Various clinical trials in this regard are currently underway worldwide. Keywords: hepatocellular carcinoma, immunotherapy, systemic therapy, conversion surgery, salvage surgery

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Rapidly Evolving Treatment Paradigms in Liver Cancer – Promise and Challenges

Dan G. Duda

Massachusetts General Hospital and Harvard Medical School, Boston, USA


Background and Purpose: Surgical treatments offer the chance for cure in liver cancers such as hepatocellular carcinoma (HCC). However, many of the resected or transplanted patients experience disease progression. Moreover, many patients present with unresectable disease at diagnosis. In such cases, until recently, available treatment options – local and systemic – have been limited in efficacy which led to dismal survival rates in advanced HCC. Materials and Methods: More recent developments in oncology have offered renewed hope for advanced HCC patients. Hypofractionated radiation has shown feasibility and promise in unresectable HCC setting, and is now being tested in a randomized phase III trial (clinicaltrials.gov identifier NCT03186898). Antiangiogenic agents have strongly impacted the management of advanced HCC, with multiple drug options in first line setting (sorafenib, lenvatinib) and second line setting (regorafenib, cabozantinib, ramucirumab). Results: Immunotherapy with anti-PD-1/PD-L1 antibodies has shown real potential to transform advanced HCC therapy, both in first line and second line settings. Finally, combinations of these new strategies are very attractive approaches, as they promise durable and profound responses in advanced HCC. But in order to achieve this promise, these concepts require greater understanding based on mechanistic preclinical studies and validation in correlative studies in clinical trials as a basis to establish optimal combinatorial strategies. I will summarize the results from clinical correlative studies and preclinical models of these diseases performed at our institution and in collaboration with other American and European investigators. Conclusion: The insights gained from this “bench-to-the-bedside and back” approach raise the hope for a more efficient development of targeted agents in combination, and in earlier stages of the disease, with the goal of increasing survival in patients afflicted with this aggressive and deadly disease. Keywords: HCC, antiangiogenesis, immunotherapy, radiotherapy, combination, neoadjuvant.

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The New Era of Immunotherapy in Bile Duct Cancer Management

Ming-Huang Chen

Center for Immuno-oncology, Department of Oncology, Taipei Veterans General Hospital, Taiwan

E mail: [email protected] Background and Purpose: The regimen of modified gemcitabine and S-1 (GS) is active and safe for patients with advanced biliary tract cancer (ABTC) in our previous study. Herein, we report the results of a single arm phase II of Nivolumab plus modified GS as the first-line treatment in ABTC patients. Materials and Methods: Patients with chemonaïve ABTC were eligible to receive nivolumab 240 mg and 800 mg/m2 gemcitabine on day 1 plus daily 80/100/120 mg of S-1 (based on body surface area) days 1-10, in a 2-week cycle. Tumor response was assessed by CT/MRI every 6 weeks according to RECIST v1.1. The PR should be confirmed by two consecutive image examinations. Trial registration number NCT04172402. Results: Between December 2019 and June 2021, totally 48 patients were enrolled. After a median of 12.2 months (95% CI, 9.2-15.3) follow-up, 1 patient got pathological CR and 20 patients achieved confirmed PR. The ORR was 43.8% with additional 21 patients (43.8%) of stable disease and a long-term disease control rate of 79.2% (CR+PR+SD>12weeks). The median progression-free survival and overall survival was 9.1 (95% CI, 7.4-not reached) and not reached (95% CI, 7.4-not reached) months, respectively. All grade 3/4 chemotherapy-related adverse events (AEs) were less than 10%, expect fatigue (14.6%) and skin rash (10.4%). Fourteen patients (35.4%) experienced immune-related AEs with skin toxicity (20.8%), hypothyroidism (8.3%), hypophysitis (8.3%) and pneumonitis (6.3%). Two patients with grade 3 pneumonitis recovered well without any treatment-related death. Conclusions: Nivolumab in combination with modified GS is a promising regimen with good safety profiles, which deserves further investigation for the management of Asian ABTC patients. Keywords: Biliary tract cancer, immune therapy, nivolumab, TS1, gemcitabine

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Surgical Strategy for HCC in the Era of Advanced Systemic Therapy

Norihiro Kokudo, Nobuyuki Takemura, Kyoji Ito, Fuminori Mihara, Fuyuki Inagaki

Department of HPB Surgery at National Center for Global Health and Medicine, Tokyo, Japan

Email: [email protected] The liver is a central immunomodulator that ensures organ and systemic protection while maintaining immunotolerance. Notably, immunotherapies have raised hope for the successful treatment of advanced HCC. Remarkable tumor response of immunotherapy may expand the indication of surgical treatment for otherwise unresectable or difficult to cure disease, as neoadjuvant setting. We have been conducting a prospective study on the use of neoadjuvant Lenvatinib for unresectable or borderline resectable HCC (LENS trial). We have completed patient accrual and the outcome will be disclosed soon. Another promising regimen for neoadjuvant setting may be Athezolizumab plus bevacizumab. We are currently planning similar prospective study. Adjuvant immunotherapy to suppress tumor recurrence after curative resection may be another promising approach. Before immunotherapy, there have been a number of trials that failed to show survival benefit of adjuvant treatment including chemotherapy, retinoid, or molecular targeted therapy. Currently, there are several ongoing studies of adjuvant immunotherapy. Prerequisite for successful adjuvant or neoadjuvant treatment may be tumor shrinkage (response rate), adverse effects, and impact on liver function or background liver. Studies on tumor immune microenvironment (TIME) may elucidate optimal styles of surgical intervention.

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Role and Limitation of Neoadjuvant Hepatic Arterial Infusion Chemotherapy in Advanced Hepatocelluar Carcinoma and Other Liver

Carcinoma

Sung-Su Yun

Department of Surgery, College of medicine, Yeungnam University, Korea Email: [email protected]

Background: The patients with advanced hepatocellular carcinoma (HCC) or multiple metastatic liver carcinoma have a poor oncologic outcome. In this study, we evaluated role and limitation of neoadjuvant hepatic arterial infusion chemotherapy (HAIC) in advanced HCC patients. And we also applied HAIC to the patients with multiple metastatic liver carcinoma resistant to standard intravenous chemotherapy. Methods: One hundred and three patients with advanced HCC and 11 patients with multiple metastatic liver carcinoma, underwent neoadjuvant HAIC, were analyzed in this retrospective study. Response to HAIC was evaluated by dividing time period into after 3 cycles and after 6 cycles, each defined as early and late period. Liver resection following neoadjuvant HAIC was offered in patients who were considered to be the candidate for curative resection with tumor-free margin as well as sufficient future liver remnant volume. Results: Advanced HCC: The median survival time (MST) in all patients was 14±1.7 months. Response rate and disease control rate were 37 (36.3%) and 83 (81.4%) in early period, respectively, and 14 (26.4%) and 25 (47.2%), in late period, respectively. Response rate in early period was significantly better than that in late period (P= 0.028). Twelve patients (11.7%) underwent liver resection following neoadjuvant HAIC and the MST was 37±6.6 months. One-, 3-, and 5-year recurrence free survival were 58.3%, 36.5%, and 24.3% respectively. Multiple metastatic liver carcinoma: After three cycles of HAIC, we had 3 partial response, 6 stable disease. We observed the tendency to prolong survival time and experienced 2 cases of clinical complete response. Conclusion: HAIC could be another alternative to treat in inoperable HCC patients and multiple metastatic liver carcinoma. with good liver function

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Multifunctional Nanocarriers for Efficient Cancer Immunotherapy

Yun-Ching Chen

Institute of Biomedical Engineering, National Tsing Hua University, Hsinchu 30013, Taiwan


While immunotherapy holds great promise for combating cancer, the limited efficacy due to an immunosuppressive tumor microenvironment (TME) and systemic toxicity impedes the broader application of cancer immunotherapy. We engineer several tumor-targeted drug/gene nano-carriers to modulate the immunosuppressive TME and stimulate anti-cancer immunity. First, we develop NanoNO, a nanoscale NO carrier with a sustained release profile that efficiently delivers NO into hepatocellular carcinoma (HCC). We demonstrate that targeting the TME with low-dose NanoNO results in tumor vessel normalization and the enhanced delivery and effectiveness of chemotherapeutic and macromolecular tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-based biological therapies. Furthermore, low-dose NanoNO polarizes tumor-associated macrophages towards an immune stimulatory phenotype and increases T cell tumor infiltration, thereby improving the efficacy of cancer immunotherapy. We also develop highly efficient and tumor-selective lipid-dendrimer-calcium-phosphate (LDCP) gene carriers for cancer immunotherapy. LDCP gene carriers with thymine-functionalized dendrimers that not only exhibits enhanced gene delivery capacity but also immune adjuvant properties by activating the stimulator of interferon genes (STING)-cGAS pathway. Tumor targeted LDCP gene carriers deliver siRNA against immune checkpoint ligand PD-L1 and immunostimulatory IL-2-encoding plasmid DNA to HCC, increase tumoral infiltration and activation of CD8+ T cells, augment the efficacy of cancer immunotherapy, and suppress HCC progression. Our work presents nanotechnology-enabled drug or gene delivery that selectively targets and reprograms the immunosuppressive tumor microenvironment to improve cancer immunotherapy, resulting in a therapeutic benefit for cancer. Keywords: Gene therapy, Nitric oxide, HCC, immunotherapy, PD-L1

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Parenchyma Sparing Major Hepatectomy

Guido Torzilli

Department of Surgery, Division of Hepatobiliary & General Surgery, Humanitas University,

Humanitas Research Hospital

E-mail: [email protected]

Liver surgery has seen several developments to increase resectability and maintain safety.

Among the most relevant techniques are portal vein embolization (PVE), two stage

hepatectomy (TSH), associated liver partition and portal vein ligation for staged hepatectomy

(ALPPS), and liver venous deprivation (LVD) followed by major hepatectomy. While these

solutions are designed to boost the future liver remnant, they all pursue a major vessel

amputation. Even if such major liver surgery is done to increase resectability, the removal of

large parts of the organ may reduce the chance of redo surgery for recurrent disease when

compared to parenchyma-sparing alternatives. However, developments in extreme

parenchyma-sparing techniques have received less attention over very extensive liver resection.

For liver lesions, looking at the target from different viewpoints may offer different perspective

to solutions. One such viewpoint is to challenge the universal pursuit for radical resection

(defined as microscopic R0 on pathology), at least in some selected situations. One particular

setting in which tumor exposure could potentially represent an acceptable oncological approach

to resection is the situation when there is tumor-vessel contact. Major intrahepatic vessels are

anatomical boundaries separating totally distinguished liver portions. Furthermore, major

intrahepatic vessels are wrapped by the Leannec capsule in addition to the Glissonean sheat, or

vein wall. Given all of that, detaching the tumor from the intrahepatic vessel (referred to as

‘R1vasc’) could be at least not heretic. A comparable recurrence risk of R1vasc and R0 surgery

for colorectal liver metastases would confirm the hypothesis in theory.

Sometimes the major vessels cannot be spared because of a lesion infiltrating the vessel. In the

event the infiltrated major vessel would be a hepatic vein, the option of major parenchymal

removal should not be considered as inevitable. In presence of tumor-vessel contact not

amenable of detachment, a compensatory circulation between the adjacent hepatic veins could

be detected almost universally. These communicating veins should be overlooked at

preoperative imaging, confirmed at intraoperative ultrasound (IOUS), and preserved during

dissection to enhance the chance of parenchyma-sparing liver resection. Indeed, the R1vasc

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surgery and the hepatectomies driven by the presence of communicating veins represent the

scaffolds of a new modality of liver resection namely the parenchyma spring vessel-guided

hepatectomy (PSVGH).

Profiting of the complexity of liver anatomy implemented the surgical options, while preserving

the liver scaffold increased the salvageability in case of relapse. Sculpturing, rather than just

amputate the organ also pushes for reconsidering the concept of minor and major hepatectomy,

implementing if not rewriting the dictionary of liver surgery. A safer clinical outcome after

major tissue deprivation in a vessel-guided hepatectomy fashion compared to that following

major resections through conventional vessels amputation should also deserve some

consideration. ALPPS has shown to be associated with an increment in liver volume which does

not translate one to one with liver function. PSVGH keeping the organ scaffold even after

removal of larger amount of liver tissue, as it happens in case of multiple complex resection for

bilobar colorectal liver metastases, has shown a low rate of liver failure. Milder regeneration of

the liver after vessel-guided hepatectomy compared to that evident after major amputation of

the organ may not be just a suggestion. Possibly, PSVGH let foresee a more tolerable large

tissue deprivation: the paradox of parenchymal sparing major hepatectomies. Indeed, PSVGH

showed in an intention to treat perspective survivals similar to those of completed TSH but

without the non-negligible 40% rate of dropout. Furthermore, a more recent multicenter case-

match analysis suggested that ALPPS and PSVGH may achieve comparable long-term results,

despite with higher mortality and morbidity rate after ALPPS.

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Open Liver Surgery: Surgical Anatomy and Anatomical Surgery of Glissonean Approach

Aleksandar R. Karamarkovic MD. PhD. FACS

Professor of Surgery, Faculty of Medicine University of Belgrade, University Clinical Center

„Zvezdara“, Surgical Clinic, HPB Dpt., Belgrade, Serbia Email: [email protected]

Liver resections are complex procedures that requires detailed knowledge of liver anatomy, precise “bloodless” surgical technique and sufficient volume of the remnant liver. Since the late 1970s, when operative mortality was more than 20% for major liver resections, much effort has been done to intraoperative control of blood loss and reduce intraoperative hemorrhage. Excessive blood loss is associated with increased perioperative morbidity and, in cases of malignant lessions, a shorter disease-free interval. Technical refinements are focused on minimizing hemorrhage during transection of hepatic parenchyma and safe dissection of the major hepatic veins and pedicles. The extrafascial dissection of Glissonean pedicle is a very important technique that can be extremely useful in particular circumstances during liver surgery, such as in multi-operated patients or in patients with cirrhotic liver or anomalous vascular and biliary variations. Regarding this technique some terminology confusion still exists (Glissonean approach, extra-Glissonean approach, Glissonean pedicle transection method, posterior intrahepatic approach, suprahilar Vascular control, perihilar posterior approach, superficialisation of Glissonean pedicles). Nevertheless, despite many titles the main surgical concept is the same, and it’s based on the anatomical fact and observation of Couinaud that portal triad elements inside the liver substance, are enveloped with fibrous Glissonean sheet, thus representing an important structure of internal architecture of the liver. The extrafascial-Glissonean pedicle approach in liver surgery provides new knowledge of the surgical anatomy of the liver and advances the technique of liver surgery. Opposite to “classic” intrafascial dissection, this technique includes extrafascial isolation of the whole sheet of Glissonean pedicle and its division “en masse”. Glissonean pedicles can be approached intrahepatically or extrahepatically. The use of vascular staplers in this situation allows quick and safe transection of the pedicle, as well as appropriate hepatic vein. The second advantage of this technique presents the quick and easy definition of the anatomic territory of the liver to be removed. Selective clamping of the appropriate isolated pedicle demonstrates the further ischemic demarcation of anatomical liver part of interest (hemiliver, section or even segment) as well as delineation of resectional planes. Recent advances of presented surgical technique includes liver hanging maneuver and some modifications with two tapes to control the main fissure of the liver or various liver resections using hanging maneuver by three Glisson’s pedicles and three hepatic veins. Video material will be included.

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Totally Laparoscopic Simultaneous Surgery for Colorectal Cancer With Synchronous Liver Metastases

Wipusit Taesombat

Chulalongkorn university, Bangkok, Thailand

The treatment of colorectal cancer with synchronous liver metastases remains challenging. Surgical treatment is the only curative treatment that can offer longterm survival. There were difference surgical strategies for this patient. Simultaneous colorectal and liver surgery is one of the most important approach which have the potential benefits of one-stop surgery but the potential disadvantage is summation of complication of two procedures. Recent advancement of laparoscopic colorectal surgery and laparoscopic liver resection resulted in more challenging to perform simultaneous surgery for this type of patient. Recent studies showed favorable peri-operative outcomes for simultaneous laparoscopic approach compared to open approach in term of shorter hospital stay, less blood loss and at least equal postoperative complications. Survival outcomes were not significantly different when compared to open approach. Patient selection was the key importance for having favorable outcomes. At present, most studies recommended only for minor liver resection and non-complicated colorectal surgery.

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Treatment strategy for multiple colorectal liver metastases considering the possibility of liver resection

Toru Beppu, Kensuke Yamamura, Shinichi Akahoshi

Department of Surgery, Yamaga City Medical Center, Kumamoto, Japan.


Liver resection is still the first-choice treatment for patients with colorectal liver metastases (CRLM) to achieve long-term survival; however, resection rates and survival time after the liver resection alone are not satisfactory. Systemic chemotherapy is equally essential to increase resectability and improve prognosis. The combination use of thermal ablation, including radiofrequency ablation (RFA) and microwave ablation (MWA) on liver resection, has become an acceptable option for patients with many bilateral CRLM without notable survival disadvantages. CRLM can divide into three groups: "resectable", "borderline resectable", and "unresectable". And oncological malignancy is a key factor to divide patients. Technical difficulty is assessed by the extent of CRLM and functional volume of the remnant liver by various diagnostic images. Oncological malignancy can be determined by the Beppu score based on the nomogram created by the Japanese Society of Hepato-Biliary-Pancreatic Surgery. "Borderline resectable" means technical difficulty and/or high oncological malignancy. Creating a treatment strategy based on the three categories is essential. Several randomized controlled trials have been completed to resolve these problems, and "Clinical practice guidelines for managing liver metastases from extrahepatic primary cancers 2021" have recently been published in the Journal of Hepatobiliary Pancreatic Science. In this symposium, we will introduce a multidisciplinary treatment for multiple CRLM considering the possibility of liver resection, mainly focusing on long-term prognosis. Keywords: colorectal liver metastases, liver resection, systemic chemotherap, thermal ablation, Beppu score, borderline resectable

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The Surgical Approach in Liver Metastases of Colorectal Origin: The Story Goes on

Irinel Popescu

Center of Digestive Diseases and Liver Transplantation, Fundeni Clinical Institute, Bucharest,

Romania [email protected]

Background and Purpose: During the last two decades, indications for surgical treatment of colorectal liver metastases (CLMs) evolved. The number of liver metastases is no longer a contraindication for liver resection (LR) and several onco-surgical strategies have been employed to enable clearance of the liver in patients with initially unresectable CLMs. The influence of such procedures (performed more frequently during the last decade) on overall survival (OS) is assessed. Materials and Methods: The patients who underwent LR for CLMs between 1996 and 2018 were analysed. The patients were divided into two intervals according to the date of LR (1996-2010 vs. 2011-2018). The median number of resected CLMs, their distribution, as well as the OS rates observed in these two time intervals were compared. The OS rates achieved by LR in patients with initially unresectable metastases that were rendered to resectability were compared to those of patients with initially resectable CLMs. Results: In 862 patients have been performed 1016 LRs for CLMs (154 repeated LRs). During the second interval the mean number of resected CLMs was significantly higher than in the first interval (2.3 vs. 1.95, respectively; p = 0.008) and the percentage of patients with bilobar CLMs was also significantly higher (35% vs. 23%, respectively; p = 0.0001). The OS rates achieved by LR during the second interval was significantly higher than those observed in the first period (54.1%, 34.1% and 19.7% vs. 44.8%, 24.6% and 13.7% at 3-, 5- and 10-years, respectively; p < 0.001). Out of 862 patients, 80 had initially unresectable CLMs that have been converted to resectability by different onco-surgical strategies (resection after portal vein oclusion – 15, two-stage LR – 9, ALPPS – 3, combined ablation and resection – 39, LR after tumor shrinkage with chemotherapy – 14). Although the OS rates of these patients were significantly lower than those observed in patients with initially resectable CLMs (p = 0.045), the 5- and 10-year OS rates of 17.8% and 7.9%, respectively, are obviously higher than those achieved even with the modern oncologic therapy. One patient with liver failure due to the insufficient functional liver parenchyma secondary to large and multiple CLMs survived 26 months after liver transplantation with a graft from an extended-criteria donor. Conclusion: OS rates of patients resected since 2011 significantly increased, although more complex operations have been performed during this interval. Long-term outcomes achieved by LR in patients with initially unresectable CLMs justify the efforts to accomplish complete clearance of the liver. Although current evidence suggests that OS rates achieved by LT are significantly higher than those accomplished by palliative chemotherapy in patients with unresectable CLMs, future studies should identify the patients who might benefit from liver transplantation, in the context of organ shortage. Keywords: colorectal liver metastases; portal vein occlusion, ALPPS, ablative therapy, conversion chemotherapy, liver transplantation

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LIVER TRANSPLANTATION AND PORTAL VEIN TUMOR THROMBUS : A CRITICAL EVALUATION

Em.Prof.Jan LERUT

Institute for Experimental and Clonical Research (IREC° Université catholique Louvain (UCL), Brussels-Belgium


Hepatocellular cancer (HCC) became again the main indication for liver transplantation (LT) worldwide. Adherence to the Milan or UCSF inclusion criteria however seriously restricts the access of many patients to a potentially curative treatment. The combination of morphological and biological tumour characteristics together with a large implementation of living donor LT in the Asian continent lead to an important extension of inclusion criteria of HCC in liver diseased patients. Good oncologic results have been obtained by sticking to such extended HCC-LT criteria with 5-years disease free survival reaching 75%. These results recently triggered the evolution from towards advanced HCC-LT criteria (meaning transplanting HCC patients presenting a macrovascular invasion in form of a portal vein. tumor thrombus (PVTT). A critical analysis of such strategy will be presented. It is clear that moving forward to advanced HCC-LT criteria can only be justified in the context of well thought, prospective studies. Such an attitude is strongly recommended in order to avoid futile liver transplantation.

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Antibody-mediated rejection in liver transplantation

Takada Y, Tamura K, Uraoka M, Utsunomiya T, Funamizu N, Sakamoto K, Ogawa K.

Ehime University, Japan


In liver transplantation (LT), antibody-mediated rejection (AMR) may occur in cases of ABO blood

type incompatible (ABO-I) matching and recipients with donor-specific antigen (DSA). Since early

times, graft injury observed in ABO-I LT has been well recognized and several treatment modalities

to alleviated AMR in ABO-I has been developed. Currently some experienced centers perform ABO-

I living donor liver transplantation (LDLT) with acceptable outcomes.

In contrast, until recently, preformed DSA were generally considered to be clinically irrelevant to

liver graft outcomes based on the rarity of hyperacute rejection and early graft loss from rejection.

However, since the early 1990s, many studies have shown a higher rate of graft loss in patients

undergoing LT with a positive crossmatch. Recent studies have confirmed inferior clinical outcomes

in some anti-HLA DSA-positive patients, assessed by the sensitive Luminex Single Antigen assay,

and suggested that preformed anti-HLA DSAs with a high mean fluorescence intensity (MFI) are

responsible for AMR. Although the impact of DSA on short- and long term outcomes has not been

clearly defined, it is required to learn about diagnosis, treatment and outcomes regarding AMR and

DSA in LT.

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Organ donation programs in Middle East & North African countries

Dr. Abdel Hadi AL Breizat

Jordan Syndicate for Physicians, Ministry of Health, JORDAN

Email : [email protected] Middle East and North African countries have a surface area about 17 million km2 with a population of 750 million with cultural and religious diversity and have different facilities, health care professionals, and funding capacities.

First living kidney transplant done in Iran (1967) where is first deceased kidney transplant was done in Jordan (1972) The first country in the region that issued the law of living and deceased organ donation (1977). First heart transplant was done in Jordan (1985) where is the first deceased and living liver transplant was done in Turkey (1988.1990).First pancreas, small bowel, multi visceral and domino liver transplant was done in Iran.

Most countries have necessary legislations based on religious backgrounds (Fatwa's) governing both living and deceased organ donation and transplantation.

Where deceased organ donation programs have grown rapidly in few countries (Iran, Turkey ,KSA) in the last 10 years still few countries have no legislations for deceased organ donation (Egypt, Pakistan ) nevertheless living organ donation is still the dominant one with living related donation being the most predominant .

Organ sharing programs are being active in gulf cooperation council countries.

Regional and international cooperation between separate countries also being active with countries such (Japan, France, Italy).

Organ donation and transplantation programs was destroyed because of aggression, invasion and civilian war (Iraq, Syria, Libia,Yemen).

In spite of legislations combating organ transplantation tourism (organ trafficking) unfortunately it is still happening and people are still being abused.

Available organs covers only about 15% of the actual needs, so reaching self-sufficiency is a responsibility of each country through a national plan based on multisector link between governmental and nongovernmental organizations and institutions which main goal should be to promote Organ donation from deceased donors. In addition to activate organ sharing programs.

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Laparoscopic Endoscopic Cooperative Surgery (LECS) for the Gastrointestinal Tract: Undated Indications

Naoki Hiki

Department of Upper Gastrointestinal Surgery/ Kitasato University School of Medicine

[email protected] Laparoscopic and endoscopic cooperative surgery (LECS) is a procedure combining laparoscopic gastric resection with endoscopic submucosal dissection for local resection of gastric tumors with appropriate, minimal surgical resection margins. The LECS concept was initially developed from the classical LECS procedure for gastric submucosal tumor resection. Many researchers reported that classical LECS was a safe and feasible technique for resection of gastric submucosal tumors, regardless of tumor location, including the esophagogastric junction. Recently, LECS was approved for insurance coverage by Japan’s National Health Insurance plan and widely applied for gastric submucosal tumor resection. However, the limitations of classical LECS are the risk of abdominal infection, scattering of tumor cells in the abdominal cavity, and tumor cell seeding in the peritoneum. The development of modified LECS procedures, such as inverted-LECS, non-exposed endoscopic wall-inversion surgery, a combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique, and closed-LECS, has almost resolved these drawbacks. This has led to a recent increase in the indication of modified LECS to include patients with gastric epithelial neoplasms. The LECS concept is also beginning to be applied to tumor excision in other organs, such as the duodenum, colon and rectum. Further evolution of LECS procedures is expected in the future. Sentinel lymph node mapping could also be combined with LECS, resulting in a portion of early gastric cancers being treated by LECS with sentinel node mapping. LECS may also be a useful technique for palliative gastric cancer surgery in very old individuals.

Keywords: local resection, early gastric cancers, submucosal tumor resection

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Minimal Invasive Surgery for Advanced Gastric Cancer

Eishi Nagai1, Takaharu Yasui1, Masayuki, Kojima1, Kentaro Motoyama1, Koji Shindo2,

Taiki Moriyama2, Kenoki Ouchida2, Yuji Nakafusa1, Masafumi Nakamura2

The department of surgery, Japanese Red Cross Fukuoka Hospital1, The department of

surgery and oncology, Graduate School of Medical Sciences, Kyushu University,

Fukuoka, Japan2


Background: Laparoscopic distal gastrectomy for gastric cancer has been widely

accepted in clinical practice and its indications have been extended from early cancer to

advanced cancer, depending on the results of multicenter randomized controlled trials.

On the other hand, laparoscopic total gastrectomy (LTG) for advanced gastric cancer is

still technically challenging. The LTG with splenectomy might be necessary for

advanced proximal gastric cancer involving the greater curvature and could increase

short-term morbidity. We herein reported our surgical technique of LTG for advanced

gastric cancer and the short- and long-term outcomes.

Surgical Procedure: The computed tomography with 3D imaging was performed to

check vascular anatomy around the stomach before surgery. The procedure of lymph

node dissection has been standardized in our surgical team. Attention was payed to

move the forceps to reduce unnecessary damage of tissue including tumor. And enlarged

lymph nodes should not be grasped directly to avoid bleeding and tumor spread.

Patients: Between January 1996 and December 2020, a total of 1239 patients with

gastric cancer were underwent laparoscopic gastrectomy in this series. And curative

LTG was carried out in 135 patients with advanced gastric cancer.

Results: The median age of the 135 patients was 69 years old. The median operation

time was 357 min, and median estimated blood loss was 47g. The median

postoperative hospital stay was 11 days. In this series, 12 out of 135 cases were

laparoscopic total remnant gastrectomy. As for morbidity, there were 4 cases with grade

IIIa and 2 cases with IIIb, according to Clavien-Dindo classification. There was no

mortality. The five-year overall survival rates of stage IB, II, III, were 82.0%, 77.8%,

54.1%, respectively in this series.

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Conclusion: The LTG for advanced gastric cancer seems to be safe and feasible.

However, the prospective study is necessary to evaluate short- and long-term outcome.

Keywords: advanced gastric cancer, laparoscopic total gastrectomy

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Selecting the Best Minimally Invasive Procedure for Proximal Gastric Cancer

Hiroharu Yamashita

Department of Digestive Surgery, Nihon University School of Medicine, Japan


Background and Purpose: Proximal gastric cancer can be defined as stomach-predominant adenocarcinoma of esophagogastric junction or cancer confining to proximal one third of the stomach. Total gastrectomy had been the standard radical procedure for advanced proximal gastric cancer, however, many recent studies show the low incidence of lymph node metastasis along with the distal portion of the stomach even from advanced disease. Materials and Methods: I review the results of recent studies specifically targeting this tumor entity and show my perspectives of minimally-invasive treatment approach. Results: When tumor confines to the upper portion of the stomach, the incidence of lymph node metastasis to stations along with the distal portion of the stomach (Nos, 4sb, 4d, 5 and 6) is quite low. Therapeutic values by their dissection are also limited. Oncologically, prophylactic dissection of these nodes seem unlikely to beneficial to improve the outcome, even for advanced disease. Proxial gastrectomy was a modified procedure for T1N0 disease but proximal gastrectomy with D2 dissection is newly defined in the current Japanese gastric cancer treatment guidelines updated on July 2021. Conclusion: Employment of proximal gastrectomy for advanced proximal gastric cancer might increase in the near future according to the results of recent studies and the new Japanese guidelines. Keywords: proximal gastric cancer, proximal gastrectomy, adenocarcinoma of the esophagogastric junction

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History of Hernia Surgery

Ching Shui Huang

Department of Surgery, Cathay General Hospital, Taipei, Taiwan


Hernia repair is one of the most common surgical procedures, the evolution of hernia management reflects the development of surgery. Recently, due to the advance of repair technique and utilization of prosthetic mesh, the overall recurrence rate was reduced from 15% to less than 5%. An ideal hernia repair should have short convalescence, low recurrence, low complications and less postoperative pain. Most tissue to tissue repairs which were still popular two decades ago, are now replaced by open tension-free repair or endoscopic repair. The open tension-free repair is the most popular repair representing 50-70% of repairs performed in the developed countries, followed by endoscopic repair which represents 30-50% of repairs, The former includes Lichtenstein repair (plain flat mesh, for 25 years), the Plug and Patch repair (for 20 years), the Kugel posterior patch (for 15 years) and Prolene Hernia System (for 16 years). In the year of 2019, over 90% of the adult herniorrhy in Taiwan utilize some kinds of mesh either open or endoscopic approach. The important concepts of herniorrhy today are: treating the myopectineal orifice as a whole, using prosthetic material to replace or re-enforce the attenuated abdominal fascia and muscles, to reduce the suture line tension and postoperative pain, and prevent the recurrences. However, hernioplasties using prosthetic mesh are not without complications. The mesh are evoluted rapidly and always improving in both material, configuration and three-dimentional design, only surgeons who know thoroughly the details of different kinds of mesh , including interaction between the mesh and human body after they are implanted, that they can select a best and proper repair for their individual patient. Further basic studies on collagen metabolism and related genetic anomaly may provide non-surgical treatment of groin hernias in the future (20211121).

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Training and Accreditation of Hernia Specialists in Japan

Nozomi Ueno1, Tetsushi Hayakawa2

1Saiseikai Suita Hospital, Hernia Center、Osaka, JAPAN, Boarding member and Board of Education Chair, Japanese Hernia Society (JHS), 2Toyota Shinsei Hospital, Department of Surgery, Nagoya, JAPAN, President, Japanese Hernia Society (JHS)

[email protected] In our country, Endoscopic Surgical Skill Qualification System managed by Japan Society for Endoscopic Surgery, is implemented from 2004. Laparoscopic inguinal hernia repair (TAPP, TEP) is positioned as a low difficulty level operation under general surgery field and is examined. A main application qualification to the system can demand creating of the list of a specified operative cases and to participate in an education seminar about endoscopic surgery additionally, and so on, in the person who is doing training of endoscopic surgery Surgeon acquisition for longer than 2 years after the Board Certified. A specified case quantity is to have the operative experience of 20 cases of a high-difficulty level or, experience of above 5 cases of a high-difficulty level operation in addition to 45 cases of a low difficulty level operation. Candidates submit 3 no edited videos of the endoscopic surgery that went recently for indirect hernia with the diameter of orifice above 1.5 cm in a male-sex, with a suture/ligation scene video. About to examine candidates' capability based on the written applications and videos. Which video data to examine among 3 pieces is decided randomly by the judging committee side. Two hernia-specified referees from the judging committee examine one candidate. When the results of judgements don't agree, an extra referee will examine newly and fixes the result of an examination. An evaluation standard is estimated within 60 points of common standards, 40 points by an organ (hernia), and 100 points in amount. Equal to or more than 70 points become a pass. An acceptance rate in hernia in 2020 was 14%. In order to acquire, it is important to train the uniform basic surgical procedures and operations in accordance with local anatomy every time. The Nationwide Survey of Endoscopic Surgery in Japan reports recurrence rates of

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inguinal hernia after endoscopic surgery is 5% in TEP in and 4% TAPP in 2012-2013, 2.0% in TEP and 1.3% in TAP in 2018～2019, what is improved after the period. It's no exaggeration to say that the Qualification System has played a big part. The Endoscopic Surgical Skill System, which has no other examples, is introduced.

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Current Trend of CBD Stones Management

Shen-Nien Wang

Division of General and Digestive Surgery,

Department of Surgery, Kaohsiung Medical University Hospital, Taiwan Email: [email protected]

Common bile duct (CBD) stones are found in 10-20 % of patients undergoing laparosopic cholecystectomy (LC). Four management strategies for CBD stones are currently available, including LC combined with ERCP on different timing as well as one-stage LC with LCBDE. Among them, ERCP followed by LC is the most preferred option in most areas. In spite of this trend, some existing drawbacks hinder its preference in some clinical situations. Herein, comparisons among these management options are reviewed in term of their sfaety and efficacy to learn more about each treatment strategy for CBD stones. It has been pointed out that LCBDE owns many benefits, including shorter hospital stay, less cost, no manipulation of Oddi sphoncter and availability for the patients with previous history of gastric surgery. Thus, we will highlight the technical principles in performing LCBDE in today’s speech. Moreover, its cautions and related compications wille be also elucidated. Keywords: CBD stones, LCBDE, ERCP

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Surgical Approach and Outcome for Perihilar Cholangiocarcinoma

Chee Chien Yong

Kaohsiung Chang Gung Memorial Hospital, Taiwan


Background and Purpose: Surgical approached and outcome for perihilar cholangiocarcinma (PHCC) was advanced in recently. But only R0 resection in N0M0 patient got better prognosis. Strategy for achievement of R0 resection is mandatory. Materials and Methods: Clinical data of 53 patients underwent surgical treatment was reviewed. The peri-operative date included age, gender, pre-op biliary drainage, surgical procedure and blood loss, pathology findings, complication and survival times. Results: Major resection associated with hepatic artery resection and reconstruction first and hilar en bloc resection associated portal vein resection was adopted in this study. There was no stastic different in patient underwent major resection with or without vessel resection in pre-op characteristic data. But the vascular resection group had more associated extra hepatic bile duct resection and longer op time, but no different in blood loss, transfusion rates and complication. Conclusion: In current study, patients undergoing curative intent resection for PHCC, vascular resection seen to be a safe procedure in selected patient, although long-term outcome need further study. Keywords: Perihilar cholangiocarcinoma, surgical treatment.

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ERCP strategy in Biliary Stricture after Liver Transplantation

Wen-Hung Hsu

Kaohsiung Meidcal University Hospita, Taiwan

Email: [email protected] Liver transplanation is the reatment of choice for end-stage liver and liver tumor. Complication of biliary tract included bile leakage and stricture remain a major source of morbidity afer orthotopic liver transplantion. Although refinements in surgical techniques and post-operation care have led to declining of bile leakage, biliary stricure still develope in a substantial proportion of liver transplantation and affect long-term recipient outcome and quality of life. In recent years, dust-to-duct anastomosis in orthotopic liver transplantation has been used in most case and endoscopic managment is feasible and become the first-line therapy for biliary stenosis after liver transplanation. Endoscopic retrograde cholangiopancreatography(ERCP) with stenosis dilation, then stenting is currently consider the fisrt-line treatment for biliary stricture. Here, we review the technical advance and short- & long-term outcomes of endoscoic management of post-liver transplantation biliary stricure.

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New classification of intraductal papillary neoplasm of the bile duct

Keiichi Kubota

Second Department of Surgery, Dokkyo Medical University, Japan. Email: [email protected]

Background and Purpose: Intraductal papillary neoplasm of the bile duct (IPNB) is characterized by dilated bile ducts filled with a noninvasive papillary or villous biliary neoplasm covering delicate fibrovascular stalks and secreting mucin in the duct lumen. Japan Biliary Association and Korean Association of Hepato-Biliary-Pancreatic Surgery performed a collaborative study and proposed new diagnostic criteria for IPNB, which is now included in WHO classification 2019. Materials and Methods: A multi-institutional, retrospective study on patients with IPNB or papillary cholangiocarcinoma was performed in two countries. In the new classification, IPNBs were classified into Type 1, being histologically similar to intraductal papillary mucinous neoplasm of the pancreas, and Type 2, having a more complex histological architecture with irregular branching or foci of solid tubular components. Results: Among 694 IPNB patients, 520 and 174 had Type 1 and Type 2, respectively. The levels of AST, ALT, ALP, γ-GTP, T. Bil, CEA and CA19-9 were significantly higher in patients with Type 2 than in those with Type 1. Type 1 IPNB was more frequently located in the intrahepatic bile duct than Type 2, whereas Type 2 was more frequently located in the distal bile duct than Type 1 IPNB (P<0.001). Hepatic resection, PD, bile duct resection (BDR) and hepato-pancreato-duodenectomy (HPD) were performed in 85.3%, 11.8%, 1.7% and 1.2% of patients with Type 1 IPNB, and 57%, 34.1%, 5.2% and 0.6% of patients with Type 2 IPNB, respectively (p<0.001). The incidence of LN metastasis was 8.8% in Type 1 IPNB and 14.7% in Type 2 IPNB with a significant difference (p=0.002). There were significant differences in 5-year cumulative survival rates (75.2% vs 50.9%; P <0.0001) and 5-year cumulative disease-free survival rates (64.1% vs 35.3%; P <0.0001) between the two groups. Conclusion: IPNBs are composed of at least two types of lesions, Type 1 and Type 2. Use of the present classification will help to further clarify the clinical and pathological characteristics of IPNBs. Keywords: intraductal papillary neoplasm of the bile duct, papillary cholangiocarcinoma, precancerous lesion

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Outcomes of vascular reconstruction for advanced perihilar cholangiocarcinoma

Satoshi Hirano

Department of Gastroenterological Surgery II,

Hokkaido University Faculty of Medicine, Japan Email: [email protected]

Background and Purpose: Perihilar cholangiocarcinoma (PHCC) occasionally requires concomitant vascular reconstruction (VR) of the portal vein and/ or the hepatic artery. However, these procedures are technically demanding and may develop several morbidities. Herein, our techniques of vascular reconstruction and their results are evaluated. Materials and Methods: In our institute, 156 patients with PHCC who underwent major hepatectomy and bile duct resection from 2008 to 2018 were retrospectively analyzed. As the operative procedures, right hepatectomy (Hx), left Hx, right tri-sectionectomy (3S), and left 3S, and central Hx were performed in 72, 63, 7, 12, and 2 patients．Among them, resection and reconstruction of the portal vein alone (PVR), hepatic artery alone (AR), and simultaneous portal vein and hepatic artery (PVAR) were performed in 66, 3, and 14 patients, respectively. In PVR, interposition anastomosis or patch plasty using some kinds of auto-vein graft were chosen in case of direct anastomosis was unsuitable. In AR, in-situ arterial grafting was mainly performed as the best alternative to direct anastomosis. Results: The R0 ratio of the patients without VR, with PVR, AR, and PVAR were 88, 83, 67, and 64%, respectively. There were no significant differences in incidence of complications of Clavien-Dindo grade III or more between the patients with each type of reconstruction, and those without. The 5-year overall survival rates of the patients without VR, with PVR, AR, and PVAR were 55, 44, unavailable, and 35%, respectively. Conclusion: Several types of VR in radical resection for PHCC were feasibly performed and their short- and long-term results were seemed to be acceptable. Keywords: perihilar cholangiocarcinoma, vascular reconstruction, hepatic artery, portal vein

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Surgical Treatment of Peri-Hilar Cholangiocarcinoma

Alfredo Guglielmi

Department of Surgery and Oncology, University of Verona (Italy) Email: [email protected]

Surgery for peri-hilar cholangiocarcinoma is one of the more demanding procedure in hepato-biliary surgery. According to the most renown experience in literature results of surgery improved during the last decades with an improvement of overall 5-years survival (38% vs 23%) and of short term results with lower morbidity and mortality rate. The surgical strategy steadily evolved worldwide with an increased rate of major or extended hepatectomy with caudate lobectomy, a more widely employment of PVE and a more precise application of preoperative biliary drainage. However, this type of surgery is still very complex with high morbidity and high mortality, also in best candidates high rate of severe morbidity (58%), mortality rate of 4,7% and a 5 years survival rate lower than 50% were observed. In order to improve short term outcome preoperative accurate preoperative management must be considered, the three main topic are: accurate preoperative planning, the optimal preoperative biliary drainage and the evaluation and management of future remnant liver volume. The long terms outcomes are related with oncological results of surgery, one of the most important factors related with long terms outcomes are the presence of positive margins. However, when considering the margins status the presence of ductal and radial margins should be carefully evaluated, because this two type of margins have similar prognostic significance. The other oncological factor is the nodal status in literature that both site and number of positive nodes are related with prognosis. The hot topics of this type of surgery are the surgical approach for Bismuth type 4 tumors, the prognostic impact of vascular resections and the role of multivisceral resection. In particular recent evidences of literature showed that Bismuth type 4 surgery have comparable results with Bismuth type 2 and 3 in terms of postoperative mortality and morbidity, moreover have similar long term results accordingly to the margins and nodal status. Also, vascular resection can be useful to achieve R0 resections with adequate long tem results especially when compared to those of unresected patients. Novel approaches of preoperative surgical planning technologies, minimally invasive surgery and the role of target therapies are more frequently applied and need to be carefully evaluated in clinical practice. In conclusions surgery for peri-hilar cholangiocarcinoma is still demanding with high morbidity and mortality, an aggressive surgical approach is frequently required to achieve a curative resection, future multidisciplinary approaches may improve results of this complex surgery

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Controversial Issues in the Surgical Treatment of Early Gallbladder Cancer

Yoo-Seok Yoon

Seoul National University Bundang Hospital, South Korea


Gallbladder cancer (GBC) is an aggressive disease with dismal prognosis, and radical surgery is

considered the only potentially curative treatment. However, there are many controversies about the

surgical treatment of T1 and T2 GBC: 1) necessity of radical surgery in patients with T1b GBC.

Although simple cholecystectomy is adequate for T1a GBC, it is still controversial whether T1b GBC

patients require radical surgery. The rate of LN metastasis in T1b GBC is reported to be 10-15%, but

some retrospective studies reported that radical surgery did not show survival difference compared

with simple cholecystectomy. 2) necessity of liver resection. LN dissection is essential part of radical

surgery because LN metastasis rate is up to 30% in T1b,2 GBC and is consistently associated with

poor prognosis. However, several studies have presented evidence for possibly omitting liver

resection in radical cholecystectomy in patients with no evidence of liver invasion. 3) extent of LN

dissection. Some guidelines recommend regional lymphadenectomy along the hepatoduodenal

ligament, while some guidelines suggest an extended approach including the posterior superior

pancreaticoduodenal lymph nodes. 4) application of laparoscopic surgery for GBC. Although this

procedure has been contraindicated in patients with GBC for a long time, many recent reports have

shown that laparoscopic surgery by experienced did not adversely affect the perioperative and

survival outcomes of patients with early GBC. Risk of peritoneal metastasis due to bile spillage and

safe selection of indicated patients are still concerns. 5) timing for re-operation for postoperatively

diagnosed GBC. The optimal time interval for re-resection for incidentally discovered gallbladder

cancer is not defined. A recent study showed the best prognosis of patients who underwent surgery at

an interval of 4–8 weeks after the initial cholecystectomy, but some guideline suggests reoperation

within 2–4 weeks as soon as possible. All these controversial issues are because most of the evidence

is based on the results of retrospective studies. Therefore, further well-designed, prospective studies

are needed to address these problems.

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Incidental Gall Bladder Cancer

Vinay Kapoor

Mahatma Gandhi Medical College & Hospital (MGMCH) Email: [email protected]

Incidental gall bladder cancer (GBC) is GBC detected for the ‘first time’ on histopathological examination of the GB specimen removed (by open or laparoscopic simple cholecystectomy) with a presumed preoperative (clinical and US) diagnosis of gall stone disease (GSD) (Kapoor AJG 2001). It does NOT include GBC suspected on preoperative imaging or on intraoperative gross examination of the GB specimen. The incidence of incidental GBC varies from region to region. Incidental GBCs are usually T1 (a lamina propria or b muscularis propria), T2 (perimuscular connective tissue) or T3 (serosa). The key issues in the management of incidental GBC are i) Is reoperation required or is follow-up alone (after the index simple cholecystectomy)

sufficient? Which patients should undergo reoperation? All patients with incidental GBC should be offered the benefits of reoperation; the only exception being T1a, node-negative, cystic duct margin negative tumor with favorable histological features, which may be followed up. ii) What investigative work up is required before the reoperation? Before the reoperation, repeat US, chest X-ray, CT (chest, abdomen and pelvis), PET scan and staging laparoscopy should be performed to exclude any distant metastases. iii) When should the reoperation be performed? Reoperation should be advised as soon as possible. In one study, best results were obtained when the reoperation was performed 4-8 weeks after the index cholecystectomy (Ethun. JAMA 2017;152:143-149). Reoperation, however, should not be denied based on delay alone. iv) What should be the extent of reoperation? Reoperation is in the form of completion extended cholecystectomy (CEC) which includes liver resection and lymphadenectomy. There is not much to choose between liver wedge and segment IVB+V resection. The role of port site excision is debatable. v. Is any adjuvant therapy required after reoperation? Systemic adjuvant chemotherapy is recommended in T2 or more and node-positive patients. In addition, patients with bile spill during the index cholecystectomy and unfavorable histological features should also receive chemotherapy. Recently, T2 tumors on the hepatic side (T2h) of the gall bladder (GB) have been differentiated from those on the peritoneal (serosal) side (T2p) and some reports recommend lymphadenectomy alone (i.e. no liver resection) for T2p incidental GBC. The Author disagrees with these reports and is of the opinion that all patients with incidental GBC should receive an aggressive approach in the form of a proper CEC, including BOTH liver resection and lymphadenectomy to reduce the risk of recurrence and improve the survival with a hope for possible cure. The Author has advocated an ‘Indian Buddhist middle path’ (Kapoor. J HBP Surg 2007;14:366-373) i.e. aggressive surgical approach for early (mostly incidental) GBC and palliative non-surgical approach for advanced (unresectable or resectable but likely incurable) GBC.

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ROLE OF NEOADJUVANT THERAPY IN GALLBLADDER CANCER

Yadav T D , Sundaram Mohan

Dept of surgical gastroenterology, PGIMER Chandigarh India Email: [email protected]

Introduction

Gallbladder cancer (GBC) is the most common biliary tract cancer in the Indian subcontinent. Most

(80-90%) are unresectable at presentation due to locally advanced or metastatic disease. This study

aims to evaluate the role of neoadjuvant chemotherapy in locally advanced and metastatic GBC.

Methods

This study is a single-center prospective observational study between July 2015 to December 2020

from a tertiary referral center in Northern India. We included locally advanced and metastatic GBC

patients in this study. We used (Gemcitabine + Oxaliplatin) regimen in our study. Patients who had

metastatic GBC at initial diagnosis were given chemotherapy with palliative intent. Patients who had

isolated aortocaval lymph node metastasis or isolated non-contiguous single liver metastasis were

considered for surgical resection if there was a complete response to chemotherapy.

Results

Total of 122 patients were included (median age 52 years,77.7% females,62.2% metastatic at

presentation,22.5% incidental GBC). 37.4% presented with jaundice. 12 (9.8%) patients were

downstaged and completed the curative-intent surgery (four in the metastatic group, eight in the

locally advanced group). The overall median survival (OS) was 8.01 months. The mean progression-

free survival (PFS) was 4.76 months. No significant difference in OS, PFS between locally advanced

and metastatic groups. Patients presented with jaundice had significantly low OS (6.3 vs. 9 months).

Patients who completed the chemotherapy course and curative surgery had a significantly better OS

of 16.3 months.

Conclusion

We have observed that curative-intent surgery is feasible after the downstaging of locally advanced

and in certain groups of metastases like an oligometastatic disease to the liver and isolated port site

metastasis, after the completion of systemic chemotherapy.

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Current and Future Directions in the Chemotherapy of Advanced Biliary Cancers

Si Young Song

Department of Gastroenterology, Yonsei University College of Medicine, Korea


Biliary tract cancers (BTCs) are aggressive tumors arising from different portions of the biliary tree and classified according to the anatomical location in intrahepatic (i) cholangiocarcinoma (CCA, iCCA), perihilar CCA (pCCA), and distal CCA (dCCA), and gallbladder cancer (GBC). Due to their silent behavior, BTCs are frequently diagnosed at advanced stages when the prognosis is poor. The available chemotherapeutic options are palliative and unfortunately, most patients will die from their disease between 6 and 18 months from diagnosis. Unfortunately, we have very limited options for the systemic chemotherapy in cholnagiocarcinoma and clinical trials are highly recommended if possible. Mostly gemcitabine and cisplatin as the 1st line and FOLFOX as the 2nd line standard regimens for the systemic chemotherapy. However, over the last decade, amounting interest has been posed on the genomic landscape of cholangiocarcinomas and deep-sequencing studies have identified different potentially actionable driver mutations. Hence, the promising results of the early phase clinical studies with targeted agents against isocitrate dehydrogenase (IDH) 1 mutation or fibroblast growth factor (FGF) receptor (FGFR) 2 aberrations in intrahepatic tumors, and other agents against human epidermal growth factor receptor (HER) 2 overexpression/mutations, neurotrophic tyrosine receptor kinase (NTRK) fusions or B-type Raf kinase (BRAF) mutations across different subtypes of BTCs, have paved the way for a “precision medicine” strategy for BTCs. Moreover, despite the modest results when used as monotherapy, beyond microsatellite instability-high (MSI-H) tumors, immune checkpoint inhibitors are being evaluated in combination with platinum-based chemotherapy, possibly further expanding the therapeutic landscape of advanced BTCs. Based on the novel target discovery, vaious novel drug development technologies have been tried such as PROTAC, mRNA, CART cell therapy, Antibody-drug conjugates, etc. For example, proteolysis-targeting chimera (PROTAC) has been developed to be a useful technology for targeted protein degradation. A bifunctional PROTAC molecule consists of a ligand (mostly small-molecule inhibitor) of the protein of interest (POI) and a covalently linked ligand of an E3 ubiquitin ligase (E3). Upon binding to the POI, the PROTAC can recruit E3 for POI ubiquitination, which is subjected to proteasome-mediated degradation. PROTAC complements nucleic acid-based gene knockdown/out technologies for targeted protein reduction and could mimic pharmacological protein inhibition. To date, PROTACs targeting ~ 50 proteins, many of which are clinically validated drug targets, have been successfully developed with several in clinical trials for cancer therapy. Most medical treatments are designed for the "average patient" as a one-size-fits-all-approach, which may be successful for some patients but not for others. Precision medicine, sometimes known as "personalized medicine" is an innovative approach to tailoring disease prevention and treatment that takes into account differences in people's genes, environments, and lifestyles. The goal of precision medicine is to target the right treatments to the right patients at the right

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time. Worldwidely many drug discovery companies have lots of interesting to the cholangiocarinoma because unsolved area scientifically and important nich market for the future. I hope in the near future we can have several tools for the patietns who suffered from this disastrous diseases and wish to step forword all with IASGO members.

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Conversion Surgery for UR-LA Pancreatic Head Cancer

Using Mesenteric Approach and Catheter Bypass of Portal Vein

Akimasa Nakao

Nagoya University, Department of Surgery, Nagoya Central Hospital, Nagoya, Japan

Background and Purpose: Because of recent developments in induction chemotherapy and

chemoradiotherapy for patients with unresectable locally advanced (UR-LA) pancreatic

cancer, conversion surgery is sometimes indicated. In conversion surgery, the mesenteric

approach and catheter bypass of the portal vein (PV) are essential techniques for successful

performance of isolated pancreatoduodenectomy (PD) (i.e., pancreatectomy under no-touch

isolation techniques). We will introduce these two operative techniques in isolated PD using

video footage.

Results: A 75-year-old man with UR-LA(SMA, PV, and SMV) pancreatic head cancer was

introduced to our department. The SMA was surrounded by the tumor (360°), and the PV and

SMV were completely obstructed by the tumor. Well-developed collaterals of the PV and

SMV were observed. The SMA and mesenteric veins were exposed using the mesenteric

approach. The middle colic artery, first jejunal artery, inferior pancreatoduodenal artery, and

dorsal pancreatic artery were ligated and divided. After the mesenteric approach, the

gastroduodenal artery was ligated and divided. By this procedure, all arterial blood flow into

the pancreatic region was stopped. Pancreatectomy combined with PV resection was then

performed using catheter bypass of the PV. The operation time was 9 hours and the blood

loss volume was 1330 mL; however, blood transfusion was not necessary.

Conclusion: This video shows the precise operative procedure of isolated PD using the

mesenteric approach and catheter bypass of the PV in conversion surgery for UR-LA

pancreatic head cancer.

Keywords: pancreatic cancer, mesenteric approach, isolated pancreatoduodenectomy,

catheter bypass of the portal vein

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Indication of Total Pancreatectomy for Pancreatic Ductal Adenocarcinoma

Yoshifumi Takeyama

KindaiUniversity Faculty of Medicine, Osaka, Japan

Email: [email protected] Background and Purpose: Total pancreatectomy (TP) has been regarded as a procedure that markedly impairs quality of life (QOL) and decreases nutritional status due to complete insufficiency of pancreatic endocrine and exocrine functions. Recently, however, the indication of TP has been increasing, particulary for main-duct type IPMN or lesions in the remnant pancreas after pereceded pancreatectomy. Moreover, the role of TP for pancreatic ductal adenocaricinoma (PDAC) remains unclear. In this paper, I aimed to show the recent status of QOL after TP, and to clarify the indication of TP for PDAC. Materials and Methods: For the assesment of QOL, 76 patients, who underwent TP in Kindai University Hospital from March 2008 to December 2018, were analyzed. We were able to properly follow up with 45 patients 1 year after surgery. (Patients who had recurrence and died were excluded for the analysis.) We evaluated medical records, patient nutritional data on 3, 6, and 12 months basis after surgery. For the evaluation of the indication of TP on PDAC, 37 patients with PDAC were analyzed among them, Results: 5-year survival rate was 45.2 %, MST was 36.6 M. BMI and Hb levels decreased until 6 months after surgery, and they stabilized afterwards. Serum Alb and TC levels decreased at 3 months after surgery, but they recovered and maintained to preoperative level after 6 months. The HbA1c levels increased within 6 months postoperatively, but they were remained within good levels of 7.2 ±1.2 % after 12 months. Among the patients with PDAC, poor prognostic factors were T3 and planned TP. Fourteen cases (93％) out of 15 cases of unplanned TP were converted to TP due to cancer positive on the intraoperative pathology using frozen section. The prognosis of the cases with unplanned TP was significantly better than that with planned TP. The low adjuvant chemotherapy rate may be one of the reasons for the poor prognosis after planned TP. TP for the lesions in the remnant pancreas was not poor prognostic factor. Conclusion: The long-term metabolic condition sfter TP is assumed to be acceptable. Indication of TP due to the preoperative-determined tumor spread does not result in good prognosis, and in such cases, we may select neoadjuvant chemotherapy at present. In contrast, unplanned TP due to intraoperative positive frozen section have demonstrated relatively good prognosis, and we should not hesitate to convert to TP in such cases. Keywords: total pancreatectomy, qualityof life, pancreatic ductal adenocarcinoma, unplanned TP, remnant pancreas.

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Two-Stage Pancreatojejunostomy After Pancreaticoduodenectomy

Taku Aoki, Keiichi Kubota

Second Department of Surgery, Dokkyo Medical University, Tochigi, Japan.

Email: [email protected] Background and Purpose: Morbidity and mortality rates associated with postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD) remains high, and it does not seem that any operative procedure or perioperative management can reduce the incidence of POPF to zero. The digestive power of pancreatic juice is activated and strengthened by the enteric contents and secondary infection after formation of pancreatic fistula. Thus, it seems safer to prevent the leaking pancreatic juice from contacting with enteric contents. In this concern, two-stage pancratojejunostomy (PJ) is a reasonable strategy to minimize the degree of morbidity following POPF. In the present study, we investigated the outcomes of PD stratified by the methods PJ. Materials and Methods: PD cases between Jan 2006 and Mar 2021 were retrospectively reviewed. The diagnosis of the disaese, the method of PJ (duct-to-mucosa anastomosis, dunking method, invagination method, two-stage PJ), and the degree of POPF were examined. In addition, the indications for and outcomes of two-stage PJ were investigated in detail. In the first procedure of two-stage PJ, a drainage tube is inserted into the main pancreatic duct and tied with the wall of the main pancreatic duct, making complete external drainage of the pancreatic juice. The stump of the pancreatic parenchyma is attached to the jejunal loop without communication. About 3 months, the second stage procedure of PJ is attempted with internal stenting tube. Results: A total of 485 PD cases (196 pancreatic cancer, 289 other diagnoses) were enrolled. Grade B/C POPF were more frequently experenced in cases without pancreatic cancer (P=0.009). Duct-to mucosa anastomosis was the most popular procedure, and dunking method, invagination method, and two-stage PJ were applied to high-risk patients. The outcomes in terms of POPF was best in the dunking method, followed by duct-to-mucosa anastomosis, and two-stage PJ. Two-stage PJ was selected in 60 patients, but the seond stage procedure was abandoned in 25 cases, mainly due to postoperative complications (n=9) and early tumor recurrence (n=10). Conclusion: Two-stage PJ following pancreaticoduodenectomy may be an option for high-risk patients for POPF. However, early tumor recurrence is the obstacle for the completion of two-stage PJ. Therefore, dunking method may be useful for patients with high-risk POPF as well as advanced-stage disease. Keywords: pancreaticoduodenectomy, postoperative pancreatic fistula, pancreatojejunostomy, duct-to-mucosa anastomosis, dunking method, two-stage pancreatojejunostomy

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Conversion Surgery for Pancreatic Cancer Patients With Portal Vein and Artery Resection and Reconstruction

Hiroki Yamaue

Second Department of Surgery, Wakayama Medical University, Japan


Background and Purpose: To improve the survival of patients with pancreatic cancer,

preoperative neoadjuvant therapy has been reported to be an independent prognostic factor

especially in borderline resectable cancer, and conversion surgery should be considered after

intensive chemotherapy even in locally advanced pancreatic cancer. In conversion surgery,

aggressive surgery including arterial resection should be required to obtain R0 status without

increasing incidence of the postoperative complications.

Surgical procedures of arterial resection during pancreatoduodenectomy: The overall

survival (OS) of BR-artery (A) patients was significantly shorter than that of the patients with

borderline resectable pancreatic cancer with portal vein/ superior mesenteric vein (PV/SMV)

involvement (n=76) and resectable pancreatic cancer (n=105) who underwent surgical resection

(median OS: 13.6 vs. 20.6 months, P<0.001). The OS of BR-A patient with neoadjuvant therapy

followed by surgical resection was significantly longer than those with upfront surgery (median OS:

20.2 vs. 12.9 months, P=0.047). Therefore, some additional strategy is strongly needed, especially

recently developed chemotherapeutic regimen including FOLFIRINOX and Gemcitabine plus nab-

paclitaxel (Okada, Yamaue et al. Cancer Chemother Pharmacol 2016, Okada, Yamaue et al.

Anticancer Res 2017). First, neoadjuvant chemotherapy (NAC) and chemoradiotherapy (NACRT)

will be discussed in this lecture, using new regimen (Okada, Yamaue et al. Oncology 2017).

PancreatoDuodenectomy with Common Hepatic Artery Resection; PD-CHAR

Next advanced surgery is combined arterial resection during pancreatoduodenectomy, and common

hepatic artery (CHA) is resected and reconstructed by splenic artery. The borderline resectable or

locally advanced pancreatic cancer located in pancreatic neck or dorsal pancreas tends to invade

CHA, and also bifurcation of CHA and gastroduodenal artery. In these cases, CHA has to resect to

obtain R0 status and reconstructed by other arteries including jejunal artery, middle colic artery, and

splenic artery. Splenic artery has been preferably used in our institution and we had a good

outcome in terms of short and long term results. However, it has remains unclear and debatable

whether arterial resection really bring a good outcome.

Conclusion: The treatment strategy for patients with borderline resectable and locally advanced

pancreatic cancer has been still controversial, and further studies and discussion will be needed to

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confirm the appropriate treatment. Especially, according to the results of RCTs, the surgical

technique should be improved to get R0 surgical margin in borderline resectable pancreatic cancer,

and allow the patients to be given a suitable preoperative and postoperative adjuvant therapy.

Keywords: advanced surgery, pancreatic cancer conversion surgery

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Operative Procedure to Reduce Delayed Gastric Emptying After Pancreaticoduodenectomy

Manabu Kawai, Seiko Hirono, Ken-ichi Okada, Motoki Miyazawa, Yuji Kitahata, and Hiroki

Yamaue

Second Department of Surgery, Wakayama Medical University, Japan Email: [email protected]

Background and Purpose: Delayed gastric emptying (DGE) is one of the most frequent complications after pancreatoduodenectomy (PD). DGE results in a frustrating complication and significant prolongation of the hospital stay. Materials and Methods: Two clinical trials regarding operative procedure have been conducted to reduce DGE as follows; comparison between antecolic route and retrocolic route dor duodenojejunostomy, and comparison between pylorus-preserving pancreatoduodenectomy (PpPD) and pylorus-resecting pancreatoduodenectomy (PrPD) Results: A randomized controlled trial (RCT) was performed to confirm the hypothesis that antecolic duodenojejunostomy reduces the incidence of DGE compared to retrocolic duodenojejunostomy. DGE occurred in 5% of patients with the antecolic route for duodenojejunostomy. On the other hands, DGE occurred 50% with the retrocolic route. As a next step, it was hypothesized that preservation of pylorus ring during PD with denervation and devascularization may be a risk factor of DGE. Another RCT was conducted to evaluate that pylorus-resecting pancreatoduodenectomy (PrPD) reduces the incidence of DGE compared to PpPD. The overall incidence of DGE was 4.5% in PrPD and 17.2% in PpPD. PrPD significantly reduced DGE compared to PpPD. Moreover, PrPD offers similar long-term outcomes with PpPD regardign nutrition status. Since PrPD with antecolic gastrojejunostomy was confirmed as a standardized procedure for pancreatic head resection in our institution, nasogastric tube in 465 patients with PrPD has been prospectively removed in the operation room immediately after intratracheal extubation. The rate of nasogastric tube reinsertion was 10.1%. The rate of delayed gastric emptying was 9.5%. Independent risk factors for delayed gastric emptying were male sex , comorbidity of cardiac ischemia, concomitant organ resection, and previous upper abdominal surgery. Conclusion: Our study clarified that PrPD can lead to a significant reduction in the incidence of DGE compared with PpPD. Moreover, PrPD offers similar long-term outcomes with PpPD. Therefore, we recommend PrPD with antecolic route. Keywords: pylorus-preserving pancreatoduodenectomy, pylorus-resecting pancreatoduodenectomy, Delayed gastric emptying, antecolic route, retrocolic route, risk factor

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Risk Factors of Recurrence After Up-Front Pancreatoduodenectomy for Resectable Pancreatic Ductal Adenocarcinoma

Seiko Hirono, Manabu Kawai, Ken-ichi Okada, Motoki Miyazawa, Yuji Kitahata,

Rryohei Kobayashi, Shinya Hayami, Masaki Ueno, Hiroki Yamaue

Second Department of Surgery, Wakayama Medical University Email address: [email protected]

Background and Purpose: Evaluation of recurrence pattern and risk factors for recurrence are essential for good rates of survival after upfront pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). Methods: This retrospective study included 167 consecutive patients who underwent upfront PD for resectable PDAC between 2000 and 2018. Postoperative recurrences were classified into three patterns according to initial recurrence site: isolated locoregional, isolated distant, and simultaneous locoregional and distant recurrences. Results: This study found 114 patients who developed postoperative recurrence (68.3%), including 37 patients with isolated locoregional recurrence (32.5%), 67 patients with isolated distant recurrence (58.8%), and 10 patients with simultaneous locoregional and distant recurrences (6.0%). When locoregional recurrence was classified based on the location of recurrent lesions, locoregional recurrence most commonly occurred around the superior mesenteric artery (SMA) (70.2%), followed by around the hepatic artery (25.5%) and in the paraaortic region (14.9%). Multivariate analyses showed that complete circumferential lymphadenectomy around the SMA, including not only the right side, but also the left side, was an independent factor for reduction of locoregional recurrence (P=0.019, odds ratio [OR]: 2.217). Lymph node metastasis was an independent risk factor for both locoregional (P<0.001, OR: 3.686) and distant recurrences (P<0.001, OR: 4.315). Non-completion of postoperative adjuvant therapy was a risk factor for distant recurrence (P<0.001, OR: 3.748). Conclusion: Based on our data, complete circumferential lymphadenectomy around the SMA might contribute to local control, and multidisciplinary treatment including neoadjuvant therapy might be needed for resectable PDAC with high risk for recurrence. Keywords: pancreatic ductal adenocarcinoma, pancreatoduodenectomy, locoregional recurrence, distant recurrence, circumferential lymphadenectomy around the SMA, lymph node metastasis

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Multi-Disciplinary Approaches to Pancreatic Cancer

Kyoichi Takaori

President, Nagahama City Hospital, Shiga, Japan, Professor, Asahi University

Pancreatic cancer is a highly lethal disease, for which mortality closely parallels incidence. While about 40% of patients are diagnosed to have metastatic disease, in really, 90% of patients are metastatic according to retrospective studies on autopsy cases. This implies that approximately 50% of patients may harbor microscopic or potential metastatic disease which cannot be detected even by the state-of-the-art CT scans. Traditionally, surgery has remained a main stay of curative treatments for pancreatic cancer. It is also true that surgery is superior to chemo-radiation therapy according to a previous randomized trial in patients with resectable pancreatic cancer (RPC). One of rationales for neoadjuvant treatment in patients with RPC and borderline resectable pancreatic cancer (BRPC) is to control the microscopic or potential metastatic lesions. Moreover, in the setting of BRPC, neoadjuvant treatments may decrease the chance of positive surgical margin. Jang et al have conducted a randomized controlled trial to compare neoadjuvant chemo-radiation (NACRT) versus upfront surgery in patients with BRPC and concluded that NACRT resulted in a significantly higher 2-year survival rate and higher R0 resection rate than did the surgery-first approach. Based on this prospective study and a large number of other retrospective studies, neoadjuvant therapy, either neoadjuvant chemotherapy (NAC) or NACRT, has become a standard of care for BRPC in the majority of specialized institutions all over the world. In contrast, there have been a long-lasting debate on the issue of neoadjuvant therapy versus upfront surgery for patients with RPC. In Europe, a few randomized trials to compare NACRT and upfront surgery have been conducted and they failed to demonstrate significant differences in survival between the two arms possibly due to the small number of recruited patients. In Japan, Unno et al. have carried out a nationwide multi-center randomized controlled trial (Prep-02/JSAP05). In this study, they have compared upfront surgery and NAC with gemcitabine and S-1 in patients with RPC. Patients in both arms received adjuvant therapy with S1. The overall survival in the group of NAC was 36.72 months while it was 26.65 months in the group of upfront surgery, resulting in a significant difference between the two arms. According to the results of Prep-01/JSAP05, the guideline of Japan Pancreas Society now recommends NAC for all patients with RPC excepting those with poor performance status or older than 80 years old. In the near future, analysis on circulating tumor DNA may provide a clue to further develop tailor-made strategies consisting of various neoadjuvant treatments for RPC and BRPC.

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Impact of Multidisciplinary Treatment for Pancreatic Cancer

Masayuki Sho, Minako Nagai, Satoshi Nishiwada, Kenji Nakagawa, Taichi Terai, Daisuke Hokuto, Satoshi Yasuda, Yasuko Matsuo, Shunsuke Doi,

Takahiro Akahori, Naoya Ikeda

Nara Medical University, JAPAN Email: [email protected]

Background: Althouh certain progress has been made in the treatment of pancreatic cancer, the overall prognosis remains unsatisfied. Currently, it is widely recognized that multidisciplinary treatment is required for pancreatic cancer. We have been trying to improve the patient prognosis for last two decades. During this time, we continuously reviewed our data and changed strategies accordingly. In this presentation, we will present our clinical data of pancreatic cancer to discuss the optimal therapeutic strategy. Methods and Results: We have introduced adjuvant hepatic arterial infusion (HAI) chemotherapy to prevent postoperative hepatic recurrence in 2006. Patients receive 3 cycles of gemcitabine every 4 weeks after surgery. Each cycle consisted of 3 weekly infusions of gemcitabine 1000 mg/m2 given by intravenous infusion for 30 minutes, followed by a 1-week pause. The concomitant 5FU 1000 mg/m2 was given by HAI for 5 hours. Then patients receive 4 cycles of S-1 afterwards. We have treated 200 patients using HAI between 2006 and 2019, and found that HAI showed favorable impact on patient prognosis and inhibited hepatic recurrence. To prevent local recurrence, we have employed neoadjvaunt chemoradiothearpy (NACRT) consiting of 54 gray radiation with weekly full-dose gemcitabine in 2008. It is likely that NACRT provide better survial in resectable, but not borderline resectable pancreatic cancer. Then we have introduced total neoadjuvant therapy for borderline resectable pancreatic cancer with arterial involvement (BR-A). As a result, we have observed much better survival in BR-A pancreatic cancer. Conclusion: We are making progress in the multidisciplinary treatment of pancreatic cancer. However, further efforts are required to improve patient care and prognosis in this fatal disease. Keywords: pancreatic cancer, hepatic arterial chemoinfusion, neoadjvuant chemoradiotherapy, total neoadjvunat therapy.

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Recent Standard of Treatment for Pancreatic Cancer

Hiromune Shimamura, Ayako Endo, Hiroki Hayashi

Department of Surgery, NHO Sendai Medical Center Email: [email protected]

Background and Purpose: Although pancreatic cancer (pancreatic ductal adenocarcinoma: PDAC) is still intractable, recent advance in chemotherapeutic agents for PDAC has given us hope to conquer this horrible malignancy. Here we review our cases of long-term survived patients with PDAC, and discuss about standardization of treatments for them. Materials and Methods: Among patients with PDAC, who underwent pancreatic resection in our hospital between Jan 2000 and May 2013, cases survived more than 60 months were recruited. Characteristics and treatments were retrospectively reviewed. Patients, who were pathologically diagnosed as invasive cancer derived from intraductal papillary-mucinous neoplasm, were excluded. Results: Among 122 operated PDAC, 20 patients (11 males and 9 females, average age: 66.0) were eligible. Median survival time was 108 months. Pancreaticosuodenectomy and distal pancreatectomy were performed for 15 and 4 patients, respectively. One patient underwent total pancreatectomy. In all cases, radical (R0) resection was achieved. In 3 cases, portal vain resection was needed to obtain R0. Chemotherapy using gemcitabine and/or S-1 was performed for all patients according to the performance status of each patient. Pulmonary resection for lung metastasis in one case seemed contributed to his long-term survival. Conclusion: We so far conclude that standardization of surgical resection to obtain R0, and of flexible administration of gemcitabine and/or S-1 may contribute to long-term survival of PDAC patients. Keywords: pancreatic cancer, long-term survival, S-1.

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Combined Arterial Resection in Advanced Pancreatic Cancer-Its Clinical Implications and Limits

Masaru Miyazaki, M.D.

Department of Surgery, Narita Hospital, International University of Health &Welfare

Professor of Emeritus, Department of General Surgery、Chiba University Chiba, Japan

Email: [email protected] Background &Purpose Surgical resection is still only hope for cure in the treatment of pancreatic cancer. However, patients with locally advanced pancreatic cancer is usually diagnosed as unresectable one due to surrounding vascular invasion, especially to arterial invasion. Therefore, combined arterial resection would be expected to be a promising therapeutic option for these locally advanced pancreatic cancer. ＭＭaterials &Methods We experienced surgical resection with combined arterial resection for locally advanced pancreatic cancer in 71 patients. Distal pancreatectomy with celiac arterial resection (DP-CAR) in 49, pancreaticoduodenectomy with hepatic arterial resection (PD-CHAR) in 17, total pancreatectomy with hepatic arterial resection (TP-CHAR) in 4 patients, were analyzed for assessing its implication and limits. Results The 5-year overall survival rates were 24% in R0, surgical margin free group, and 3.8% in R1, surgical margin positive group (p<0.0001). The 5-year survival rates were 23% in DP-CAR group and 5.0% in PD-CHAR and TP-CHAR groups (p<0.01). Surgical mortality rates in 71 patients of all combined arterial resection was 1.4%. Conclusion Combined arterial resection could be safely undergone without increased surgical morbidity and mortality at high-volume center by HPB surgeons with sufficient surgical expertise. Even in patients with locally advanced pancreatic cancer involving surrounding arteries, combined arterial resection might bring about beneficial effects on the prognosis in some selected patients. Keywords Pancreatic cancer, arterial resection, DP-CAR, PD-CHAR,

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Pancreatoduodenectomy with the portal vein-superior mesenteric vein reconstruction for advanced pancreatic head carcinoma

Kiyoshi Hasegawa, Rihito Nagata, Masaki Yamamoto, Nobuhisa Akamatsu, Akihiko Ichida,

Yuichiro Mihara, Yoshikuni Kawaguchi, Takeaki Ishizawa, Junichi Kaneko, Sumihito Tamura, and Junichi Arita.

Hepato-Biliary-Pancreatic Surgery Division

Department of Surgery, Graduate School of Medicine, the University of Tokyo, JAPAN Email: [email protected]

Background: For advanced pancreatic head carcinoma, removal and reconstruction of the portal vein-superior mesenteric vein (PV-SMV) is sometimes necessary to achieve R0 resection. Although there are several surgical techniques for the reconstructing in pancreatoduodenectomy, reconstruction using cryopreserved homologous veins has been performed in the Tokyo University Hospital. Case Presentation: The patient was an 81-year-old male with pancreatic head carcinoma invading to the PV-SMV. Because the first jejunal vein was also invaded, direct anastomosis following resection of the part of SMV seemed to be difficult. Reconstruction of the SMV and the first jejunal vein using cryopreserved femoral vein allograft was successfully done. The total time of clamping SMV was 50 minutes, and the portal flow was sufficient after the reconstruction. The operative procedures of the reconstruction will be shown by a short videoclip. Results: In 18 patients undergoing pancreatoduodenectomy, there was no mortality and no morbidity above Clavien-Dindu grade 3a. The 1-, 6-, and 12-month patency for PV-SMV was 100%, 87%, and 67%, respectively. Conclusion: Reconstruction of the PV-SMV using cryopreserved venous allografts is safe and feasible in pancreatoduodenectomy for advanced pancreatic cancer. Keywords: Pancreatoduodenectomy, portal vein reconstruction, and cryopreserved venous allograft

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Nutritional issues in Pancreatic cancer patients

Joon Seong Park, MD,PhD..

Hepatobiliary Pancreas Cancer Clinic, Department of Surgery,

Gangnam Severance Hospital, Yonsei University Health System, Aouth Korea


Patients with pancreatic carcinoma are characterized by a high frequency of malnutrition- related symptoms such as weight loss and diarrhea. Pancreaticoduodenectomy has become safe procedure in tertiary centers, but many patients experienced GI complications. Patients received PD are usually malnourished and it has been reported that 52%–88% of postoperative patients were at medium- high risk of malnutrition. Dietary intake after PD is usually suboptimal and poor and this can aggravate nutritional status of the patients. During surgery, proteins are degraded in the skeletal muscles as an adaptive process. The amino acids released are used for the synthesis of proteins required in wound healing or for oxidation in peripheral organs.The lack of protein can contribute to immune deficiency as a result of inadequate endogenous protein synthesis in immunocompetent cells. Protein enriched enteral nutrition was shown to reduce the incidence of pneumonia, bacterial infection, and severe sepsis after multiple trauma. On the basis of recent studies, protein enhanced diet appears to have numerous advantages over usual nutrition.

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Diagnosis and Therapeutic Strategies for Intraductal Papillary-Mucinous Neoplasm (IPMN) of the Pancreas, Up to Date

Wataru Kimura

Toto Kasukabe Hospital, Japan

Email: [email protected] IPMN is characterized by dilated main pancreatic duct and/or its branches. The dilatation of the oriface of the papilla of Vater by mucin is also the characteristics. The marked histological papillary projection and egg-like appearance are slso the characteristics of this disease, IPMN. Macroscopically confirmed mucin production is very important in this tumor. When IPMN is resected as adenoma, the prognosis is good 100%, and if it is carcinoma in situ, the prognosis is also good. When IPMN invades, the prognosis is much worse., bout 60%. With this reason, we should remove this deisase when this is carcinoma in situ. In 2017, the third edition of the guideline was created, and the main point of how to follow up was added. In particular, cyst enlargement was added to one of the items of “worrisome features”. B. Significance of increased changes in cyst size One of the items of IPMN “worrisome features” is that the increase in cyst size is significant. Increasing cysts has several implications. a. Mucus is produced from the epithelium in the cyst. b. The branch of the pancreatic duct that was in traffic should be blocked for some reason and not leak anywhere. c. The traffic area between the branch of the pancreatic duct that flows out and the main pancreatic duct is narrow. d. Mucus is viscous and difficult to flow out. From the above inferences, this cystic epithelium is neoplastic, yet active and resistant to degeneration. This means that you can think of malignancy. It is natural that this was put in “worrisome features”.

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Pancreatic Perfusion Chemotherapy for Advanced Pancreatic Cancer

Satoru Murata, Shiro Onozawa, Daisuke Yasui, Tatsuo Ueda, Kenichi Suzuki, Hiroyuki Tajima

1Department of Radiology, Interventional Radiology Center, Teikyo University Chiba Medical

Center, 2Departments of Radiology, Center for Advanced Medical Technology, 3Medical Engineering, Nippon Medical School, 4Departments of Radiology, Saitama University International

Medical Center, Japan Email: [email protected]

Background and Purpose: Percutaneous isolated pancreatic perfusion (PIPP) is a technique in interventional radiology to obtain high drug concentration by occluding the arterial inlet and venous outlet of the pancreas. The study aimed to evaluate the contrast distribution in PIPP under various conditions using pig models. Materials and Methods: This study was approved by a local animal experiment ethics committee. Nine pigs were divided into Groups 1, 2, and 3, by infusion rates of 12, 24, and 36 mL/min. Groups 4 and 5 (3 pigs each), and Group 6 (2 pigs) underwent modified PIPP at the same respective infusion rates without and then with balloon occlusion of the anterior mesenteric artery (AMA). Computed tomography (CT) arteriography was performed during PIPP with non-ionic contrast media. The enhanced volume was calculated by adding the enhanced area in each slice using 1.25-mm axial images. The percent enhanced volume to the whole pancreas (%eV) was used to simulate drug distribution; the result was compared among groups. Results: Without AMA occlusion, a larger %eV was obtained with high infusion rates (P = 0.039). The median %eV in Groups 1, 2, and 3 were 57.7%, 74.2%, and 90.5%, respectively. With AMA occlusion, CT demonstrated duodenal enhancement at an infusion rate of 36 mL/min, and the median %eV in Groups 4, 5, and 6 were 92.8%, 95.4%, and 98.5%, respectively. A significantly larger %eV was obtained after AMA occlusion (P = 0.031). Conclusion: A higher infusion rate or AMA occlusion increases the enhanced volume in PIPP in pig models. Keywords: isolation; pancreas; perfusion; intervention; computed tomography

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Multivisceral Resection In Pancreatic cancer

Dejan Radenkovic

Professor of Surgery,President of Serbian Pancreatic Club, Head of the Doctoral Studies in

Surgery, Vice Chair of Department of Gastrointestinal - First Surgical Clinic, Clinical Center of Serbia and Medical Faculty, University of Belgrade 6 Koste Todorovica Street, 11000 Belgrade, Serbia

E-mail: [email protected]

Background and Purpose: A statement of the hypothesis or research question. Materials and Methods: An explanation of the study design and experimental methods used. Results: A concise summary of the major findings of the experiment or study. Sufficient data must be provided to permit evaluation by the reviewers and public reading the abstracts. Statements such as "the data will be discussed" are not acceptable. Conclusion: Summary of the overall findings and the importance of the study. Keywords: A tool to help indexers and search engines find relevant papers.

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Impact of Neoadjuvant Treatment in Radical Surgery With Venous Resection in Locally Advanced Pancreatic Tumors

Emilio Vicente

Sanchinarro University Hospital. “Clara Campal“ Oncological Center

Locally advanced pancreatic cancer (LAPC) is a highly malignant carcinoma, one of leading causes of cancer mortality in developed countries. LAPC has a median survival ranging from 6 to 24 months, depending on the ability to perform both local and systemic treatment. Although early detection of pancreatic cancer (PC) and surgical resection remains the only curative option, the majority of patients are diagnosed at an advanced or even incurable stage. Unfortunately, only 10% to 20% of patients are candidates for surgical resection. Several factors contribute to the low resectixon rate including: liver metastases, extensive lymph node involvement, invasion of superior mesenteric artery (SMA), celiac axis (CA), or the superior mesenteric vein (SMV) and portal vein (PV). The involvement of major vascular structures has traditionally been considered a contraindication to resection of advanced tumors because of the poor long-term prognosis and high surgical risk. Nevertheless, in the last decade several studies have shown satisfactory results after concomitant tumor and vascular resection (VR) at various localizations. Currently, venous resection has been reported in up to 20% of pancreatic surgery (PS) at high-volume pancreatic surgery centers. The recent uptake of news neoadjuvant protocols as FOLFIRINOX (folinic acid, fluorouracil, irinotecan, oxaliplatin) or GEM-Abraxane may eventually lead to higher down-staging rates for pancreatic cancer, which could increase the application of resection and improve survival rate. The aim of the presentation was to determine whether this extended surgical procedure is justified. To evaluate the clinical implications and role of VR, we investigated. Demographics, operative factors, morbidity, mortality, and overall survival of a consecutive single center series of 81 patients with venous resection in LAPC.

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Is a nihilistic approach justifiable for Pancreatic cancer

Elroy P Weledji

University of Buea, Cameroon, Email: [email protected]

Introduction

Pancreatic ductal adenocarcinoma is the 13th commonest cancer but the fourth most common cause of cancer-related death. The persistent dilemma in the management of pancreatic cancer is not helped by the preconceived knowledge of its poor prognosis.

Objectives

The aim of the study is to debate the arguments of the realist approach to management in positive patient selection for radical resection or palliative stent or surgical bypass, and, the nihilist approach of palliative stenting and bypass of pancreatic cancer even within an MDT setting

Materials and Methods

Electronic searches of the Medline (PubMed) database, Cochrane library and science citation index were performed to identify original published studies on the management of pancreatic cancer. Relevant articles were searched from relevant chapters in specialized texts and all included.

Results

The arguments for the realist approach to management are as follows: 1) PDAC is increasing in incidence and although it is considered a disease of the elderly more than 40% of men and 35% of women present under the age of 70 years; 2)The use of modern diagnostic imaging techniques or the novel protein marker glypican-1 (PC1) can pick up tumours at an early stage, 3) Even though the chances of cure are <10%, the only hope for cure of early PDAC is by surgical resection; 4) Cancers of distal CBD, duodenal mucosa, ampulla of Vater which have 5-year survival rates of >30% may not be resected with a nihilistic approach; 5) In some cases resectability can only be defined intraoperatively; 6) a potentially curative R0 resection - median survival of 12 months, and a 5-year survival rate of 15-26%, improved by neoadjuvant/ adjuvant Ctx; 7) resection ameliorates the diabetes in preoperative new-onset diabetes but not long standing diabetes. Thus, confirming a marker of early, asymptomatic cancer; 8) although a complex procedure associated with considerable perioperative morbidity and mortality, the operative mortality has fallen to 5% or less in experienced hands. The arguments for the nihilist approach are 1) PDAC usually has and insidious presentation and physical signs of metastatic spread are commonly present at initial consultation; 2) It is a disease of elderly patients and 50% are >70 yrs, many are unfit, weak, emaciated and suffer from other concomitant medical conditions; 3) Endoscopic bypass is all that can be offered. The palliation of biliary and gastric outlet obstruction by surgical bypass if the endoscopic method fails and patient fit for surgery; 4) An unsuccessful resection can result in a high mortality and morbidity with a costly period of treatment.

Conclusions

From all the above evidence, a nihilistic approach of simply palliative stenting or bypass of all pancreatic cancers is not justified.

Keywords: Pancreatic cancer, management, realist, nihilist

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Evidence for Robotic Pancreatic Surgery

Thilo Hackert

Department of General, Visceral and Transplantation Surgery/University Hospital of Heidelberg

Email: [email protected] Robotic pancreatic surgery procedures have been implemented and become an important development in pancreatic surgery with an increasing acceptance worldwide in recent years. Nearly all types of pancreatic surgery have been performed robotically and especially standardized resection like distal pancreatectomy and partial pancreatico-duodenectomy have gained importance despite a potentially long learning curve and increased procedure costs. The implementation of a robotic program requires a structured curriculum of training that includes skills simulation, biotissue exercises, cadaver training, case observations and proctoring. Furthermore, it has to be respected that the learning curve for complex procedures, i.e. Whipple resections, comprises up to 80 procedures which implies that a relevant case load and center expertise is mandatory. Robotic pancreas procedures have today only been reported in observational patient cohorts, therefore, no evidence-based recommendation can currently be given. In centers with the respective expertise, robotic approaches seem to be not only feasible but also potentially advantageous in terms of blood loss, time to recovery and length of hospital stay without compromising oncological radicality. Also extended robotic approaches in pancreatic cancer surgery, including pancreato-duodenectomy with venous resection as well as DP-CAR have been reported with good outcomes. These findings remain to be confirmed in larger series and are – as all advanced surgical procedures – depending on an extensive experience of the surgeon as well as the center. Current randomized and thereby high-level evidence studies on the impact of robotics in pancreatic cancer surgery are ongoing and focusing not only on perioperative but also on long-term oncological results. The uncritical acceptance and widespread application of new approaches like robotic pancreatectomies should not be done prior to the retrieval of result from properly performed clinical trials showing superiority or – at least – non-inferiority of these innovative procedures.

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Hepatic Steatosis after Pancreatectomy

Masafumi Nakamura

Kyushu University Email: [email protected]

Hepatic steatosis (HS) is one of the most significant long-term complications after pancreatectomy, which influences not only hepatic function but also survival rate. Pancreatic exocrine insufficiency (PEI) is expected to be the main cause of HS after pancreatectomy and pancreatic enzyme replacement improves HS well. However, significance of HS and PEI after pancreatectomy has not been well recognized yet. Meanwhile, significant number of patients after pancreatectomy develop HS, though they are given large amount of pancrelipase. We found that ratio of carnitine fraction is one of significant risk factors for HS after pancreatectomy. Furthermore, L-carnitine administration improved pancrealipase-resistant HS after pancreatectomy. The basic concept of HS and EPI after pancreatectomy and rationale of L-cartinine therapy will be presented.

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Robotic Pancreaticoduodenectomy

Yuichi Nagakawa

Department of Gastrointestinal and Pediatric Surgery, Tokyo Medical University, Japan Email: [email protected]

The anatomical structure around the pancreatic head is very complex, and it is important to understand its precise anatomy and corresponding anatomical approach to safely perform minimally invasive pancreatoduodenectomy. As an advantage of robotic surgery, a surgical view obtained through high scope resolution and magnification has enabled the recognition of precise anatomical structures, which can be used as landmarks to determine the appropriate cutting line during surgery. Therefore, an understanding of the precise anatomical structures encountered during robotic pancreatectomy enables more reliable surgical procedures, which may lead to further improvement in surgical outcomes. I introduce our surgical approach based on precise anatomy. Keywords: robotic pancreaticoduodenectomy, minimaly invasive surgey, robotic surgery.

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Expanding the Limits of Laparoscopic Liver Resection

Brian K. P. Goh

Singapore General Hospital, Singapore Email: [email protected]

Background: Laparoscopic liver resection (LLR) is increasingly adopted world-wide. Although the learning curve was reported to be steep, this is rapidly decreasing with the wide dissemination of knowledge and improvement in technology. Grading the difficulty of LLR is essential for surgeons to perform LLR according to their experience level. Today, the indications of LLR has expanded rapidly to complicated procedures such as major hepatectomies, tumors in difficulty locations, huge tumors, repeat liver resections and concomitant hepaticojejunostomies. Conclusion: LLR can be adopted safely today. It can be performed for all types of liver resection for tumors in all locations by experienced surgeons. Keywords: laparoscopic liver resection; laparoscopic hepatectomy; learning curve; limits

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Evolution and revolution of laparoscopic liver resection in Japan

Hironori Kaneko

Toho University School of Medicine Department of Surgery, Japan Email: [email protected]

Abstract: Laparoscopic liver resection (LLR) is now considered the approach of choice and is increasingly performed worldwide due to important technologic developments and improved endoscopic technique. Recent systematic reviews and meta-analyses of observational data reported that LLR was associated with less bleeding, fewer complications, and no oncological disadvantage; however, no prospective randomized trials have been conducted. LLR will continue to evolve as a surgical approach that improves patient’s quality of life. LLR will not totally supplant open liver surgery and major LLR remains to be technically challenging procedure. The success of LLR depends on individual learning curves and adherence to surgical indications. A recent study proposed a scoring system for stepwise application of LLR, which was based on experience at high-volume Japanese centers. A cluster of deaths after major LLR was sensationally reported by the Japanese media in 2014. In response, the Japanese Society of Hepato-Biliary-Pancreatic Surgery conducted an emergency data collection on operative mortality. The results demonstrated that mortality was not higher than that for open procedures except for hemi-hepatectomy with biliary reconstruction. An online prospective registry system for LLR was established in 2015, to be transparent for patients who might potentially undergo treatment with this newly developed, technically demanding surgical procedure.

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A surgical training model using a goat for laparoscopic anatomical liver resection

Goro Honda, Yusuke Ome, Yusuke Kawamoto, Masakazu Yamamoto

Institute of Gastroenterology, Tokyo Women's Medical University, Japan1


Background and Purpose: A swine model has been generally used for surgical training worldwide. However, swine’s liver is not suitable for the training of anatomic liver resection because its liver anatomy is much different from the human liver. Materials and Methods: A 3-year-old female goat weighing 42 kg was used for the surgical procedure. Following the partial liver resection in the left lateral section for checking a similarity in the texture of the parenchyma to the human liver and a tolerability against inflow control under the Pringle maneuver, left hemihepatectomy was performed by our standardized procedure for humans. Results: We found that the morphology of the liver and anatomy of the blood vessels in goats were quite similar to those seen in humans, as well as the texture of the liver parenchyma and blood vessels, which were seen during dissection using the CUSA. Conclusion: We herein report the results of a laparoscopic left hemihepatectomy using goat model and discuss its feasibility as a novel training model. Keywords: laparoscopic surgery, training, goat, CUSA, anatomical hepatectomy

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5

Robotic vs Laparoscopic for difficult liver segments: Which is better?

Adrian Chiow

Changi General Hospital, Singapore


The resection of difficult liver segments via minimally invasive methods continue to be challenging for the liver surgeon. Few studies have addressed the best modality for resection in these difficult liver segments especially direct comparisons between laparoscopic and robotic approach. 2 studies from the international laparoscopic and robotic liver rescction study group was presented showing results of limited resection of the difficulty segments as well as posterior sectionectomy. These results from propensity score matching and coarsen exact matching showed benefits of lower blood loss and fewer open conversions of the robotic group vs the laparoscopic cohort. Limitations of these studies are discussed and more studies are needed to confirm these findings. Keywords: robotic liver resection, laparoscopic liver resection, difficult liver segments, posterior sectionectomy

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Possibilities of Laparoscopic Liver Surgery

Nikola Vladov

Military Medical Academy – Sofia, Sofia, Bulgaria


Laparoscopic liver surgery (LLS) has experienced tremendous development in the past decade. With superior results in respect to blood loss, hospital stay and post-operative complications, as well as similar oncologic outcomes, it has gained acceptance for the treatment of benign and malignant conditions. There is already enough evidence to suggest that LLS is equivalent or even superior to the open approach in terms of short-term outcomes. Currently the focus is shifting towards the long-term results. We present the current trends in minimally invasive liver surgery. Since the meeting in Morioka, laparoscopic major hepatectomy has gained wide acceptance. Concurrently parenchyma sparing techniques are becoming increasingly more common, even in the postero-superior liver segments. Two-stage hepatectomies, as well as synchronous colorectal and liver resections may be greatly facilitated by the laparoscopic approach. The final frontier are the techniques for laparoscopic donor hepatectomy. As a tertiary referral hepato-biliary centre, we have performed more than 1100 liver resections in the past 12 years, including 254 laparoscopic hepatectomies. Our results demonstrate shorter postoperative stay (5 vs. 8 days), reduced blood loss and transfusion requirements, as well as fewer bile leaks (7% vs. 11%) in the laparoscopic group. Compared to the conventional approach we report fewer postoperative complications (21% vs. 27%) and a nil mortality. A gradual increase in difficulty, corresponding with the progression of the learning curve is mandatory for the safe implementation of a laparoscopic liver program. With accumulation of experience, the indications for laparoscopic liver resections become broader, including moribund, obese patients as well as technically challenging cases. Keywords: liver; laparoscopic; minimally-invasive; major hepatectomy; parenchyma-sparing;

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6

Enhanced Precision in Robotic Liver Surgery with Indocyanine Green (ICG) Imaging

Roland S. Croner

Department of General-, Visceral-, Vascular- and Transplantation Surgery, University Hospital

Magdeburg, Germany Email: [email protected]

Keywords: A tool to help indexers and search engines find relevant papers.

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The Value of 3D Rendering in Laparoscopic/robotic Liver Surgery

R. Troisi, F. Pegoraro, GL Rompianesi, MC Giglio, N Rashidian, R. Montalti

Federico II University Hospital Naples Italy Email: [email protected]

Background and Purpose: Parenchyma-saving liver surgery, calculation of the future liver remnant and proper surgical technique are a necessity today for improving minimally invasive liver surgery (MILS) while achieving textbook outcomes. 3D rendering (3DR) via medical images processing allows the planning of the surgical gesture helping with intraoperative identification of lesions and their relationship with biliary and vascular structures. The present study aimed to describe our experience with 3DR for MILS. Materials and Methods: Since the implementation of 3DR technology at our Institution, 246 liver resections were carried out during November 2019 and July 2021. All the patients eligible for a preoperative 3D reconstruction underwent a preoperative 0.5 or 1 mm-thick slices tri-phasic abdominal CT scan at our Centre as the only additional preoperative examination, if not already executed previously. CT protocol included pre- and post-contrast imaging in arterial (15-30s), hepatic/portal (60-80s), and delayed phases (120s). In 82 (33.3%) cases we performed a preoperative 3DR to plan surgical strategy. Our inclusion criteria for 3D model implementation were lesion multifocality or large dimensions; proximity, encasement, or invasion of critical vasculo-biliary structures; major or minor resections in patients with increased surgical risk; planning of parenchyma-sparing resections and substantial anatomical vasculo-biliary variations. Patients with a 3DR were compared to those without (2D) with a PSM analysis for age, gender, ASA score, BMI, indication, neoadjuvant chemotherapy, previous abdominal surgery, previous hepatectomies, type of surgery, PS segments, number of lesions, and total size of the lesions >5cm. Results: The majority of patients benefited from a laparoscopic approach (54.8%), followed by an open procedure (34.2%) and a robotic approach (11%). Considering all 82 cases of 3DR, we recorded a total of 28 (37.0%) preoperative variations of the original surgical plan. Amongst them, 14 preoperative modifications concerned surgical access, anatomic variations, middle hepatic vein management, and preservation or resection of liver portions (additional small wedge resections or thermal ablations of newly found small lesions unreported by radiologic description). Other 9 were deemed unfit to undergo any surgical procedure after 3DR evaluation, due to disease extension, FLR insufficiency, and/or major liver resections in patients with high surgical risk due to severe comorbidities. The other 5 patients received a new surgical indication after initial contraindication. The PSM analysis identified 32 cases in each group (3DR and 2D). A significant difference in terms of total nodules dimensions between the two groups (69.4% of 3DR ≥5cm vs 38.7% in 2D, p=0.003) but no differences in the number of repeat hepatectomy (p=0.109), type of resection (p=0.162), number of PS resections (p=0.118), and number of nodules (p=0.131) was found. The conversion rate (12.5% vs 18.7%, p=0.731) and blood loss (450 cc vs 425 cc, p=0.568) were similar between the two groups. Conversion was necessary due to severe adhesions (3 in 3DR patients and 4 in 2D patients) and bleeding (1 3DR patient and 2 in 2D patients). Blood transfusion (31.3% vs 43.8%, p=0.439), R1 vascular (12.5% vs 31.3%, p=0.129), incidence of Clavien-Dindo complications ≥3 (3.1% vs 12.5%, p=0.355), and length of stay (4.5 vs 5 days, p=0.545) resulted slightly improved in the 3DR group, although statistically not significant. Operative time (450 min vs 425 min, p=0.013) was significantly increased in 3DR group. Conclusion: 3DR in MILS has the potential to improve perioperative parameters, refine surgical strategy and allow a safe intraoperative change in surgical strategy leading to a more conservative approach while removing more liver lesions. Further studies are needed to explore its value. Keywords: 3D rendering liver surgery; Virtual reality laparoscopic and robotic liver surgery

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Pancreatic anastomosis during robotic pancreaticoduodenectomy

Marino MV

Istituto Villa Salus, Siracusa, Italy


Background and Purpose: Several pancreatic anastomosis have been proposed with the aim to reduce the post-operative pancreatic fistula rate. No studies have analyzed the pancreático-jejunostomy (PJ) vs pancreato-gastrostomy (PG) during robotic pancreaticoduodenectomy RPD. Materials and Methods: A retrospective analysis of our prospectively maintained database have been conducted since 2015 to 2020. The outcomes of patients undergoing PG vs PJ anastomosis during RPD have been compared. Results: The PJ was associated to a longer operative time, but the POPF rate was similar between the two groups. Conclusion: Summary of the overall findings and the importance of the study. Keywords: A tool to help indexers and search engines find relevant papers.

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Challenge and Tips in CME and High BMI by Robotic Surgery

Jaw-Yuan Wang

Division of Colorectal Surgery Department of Surgery Kaohsiung Medical University Hospital Kaohsiung Medical University, Taiwan


Background and Purpose: Complete mesocolic excision (CME) was first proposed by Hohenberger et al. in 1992 on the basis of embryology and anatomy. Reports demonstrate laparoscopic colorectal surgery in obese patients is associated with higher conversion to laparotomy and complication rates. Results: Complete mesocolic excision has the potential to reduce the risk of recurrence and improve long-term outcome after resection for all UICC stages I–III of right-sided colon cancer. A meta-analysis have shown that there is no difference in conversion to laparotomy and overall complication rates in non-obese and obese patients undergoing robotic-assisted colorectal surgery. However, obesity is associated with a higher prevalence of wound complications. Robotic-assisted surgery may minimize conversion to laparotomy and complications typically seen in obese patients due to improved visualization, instrumentation, and ergonomics. Conclusion: Summary of the overall findings and the importance of the study. Keywords: CME, High BMI, robotic surgery

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Quality of Life After Major Surgery for Rectal Cancer

Viorel Scripcariu

Grigore T. Popa” University of Medicine and Pharmacy Iași, Romania Email: [email protected]

Background and Purpose: Surgery is the treatment of choice in rectal cancer, with or without the association of neoadjuvant radiochemotherapy. Depending on the location of the tumor, the options are (very) low anterior resection of the rectum with total mesorectal excision, or abdominoperineal excision of the rectum. These interventions are of major impact on the patient and on the quality of life. One of the former’s important effects on quality of life is the low anterior resection syndrome; the latter, alongside the impairments given by having a stoma, may present local complications in the perineal area, such as postoperative incisional hernia at this site. Materials and Methods: Through these studies we aimed to evaluate effect on quality of life that the aforementioned interventions have, with emphasis on the evaluation of the anal sphincter function and on diagnosis and treatment of perineal incisional hernia. We included in our study cases with rectal cancer operated upon in the First Surgical Clinic of the Regional Institute of Oncology in Iasi. Out of these cases, 30 were included in the study evaluating anal sphincter function in patients after neoadjuvant treatment through incontinence scores and anal sphincter manometry and low anterior resection; 256 patients with abdominoperineal excision were followed up and 14 cases of perineal incisional hernia were identified. Results: We identified there is an inverse correlation between Wexner score and anorectal manometry, which means there is a correlation between objective findings through manometry and subjective sensations of the patient. The impact of patient’s characteristics on the anal pressure showed a higher squeeze pressure in males compared to females. Moreover, squeeze pressure was shown to vary in accordance with Charlson comorbidity index of the evaluated patients and the timespan between ileostomy formation and its closure. Regarding perineal incisional hernia, symptoms varied from painful perineal discomfort and perineal swelling with specific consistency as most frequent to bowel movement disorders and trophic skin disorders in the area of the hernia sac. Ten out of 14 patients were treated for this pathology through techniques that included anatomic and mesh repair, by perineal and abdominal approach. None of the abdominal interventions were performed laparoscopically. Conclusion: Manometric evaluation of the anal sphincter pressures is correlated with the Wexner incontinence score, thus a correlation can be made between an objective measurement and a subjective perception of the patient. Female gender, multiple comorbidities and a long interval until ileostomy closure are risk factors for an impaired continence. Perineal incisional hernia is a rare late complication of abdominoperineal excision. Its treatment is challenging. 5.4% of cases with abdominoperineal excision developed perineal incisional hernia in the studied group. There were no recurrences in said group. Keywords: Rectal cancer, quality of life, anorectal manometry, incontinence, perineal incisional hernia.

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Laparoscopic Surgery for Ulcerative Colitis

György Lázár1, János Tajti Jr.1, Attila Paszt1, Zsolt Simonka1, Szabolcs Ábrahám1, Klaudia Farkas2, Tamás Molnár2

1University of Szeged, Department of Surgery, Szeged, Hungary

2University of Szeged, First Department of Internal Medicine, Szeged, Hungary

Email: [email protected], [email protected] Background and Purpose: The objective of our study is to compare the mean 64 (1-158) month follow-up results of patients with ulcerative colitis (UC) treated with open and minimally invasive surgical methods. Materials and Methods: Between 2005 and 2021 a total of 99 patients had undergone surgery for UC, out of which 31 (32%) were emergency (total colectomy with mucous fistula) and 68 (68%) were elective cases (proctocolectomy and ileal pouch-anal anastomosis). Laparoscopy was used in 74 (74%) and conventional method in 25 (26%) cases. Quality of life was examined with questionnaires. Results: During the long term follow-up, significantly fewer complications were in the laparoscopy group such as septic condition (8.1% vs. 64%), intestinal obstruction (22.9% vs. 56%) and "other" complications (6.7% vs. 52%) such as hernia formation, anastomotic stenosis, per anum bleeding, and pouch-vaginal fistula. Trait anxiety was significantly lower in patients having undergone laparoscopic surgery compared with patients who had had open surgery (P=0.018) (average value of trait anxiety in patients with open surgery was 48.71, SD=10.91; this value was 40.22, SD=9.82 in the laparoscopic group). The incidence of abdominal pain was significantly less common (1.895 vs. 2.769; P=0.024) in the laparoscopic group based on the Gastrointestinal Quality of Life. A significant correlation was found between the results of the psychological and gastrointestinal questionnaires. Conclusion: Minimally invasive technique provides a better long-term outcome for patients with UC, fewer late complications and a more balanced emotional condition. Keywords: ulcerative colitis, laparoscopic surgery, IBD.

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Bowel obstruction as a result of advanced ovarian cancer

Christian Petkov, Sabrie Bekir

First Surgical Department, “Princess Clementine” General Hospital, Sofia, Bulgaria Email: [email protected]

Introduction The growth of ovarian cancer in numerous cases is without symptoms and the first sign of this disease is bowel obstruction. This brings these patients to the Emergency Surgery teams. Different patients will have different time for diagnistic work-up before surgery, depending on the general condition of the patient and abdominal status. Aims To analyze what kind of lesions (primary or metastatic) lead to bowel obstruction in ovarian cancer patients and the type of operations performed. As well as survival levels. And … illustrative cases

Patients and Methods We analyze 36 ovarian cancer patients with bowel obstruction in our department for 3 years in regard of the perfrormed surgical procedures for maximal cytoreduction. The operation we made was Primary or Secondary to some patients. Besides the standard technique for ovarian cancer (2 pts) the other procedures were - Hartmann as part of Posterior Pelvic Exenteration – 9; total PE – 1; small bowel resection – 2; right hemicolectomy – 2; LN dissection – 6; omentectomy – 4; splenectomy – 3; hepatic resection – 2; a combination of the listed procedures is usual. Ablation or excision of peritoneal implants is necessary in most cases. Explorative laparotomies and palliations also reviewed. Postoperative mortality and survival are analyzed for the two groups of patients – with Primary and Secondary operations. What to take home? The ovarian cancer often growths without clinical symptoms and the first sign of this disease appear when peritoneal dissemination and/or abdominal mass are present, and these result in bowel obstruction Ovarian cancer disseminates quite early – in the early stages of the disease. In regard to peritoneal implants ovarian differs from cancers like colorectal and gastric. Peritoneal implant metastases are Stage ІІ and III for ovarian cancer, while this definitely the last stage ІV for colorectal and gastric cancer. For patients of advanced (IIIC-IV) stage ovarian cancer , it is necessary to add extensive upper abdominal surgery to the standard surgical technique - extensive multivisceral operation – in order to achieve a visible disease-free cytoreductive result. Aiming at maximal cytoreduction, please take care to avoid iatrogenic lesions to other organs – this will increase morbidity and will not benefit survival. Maximal safe cytoreduction might be suboptimal but it is safe regarding morbidity There are no rules about the survival of the advanced ovarian cancer patients with bowel obstruction. It is low for patients with explorative laparotomy and for FYGO IV stage A Secondary operation may benefit the survival to 23 – 44 even 48 – 72 months

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Nutrition for Surgical Cancer Patients

Kazuhiko Fukatsu

Surgical Center, The University of Tokyo Hospital, Tokyo, JAPAN Email: [email protected]

Background and Purpose: Recent advances in nutrition therapy and surgical technique have made early restart of oral food intake after surgery a standard therapy. Because oral or enteral nutrition has great advantages over parenteral nutrition in terms of host defense against infection and surgical insults, clinical path including early oral intake may has beneficial impact on postoperative course. However, there are still many patients who cannot receive enough amount of nutrients after surgery. In case such patients suffer from preoperative malnutrition or postoperative complications, surgical outcomes may become very poor. Supplemental administration of nutrients should be considered. Thus, surgeons must understand the importance of nutrition therapy. Materials and Methods: Here, in this presentation, I will focus on the following subjects. 1) Benefits of enteral nutrition 2) Disadvantages of starvation 3) Actual situation of perioperative nutrition therapy in Japan 4) Development of ideal parenteral nutrition Results: Enteral nutrition improves host defense in terms of gut and hepatic immunity and might contribute to long survival after cancer operation. However, the beneficial effects may be lost when amount of nutrients delivered is small. In Japan, surgeons may not give enough amount of nutrients to surgical patients. Though early oral intake or enteral nutrition is recommended, surgeons need to consider supplemental parenteral nutrition in some cases. To develop better parenteral nutrition formula, basic and clinical research is needed. Conclusion: We must improve nutrition therapy for surgical cancer patients. Keywords: early oral intake, enteral nutrition, host defense, questionnaire survey, parenteral nutrition

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Perioperative Nutrition Therapy After Gastric Cancer Surgery

Ryoji Fukushima

Teikyo Heisei University/Teikyo University school of Medicine, Tokyo Japan

Body weight loss is common in gastric cancer patients. It occurs preoperatively in

advanced cases and is inevitable after gastrectomy. In our cases, weight loss continued up

to sixth months after surgery and the decrease was greatest in the early postoperative

period. Body weight loss during the first week after surgery was significantly greater than

that during the subsequent 3 weeks, and loss of lean body mass accounted for a significant

part of the body weight loss during the first week. It is reported that body weight loss is

associated with various adverse outcomes and thus nutritional support takes an integral

part of patients’ care in the gastric cancer surgery.

Recently, ERAS (Enhanced Recovery After Surgery) protocol has been applied to various

types of major surgery and now becoming a standard in perioperative management. It is

not an exception in gastric cancer surgery. As a result, early oral feeding has becoming

popular after gastrectomy. However, in contrast to colonic surgery, postoperative intake

is more restricted in gastrectomy patients even though they can eat early in their

postoperative courses. Thus, some patients need an individualized approach.

Supplemental peripheral parenteral nutrition is an option and early enteral catheter

feeding may be applied to selected patients those with preoperative malnutrition and those

predicted to have poor oral intake after surgery.

What is important is not the meals you prescribed but actual amount of oral intake. Daily

actual nutritional intake of individual patient should be monitored and it is necessary to

inform the patient himself how much energy and protein are deficient every day.

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Nutrition Therapy for the Critically Ill Patients

Joji Kotani

Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe

University Graduate School of Medicine

It has been well known that eating/feeding is necessary in recovery from severe illness

such as acute surgical patients. In patients in the emergency / intensive care unit, energy

consumption increases due to severe pathological conditions and various nutrients are

depleted, so that biological functions are disrupted unless appropriate nutrients are

administered. However, there is still debate about the optimal route of administration,

timing of administration, dosage, and nutrients to be administered.

In this session, I would like to explain 1) Priority of enteral nutrition over parenteral

nutrition, 2) Initiation of early enteral nutrition, 3) Limitation of early energy dose, 4)

Pros and cons of early protein administration (Opinions and evidences are mixed), 6)

Place of feeding tube and so on, with the case study.

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Current Status of Surgical Metabolism in the Philippines

Jesus Fernando B. Inciong

St. Luke’s Medical Center, Quezon City Philippines


Recent advances in surgery has been reshaping the future of surgery. There are newer techniques in minimally invasive surgery, the use of robotics and perhaps soon to come would be augmented reality and virtual reality. However, at this time, despite these advances, almost 30% of patients undergoing major abdominal surgery would still develop complications. Also, in recent years, there has been a renewed interest in the value of nutrition and metabolism in field of surgery and how it may affect our clinical outcomes. In the Philippines, initial awareness of the problem began to spread with studies from different institutions highlighting the presence of malnutrition in surgical patients and the complications associated with. This led to the establishment of the PhilSPEN (Philippine Society for Parenteral and Enteral Nutrition). Aggressive efforts from the society along with the cooperation of the Philippine College of Surgeons Committee on Critical Care & Surgical Nutrition gave birth to training modules such as the PCS-IONS (improving outcomes with nutrition support). A decade later, with the increasing popularity and acceptance of fast track surgery protocols, the ERAS Society Philippines was established with at least 2 government and private institutions taking the lead. Soon, as the surgeons bond together in recognition of the discipline of surgical nutrition and metabolism, our own local society will be organized.

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Application of Vitamin D3 in Sepsis Induced-Acute Lung Injury: An Obese Animal Model for Clinical Critical Illness

Chiu-Li Yeh, Ming-Tsan Lin

School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical

University and Department of Surgery, National Taiwan University Hospital, National Taiwan University, Taipei, Taiwan

Obesity is a state with chronic inflammation and dysregulated immune responses. The enlarged adipocytes and aggregated macrophages result from obesity secrete various adipokines which lead to pro-inflammatory cytokine production and increase the risk of complications in several organ systems in the critical patients. Due to the high prevalence, obesity affects almost 20% of ICU patients. Previous animal and clinical studies had shown that obesity is correlated with adverse outcomes and increased risk of mortality in the critical illness. Obesity has become an important concern in the populations of critically ill. Vitamin D is an important nutrient with anti-inflammatory and immunomodulatory properties. Numerous studies had shown that there is a high prevalence of low vitamin D levels in the critically ill patients. Sepsis is the leading cause of death in ICUs. Studies also found inverse correlations between vitamin D levels and clinical consequences of sepsis. Both obesity and low levels of vitamin D are associated with adverse outcomes in sepsis. Vitamin D supplementation was found to have favorable clinical influences in the critically ill. The lungs are the most frequently affected organ during sepsis and the homeostasis of the renin-angiotensin system (RAS) is closely correlated with the severity of acute lung injury (ALI). Our study had shown that intravenous calcitriol administration after sepsis increased plasma vitamin D levels, upregulated the anti-inflammatory RAS pathway and consequently alleviated sepsis-induced ALI in obesity. Since most clinical trials provided mega-dose cholecalciferol enterally, we administer either cholecalciferol enterally or/and calcitriol parenterally to compare their impacts on ALI in obese mice complicated with polymicrobial sepsis. The preliminary findings showed that both forms of vitamin D reduce lung injury score, however, intravenous calcitriol administration after sepsis seems to have more pronounced effects on upregulating the anti-inflammatory RAS signaling pathway and reduces inflammatory mediator expressions in the lungs. Our findings imply that the active form of vitamin D may be more useful in applications for clinical critical obese patients who are at risk for ALI and acute respiratory distress syndrome.

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Keywords: cholecalciferol, calcitriol, renin-angiotensin system, anti-inflammatory pathway

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Exploring Predictors of Treatment Efficacy of Radiofrequency Ablation for Benign Thyroid Nodules

Chi-Yu Kuo1, Ming-Hsun Wu2, Wen-Ching Ko1, Shih-Ping Cheng1

1Department of Surgery, MacKay Memorial Hospital and MacKay Medical College, Taipei,

Taiwan, 2Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan, 3Department of Pharmacology, School of Medicine, College of Medicine, Taipei Medical University,

Taipei, Taiwan Email: [email protected]

Background and Purpose: Radiofrequency ablation (RFA) is a relatively safe and efficient alternative to surgery for patients with benign thyroid nodules. We investigated predictive factors associated with volume reduction using digital imaging analysis. Materials and Methods: In this retrospective study, a prospectively maintained database containing the data of patients who received treatment from April 2019 to March 2020 was analyzed. Computerized analysis for quantitative measurement of echogenicity, heterogeneity, and the proportion of cystic components was performed on ultrasonographic images. The volume reduction rate (VRR) was calculated during follow-up. Treatment efficacy was defined as a volume reduction greater than 50% of baseline volume. Results: The median volume of 58 benign thyroid nodules before RFA was 22.7 mL. Of 53 nodules with sufficient follow-up, the median VRR was 46.4%, 61.5%, 63.4%, and 67.4% at 1, 3, 6, and 12 months, respectively. Overall, at one-year follow-up, treatment efficacy was achieved in 39 (74%) nodules. In a multivariate regression analysis, the proportion of cystic components and RFA treatment time were independently associated with treatment efficacy. A subgroup analysis focusing on solid nodules indicated a negative correlation between echogenicity and VRR. Conclusion: The proportion of cystic components in thyroid nodules is the main predictor of RFA treatment efficacy. In solid nodules, higher echogenicity is associated with a lower volume reduction. Keywords: benign thyroid nodule, radiofrequency ablation, volume reduction rate

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Mortality Factors in Recurrent Parathyroid Cancer: A Pooled Analysis

Wen-Hsuan Tsai1, Yi-Hong Zeng1,2, Chun-Chuan Lee1,2, Ming-Chieh Tsai1,2*

1Division of Endocrinology and Metabolism, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan (ROC), 2Department of Medicine, MacKay Medical College, New Taipei

City, Taiwan (ROC) Email: [email protected]

Background and Purpose: Parathyroid cancer is a rare disease with high recurrence rate. The prognostic factors for recurrent parathyroid cancer are yet to be conclusively determined. We aimed to establish the association between recurrent parathyroid cancer and previously reported prognostic factors. Materials and Methods: We conducted a PubMed search using the keywords ‘parathyroid cancer’, ‘parathyroid neoplasm’, and ‘hypercalcemia’ during 1966–2019 and included 3272 articles. We focused on 73 patients with recurrent parathyroid cancer from 55 studies. We conducted survival analysis by Cox proportional hazard model with 95% confidence interval. Results: For the 73 patients included in the analysis, the mean ± standard deviation age was 44±13.2 years, and 36 of the patients were women (49.3%). During 5236 person-months at risk (mean follow-up 71.7 months, range 3-264), 38 patients died. The incidence of local recurrence, lymph node metastasis, lung metastasis, and bone metastasis was 60.3, 12.3, 56.2, and 24.7, respectively. Bone metastasis, disease-free interval shorter than 1 year, and total surgeries <3 were significant prognostic factors in univariate analysis (log-rank test P = 0.0063, P = 0.0006, P = 0.0056, respectively). In multivariate-adjusted analysis, the mortality risk were significantly increased in patients with bone metastasis with hazard ratio (HR) as 4.83 (95% CI 1.16-20.2; P = 0.03), disease-free interval > 1 year as 0.17 (95% CI 0.05-0.54; P = 0.003) and total surgeries >=3 as 0.09 (95% CI 0.02-0.36; P = 0.001), considering as predictively prognostic factors. Conclusion: Bone metastasis, duration of disease-free interval, and total number of surgeries predict survival in recurrent parathyroid cancer. Keywords: parathyroid cancer, recurrence, bone metastasis, prognostic factor

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Pattern of Recurrence Following Parathyroidectomy for Renal Hyperparathyroidism: A 10-Year Review

Si-Yuan Wu1, Giien-Shuen Chen2, Shih-Hua Lin2, Pauling Chu2, Jyh-Cherng Yu1, Teng-Wei

Chen1, Ming-Lang Shih1

1Division of General Surgery, Department of Surgery and 2Division of Nephrology, Department of Medicine, Tri-service General Hospital, Taipei, Taiwan.


Background and Purpose: Recurrence following parathyroidectomy for renal hyperparathyroidism is uncommon but not easy to handle in terms of localization and the reoperative setting. We reviewed our experience and aimed to identify the recurrence pattern and effectiveness of various localization tests in the reoperative setting. Materials and Methods: From 2010 to 2020, 376 patients who underwent parathyroidectomy for renal hyperparathyroidism were included. Total parathyroidectomy with forearm graft was preferred if all four glands could be identified from our practice. The patient's demographic data, serum blood test (iPTH, Phosphate, Calcium) before and after the first operation, as well as reoperation, were collected. The localization studies before each operation were reviewed and correlated to the operative findings and pathologic results. Patients who had a second operation within six months were recorded as persistent, otherwise recurrent. Results: 323 patients underwent total parathyroidectomy with forearm graft at the first operations, while 53 patients underwent subtotal thyroidectomy because of less than four glands identified. Nineteen patients had reoperations, including 9 for recurrent and 10 for persistent disease. The dominant sites of recurrence were within the neck. Supranumber glands were the most common reason for persistent (7/10) and recurrent disease (4/9). Common locations for the persistent disease were glands with posterior location (n=2) and glands in the upper mediastinum (n=2). Ultrasound failed to localize disease in the neck in 23% of cases. Conclusion: The neck is the most frequent site of recurrence following intentional total parathyroidectomy for renal hyperparathyroidism. A surgeon should be aware of the possibility of supranumber glands and glands falling into the thyrothymic tract or behind thyroid parenchyma: the most common missed exploration site. Keywords: parathyroidectomy, renal hyperparathyroidism, recurrence, localization

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Use of ICG in Parathyroid Imaging

Eren Berber

Cleveland Clinic, Ohio, USA [email protected]

Background and Purpose: The purpose of this talk is to describe the technique for ICG imaging of parathyroid glands, summarize the data and give recommendations about optimal use. Materials and Methods: The talk will summarize the literature and show videos demonstrating the technique. Results: ICG fluorescence has a role in the assessment of the perfusion for parathyroid glands as well as localization of parathyroid glands in parathyroid and thyroid surgeries. There are certain limitations related mainly due to the interfering fluorescence from the thyroid gland. Most utility is in ectopic parathyroid glands, re-operative parathyroid surgery and assessment of parathyroid perfusion in case of subtotal parathyroidectomy or at the end of total thyroidectomy. Conclusion: ICG fluorescence imaging of parathyroid glands is an easy imaging modality to master. Once learned, this imaging can provide additional information to complement conventional technique. Keywords: Indocyanine green, fluorescence, parathyroidectomy, thyroidectomy

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Ultrasound Applications in Thyroid Surgery

Ming-Hsun Wu

National Taiwan University Hospital, Taipei, Taiwan Email: dtsurgp9@gmail

Ultrasound serves as the first-line imaging modality for thyroid and parathyroid diseases. In the hands of a surgeon, ultrasound plays a vital role in the preoperative, intraoperative, and postoperative environment. The most critical point is that surgeon-performed thyroid, and parathyroid ultrasound requires training, validation, experience, and capacity building. In addition, endocrine surgeons currently may involve in the practice of ultrasound-guided procedures, including fine needle aspirations (FNA), core biopsies, ethanol injection (EA) and thermal ablations as radiofrequencies (RFA), High-intensity focused ultrasound (HIFU), lacer (LA) etc. Familiarity with these techniques will enrich surgeons' options for better diagnosing and treating thyroid and parathyroid diseases Keywords: Ultrasound; thyroid surgery; computer-aided diagnosis; ultrasound-guided procedure

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New Technology Applications in Thyroid Surgery

Ting-Chun Kuo


Email: [email protected] Background and Purpose: What concerns thyroid surgeons and the patients. Materials and Methods: A retrospective analysis was used on patients who underwent TOETVA at our hospital between December 2016 and July 2019. The cumulative sum graphic model was used to implement the learning curve as a surrogate for procedural proficiency.. Results: The 119 patients had a mean age of 44.65 years and a mean body mass index of 22.49 k/m2, including 107 women, 20 thyroiditis, and 106 hemithyroidectomy. The learning curve revealed two phases, an initial (35 cases) and a mature (84 cases) phase, for surgeons based on operation time (144.2 vs. 114.2 min, p = 0.0001). Procedure-related complications decreased significantly in the mature phase in comparison to the initial phase (3.57% vs. 31.43%, p = 0.0001). Conclusion: The learning curve of TOETVA with neuromonitoring is 35 cases. With the accumulation of proficiency, the indications will expand. Step-by-step improvements from the experience of each case can reduce procedure-related complications. Keywords: TOETVA, IONM, hemostatic sealing device

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Treatment of Anaplastic Thyroid Cancer

Shyang-Rong Shih

Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan

University Hospital, Taipei, Taiwan. Email: [email protected]

Anaplastic thyroid cancer (ATC) is a rare and highly lethal form of thyroid cancer. American Thyroid Association guidelines for management of patients with ATC by Bible et al. were published in 2021. Recommendations are summarized as the following:

Fine needle aspiration cytology is important for initial diagnosis of ATC, but core biopsy may be necessary for definitive diagnosis and molecular interrogation. If the patients receive thyroidectomy, pathology evaluation should focus on definite diagnosis of ATC, extent of disease, presence of any coexisting differentiated thyroid cancer. Molecular profiling should be performed, especially BRAFV600E mutation, to inform decisions related to the use of targeted therapies. Initial radiological staging should include computed tomography (or MRI) of neck to pelvis with contrast and FDG PET/CT. Brain MRI should be performed if clinically indicated. Comprehensive disease-specific multidisciplinary input should be attained and decision should be made with the patients. Palliative care with pain and symptom control should be included in the management. Hospice care is an important option.

For patients with confined ATC in whom R0/R1 resection is anticipated, surgical resection is recommended. Radical resection is generally not recommended given the poor prognosis of ATC. Following R0/R1 resection, radiotherapy with concurrent systemic therapy should be offered in patients in good performance status and without metastatic disease. Patients who have undergone R2 resection or have unresectable disease without metastasis could be offered radiotherapy with systemic disease.

In BRAFV600E mutated ATC, combined BRAF/MEK inhibitors can be considered. In patients with NTRK or RET fusion and stage IVC disease, initiation of a TRK inhibitor or RET inhibitor is recommended if available. In IVC ATC patients with high PD-L1 expression, checkpoint inhibitors can be considered as a first-line therapy in the absence of other targetable alterations or as later line therapy. In metastatic ATC patients lacking other therapeutic options including clinical trials, cytotoxic chemotherapy such as taxane, anthracyclin, and carboplatin should be considered. Keywords: anaplastic thyroid cancer, treatment

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A therapeutic approach for RAI refractory thyroid cancer

Min Ji Jeon

Asan Medical Center, Seoul, Korea


Most differentiated thyroid cancers have a very favorable outcome, but some will have distant metastases from thyroid cancer. Around 60-70% of these patients with distant metastatic DTC will become radioiodine refractory and have a poor prognosis. Multikinase inhibitors treatments have been available and ongoing studies are evaluating the efficacy of several novel treatments for thyroid cancer. The treatment of advanced RAI-refractory thyroid cancer is challenging, and appropriate assessment and treatment is an important issue in real clinical practice. During my talk, I will discuss the recommended management for RAI refractory thyroid cancers from the recent European thyroid association and NCCN guidelines. I will also show you recent studies for new therapeutic approaches of thyroid cancer targeting specific genetic alterations.

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MEN1-Related pHPT: Recognition and Management

Carla Pieterman

UMC Utrecht the Netherlands


Multiple Endocrine Neoplasia Type 1 is an autosomal dominant inherited syndrome, caused by mutations in the MEN1 gene on chromosome 11. The MEN1 is a tumor suppressor gene that encodes the menin protein. Menin is a nuclear scaffold protein that is involved in gene transcription through regulation of chromatin remodeling. MEN1 is a rare syndrome with an estimated prevalence of 2-3/100,000. Patients with MEN1 are prone to develop multiple endocrine and non-endocrine tumors throughout the course of their lives. The syndrome is highly penetrant, and its major manifestations are Primary Hyperparathyroidism (>95%), duodenopancreatic Neuroendocrine tumors (>80%) and Pituitary adenomas (ca.50%), collectively known as the three Ps. Other tumors that can occur in patients with MEN1 are NETs of the thymus, lung and stomach and adrenal adenomas. Female patients with MEN1 have an increased risk of breast cancer. Diagnosis of MEN1 leads to the advice to adhere to a lifelong surveillance program to allow early detection of tumors so timely intervention can prevent morbidity and mortality while minimizing treatment-related mortality and preserving Quality of Life. Timely diagnosis of MEN1 is essential to prevent morbidity and mortality of the patient and family and allow adequate management of individual manifestations. Recognition can be challenging as some of the tumors within the MEN1 spectrum are also frequent in het general population. MEN1 should be considered in any patient with multiple MEN1-related tumors, a family history of MEN1-related tumors, multiple tumors in a single organ, MEN1-related tumors at a young age and specific tumors of which a high percentage are related to MEN1 (such as gastrinoma and thymusNET). De Laat et. al have developed a nomogram to predict the risk of an MEN1 mutation in patients with commonly occurring endocrine tumors, that can be of use in clinical practice. Diagnosis of MEN1 can be made genetically in a patient with a (likely) pathogenic variant in the MEN1 gene. A familial diagnosis can be made in a patient with one main manifestation and a first degree relative with MEN1. The use of a clinical diagnosis of MEN1 (2 out of 3 main manifestation) in patients with negative genetic testing has been called into question in the last years, because patients with genotype-negative clinical MEN1 seem to have a different clinical course and better survival compared to patients who are genotype positive. After a diagnosis of MEN1 timely family screening is important and patients should be advised to adhere to surveillance programs, preferably in expert centers. MEN1-related pHPT is often the first manifestations of the syndrome. It is a multi-gland disease (MGD) although glands may be affected asymmetrically and asynchronously. Compared to sporadic pHPT patients with MEN1 are younger, have an equal gender distrubtion, lower Ca/PTH, lower bone mineral density and due to MGD, more often recurrence. The aim of initial parathyroidectomy in MEN1 is to achieve eucalcemia for as long as possible, while preventing hypoparathyroidism and facilitating subsequent surgery. Indication for initial surgery are symptomatic patients, significant hypCa, renal/skeletal complications or gastrinoma. The optimal timing in asymptomatic mild pHPT in MEN1 is unclear, and consideration are different for children compared to adults. Initial operation of choice is a subtotal parathyroidecotmy. Due to MGD recurrence is common. Hypoparathyroidism is frequently seen in MEN1 due to multiple operations. Important to realize that unless patients are truly aparathyroid, recovery can even occur after several years. Most important preventive measure is careful remnant creation during initial surgery. There has been debate in the literature to offer unilateral clearance as a stepwise approach in young patients with MEN1, however this approach is still controversial at present. Keywords: MEN1, pHPT, Timely diagnosis, Genetic testing

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Thyroid Cancer and Accuracy of Fine-Needle Aspiration Cytology at a UAE Referral Hospital

Yasir Akmal

Cleveland Clinic Abu Dhabi, United States


Background and Purpose: Thyroid nodules are a common presentation in clinical practice. Fine‑needle aspiration cytology (FNAC) is a useful method of triaging patients between benign, suspicious, and malignant categories. The objectives of this study were to identify the correlation of cytological results to final pathology results of thyroid FNA biopsy inpatients treated at Cleveland Clinic Abu Dhabi in comparison to regional and global rates. Materials and Methods: This is a retrospective review of the electronic medical record of all surgical thyroid patients presenting to our institution between July 2015 and June 2017. The cytological and histological data were reviewed and correlated based on the Bethesda system for reporting thyroid cytopathology. Results: Two hundred and seven patients underwent thyroidectomies during that period of which 164 had preoperative FNAC. The female‑male ratio of 4.9:1. On histology, 52% of nodules were benign and 48% of nodules were malignant. When comparing with cytologic diagnosis, FNAC showed a sensitivity of 52%, specificity of 95%, positive predictive value of 92%, negative predictive value of 64%, false positive rate 5%, and false negative rate 48%. Total accuracy was found to be 72%. Conclusion: FNAC is a useful tool in deciding management options for patients, but has limitations, particularly when evaluating follicular lesions. This leads to discrepancy in the calculation of statistical values in literature.

Keywords: Fine needle‑aspiration, middle east, thyroid cancer, thyroid nodules, thyroidectomy

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Long Standing Goiter as a risk of thyroid malignancy

Mohamed ElMakki Ahmed

University of Khartoum and Khartoum Teaching Hospital, Sudan Email:[email protected]

Abstract Background: Goiter is endemic in Sudan with wide spectrum of presentations. Among literature and global studies, the risk of malignancy in long standing goiter was 2 - 3%. The current practice in The Sudan is long term prescription of oral Thyroxine before referral to surgical department when patients develop pressure symptoms . Objective: To report the risk of malignancy in long standing goiter (more than 10 years).

Material and Methods: Analytical single centre study conducted from march 2017 to September 2018 at Khartoum Teaching Hospital.

A total of 160 patients with long standing goiter of 10 years or more were on medical treatment were included ..

Result: Of 160 patients studied, 28 were males (18%) and 132 females (82.0%) ,with male to female ratio of 1.0:4.5. Age ranged between19 and 81 year. Twenty eight patients had recurrent goitre (17.5%). A hundred and thirty one were euthyroid, (81.9%) ,13.8%(n=22) hyperthyroid and 4.4%(n=7) were hypothyroid. Most patients (94.4%(n=151) had pressure symptoms Thoracic inlet x-ray was sufficient in 74.4%(n=119) of patients and CT used for 25.6%(n=41) to mark extent of retrosternal extension.

Clinical suspicion of malignancy was considered in 27.5% ( n=44) patients.

Post total thyroidectomy, refractory hypocalcaemia was 7.5%(n=12),RLN injury 3.1%(n=5) all with malignant goitres that had debulking.

Histopathology , 67.5%(n=106) were benign and 32.5%(n=54) were malignant , 23 (14.4%) were follicular ,21(13.1%) papillary ,8(5%)anaplastic, 1 (0.6%) medullary and 1 (0.6%) squamous cell carcinoma.

Conclusion:In 44 patients with malignant goitre the clinical diagnosis was obvious and confirmed by FNNABC in the remaining 10 patients malignancy was incidental finding. Long standing goitre has a greater risk of malignant transformation So, is it the time now to consider surgery for those patients

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Patient Reported Outcomes: Helping to Address Cancer Patients' Care Needs, and Improve Adherence to Medication and Symptom Burden

Afaf Girgis

University of New South Wales, Australia


Cancer patients report high unmet needs and impaired psychosocial wellbeing, which vary in their severity and impact over time. Much of that morbidity remains undetected if not directly reported by the patient. Significant patient and survival benefits and reduced emergency department presentations have been demonstrated through the routine assessment and clinical utilisation of electronically collected patient-reported outcomes (ePROs). However, beyond the research environment, such benefits will not be fully realised on a large scale without the implementation of ePROs as routine care. Since 2011, our team has developed an ePRO system, PROMPT-Care, and demonstrated its acceptability, feasibility and efficacy in a broad population of cancer patients in NSW. During 2020 and 2021, through collaboration with our local health service and the Cancer Institute NSW, we have been implementing ePROs in the routine care of patients with lung cancer in the cancer centres in 3 of our hospitals. This presentation will provide an overview of the rationale for collecting and using PROs, and steps for clinicians who wish to introduce PRO collections as part of their routine care. Keywords: Patient reported outcomes; patient-centred care; self-report; symptom assessment

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Current Perspectives on Cancer Survivorship Care: Improving Outcomes Through Healthcare Delivery Research

Paul Jacobsen

Healthcare Delivery Research Program, National Cancer Institute, United States of America

[email protected]

Over the past few years, there has been growing recognition of the importance of survivorship as a distinct period on the cancer control continuum. The objectives of this talk are to: 1) define the survivorship period and the goals of survivorship care; 2) summarize initial efforts to improve outcomes for cancer survivors through the use of survivorship care plans; 3) summary existing research on models of survivorship care with an emphasis on the shared care model; and 4) identify future directions for healthcare delivery research on survivorship care.

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Changes of Psychological Distress, Unmet Care Needs, and Quality of Life in Taiwanese Colorectal Cancer Survivors

Sui-Whi Jane

Chang Gung University of Science and Technology, Taiwan


Background and Purpose: The survival rate of patietns with colorectal cancer (CRC) has been increased due to the improvement of advanced medical technology and early cancer screening; still, CRC survivors might encounter certain degree of symptom distress and unmet care needs due to anticancer treatment, compromising their quality of life(QOL). However, the longitudial impacts of anticancer treatments for CRC survivors is lacking. Thus, the purpose of this study aimed exploring the trends of psychological distress, unmet care needs, and QOL in CRC survivors 3 months after completion of treatment. Materials and Methods: This was a descriptive study with longitudinal design, repated meassures to examine the trends of psychological distress, unmet care needs, and QOL in 80 Taiwanese CRC survivors over a 9-month period after 3 months completition of treatment. The HADS (Hospital Anxiety and Depression Scale), CaSUN(Cancer Survivors’ Unmet Supportive Care Needs), and EORTC QLQ-C30 were employed to examine the trend changes with measureing at 3, 6, and 12 months after completion of treratment. The generalized estimating equation (GEE) was used to determine the changes, if any, in trends of the emotional distress, unmet care needs, and QOL. Results: Overall, the results from GEE analyses indicated that the anxiety status, emotional /interpersonal and QOL issues measreud with CaSUN, and functioning, symptom, and global health of QOL had statistical improvements over time. The majority of participants , however, experienced borderline abnormal status of depression mood (10.1± 1.5) over time and the strength of unmet emotional/interpersonal issues (7.0 ± 1.2) was higher than the informational and quality of life dimensions of unmet care needs. Conclusion: In summary, the CRC survivors in this study reported having improvement in anxiety status, unmet care needs, and the overall QOL, over a 9-month period after completion of anticancer treatments; and yet, most participants still experienced some degrees of depression mood and interpersonal issues. In the future, the heathcare providers might consider developing tailored program to assist this sepecific population in managing their emotional distress. Keywords: Taiwanese Colorectal cancer survivors, psychological distress, care needs, quality of life, longitudinal study

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Individualized Care for the Changes in Nutritional Status, Body Composition and Quality of Life in Patients with Operable

Pancreatic Cancer

Shiow-Ching Shun

National Yang Ming Chiao Tung University Recently, a growing body of scientific evidence related to preventing the impairment from cancer-related treatment (Prehabilitation) could offer an opportunity to improve care outcomes. Significant changes in fatigue and body composition (body weight loss and muscle loss) are the major concerns in the patients with pancreatic cancer after surgery. Post-operative accelerated muscle loss negatively impact survival after resection of pancreatic cancer. Therefore, this lecture focuses on (1) introducing concept development of cancer prehabilitation prehabilitation care model for patients with pancreatic cancer. (2) reporting the current evidences related to the changes in nutritional status, body composition and quality of life. (3) Last, the roles of oncology nurse in cancer prehabilitation model for pancreatic cancer are proposed and suggested for the future research and clinical implications.

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Symptoms and Perceived Care Needs in Operable Gastric Cancer Patients

Meng-Ping, Hsiao

National Taiwan University Cancer Center, Taiwan

Email: [email protected] Background and Purpose: Surgery is one of the major treatments for patients with early stage gastric cancer. These patients usually suffer from gastrointestinal (GI) related symptoms after surgery and experience psychological distress because of concerning of high recurrences rate after surgery. Thus, the purposes of this study is to symptoms and perceived care needs in operable gastric cancer patients. Materials and Methods: This cross-sectional study was recruited 133 post-operative gastric cancer patients at Surgical Outpatient Center in Northern Taiwan. Supportive Care Needs Survey-34 (SCNS-34) with added newly developed 17-item gastric cancer module Chinese versions (SCN-GI-C) were applied in the research. Results: The results showed the domains of needs as their descending order were: symptoms and nutrition needs, health system and information needs, E-health needs, care and support needs, psychological needs, physical and daily living needs, cognitive and psychological needs, daily functional needs, and sexuality needs. Conclusion: Summary of the overall findings and the importance of the study. The study found the some specific unmet care needs in gastric cancer patients after surgery. We suggest that we need to assess gastric patients’ care needs in each treatment or medical transition time to provide more personalized nursing care interventions. Psychological interventions and symptom management are needed to support these patients. Keywords: Gastric Cancer, Symptom Severity, Care Needs

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Health Literacy and Survivorship Care

Li-Lu Chang

Koo Foundation Sun Yat-Sen Cancer Center, Taiwan


Given the increasing complexity of cancer diagnosis and treatment plan, health literacy is critical to delivery of patient-centered care. Cancer survivors will need to know about their diseases and its treatments, so that they can adhere to treatments, manage their symptoms and maintain functional life. Low health literacy in cancer survivors has been reported to be associated with poor treatment outcomes and worse quality of life. Supporting patients and families in the very complex tasks of monitoring, communicating, and managing disease- and treatment-related symptoms is essential for cancer survivorship care. Currently, patient navigators or case managers are well positioned to support patients’ health literacy and communication needs across the continuum of cancer care. Furthermore, a complete and effective plan to address cancer survivors’ diverse health literacy needs and to train professional staff with this ability is pivotal.

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Perioperative Care of Anesthesia Services in Japan

Yuki Umeno

Juntendo University Hospital, Japan Email: [email protected]

Background and Purpose: Japan had the world’s most elderly population. Moreover, the continuing low fertility rate has already resulted in the onset of depopulation, along with decreased working-age population, resulting in one worker supporting 1.5 senior residents. To resolve such social issues, the Japanese government has been endeavoring “Work-style Reform”, especially anesthesiology. Materials and Methods: This presentation includes current trends of nursing; how and why various anesthesiology-related nurses are providing perioperative care. Results: Medical profession’s (especially physicians and nurses) roles are being reexamined and rebuilt under work-style reform. The presentation does not detail each nursing practice but briefly shows various nursing professions providing anesthesiology-related perioperative care and acts. Conclusion: Japan is at the forefront of societal aging. Current movements of perioperative care providing nurses in regard to work-style reform may help other countries in the near future. Keywords: aging society, work style reform, nursing, perianesthesia, surgery

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Experience and Vision on Caring Patients Receiving Liver Transplantation, From the Perspective of Nurse Practitioner

Hsiang-Ying Lin

Taipei Veteran General Hospital, Taiwan

Email: [email protected] Abstract

First, I will give a brief history of liver transplantation. Then, I will introduce the indications and contraindications for liver transplantation, the types of liver transplantation and the surgical procedures. Next, I will provide some clinical expectations for the operating room and the anesthesia nurse practitioner. In the middle of the presentation, the theme of this conference, Harmony of Humanity and Technology-application of AI in GI diseases, introduces the important achievements of AI and the development of our transplant business. Finally, we shared our achievements in liver transplantation from an international perspective.

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Care management of surgery recovery period

PIN-HSIEN,CHANG

Linkou Chang-Gung Memorial Hospital, Republic of China (Taiwan) Email: [email protected]

Abstract: During the postoperative period, reestablishing the patient’s physiologic balance, pain

management and prevention of complications should be the focus of the nursing care. To do these it is crucial that the nurse perform careful assessment and immediate intervention in assisting the patient to optimal function quickly, safely and comfortably as possible.

The focus of the physical assessment includes the patient's vital signs , conscious level. These are the focus of evaluation for patients in recovery period.

Moreover, patients in the recovery period after anesthesia are required to perform vital signs monitoring, evaluation of the recovery period index after operation, and pain assessment according to the doctor’s instructions.

The patient can be transferred out, discharged from the hospital or out of the recovery period after anesthesia after the doctor's assessment or meets the transfer criteria.

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Growing Your Own: OR Nurse Residency Program

Sharon Woan-Hsiang Yeh

RWJUH Somerset, NJ, US Email: [email protected]

Background and Purpose: Nursing shortage is a long-term challenge for our profession, especially in the perioperative field. Perioperative nursing education is usually covered under surgical nursing curriculum with minimal hours of clinical observation, yet not fully covered in detail. This Program will share the process of orienting new nurses to the perioperative environment, describe the essential components of an orientation process for our new perioperative nurses, and explore types of perioperative practice setting and methods of orientation. Materials and Methods: Power Point Presentation Keywords: Orientation, Periop 101

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Ignite Nursing Innovation

Jean Lovell

Parkland Health & Hospital System

Email: [email protected] Nurses by nature are inquisitive for good reason(s). Nursing innovation is not a new concept to the nursing profession. Nurses worldwide are engaged in innovative activities daily. In Nursing profession, innovation is a nursing practice. Nurses put new ideas into practice or existing ideas into practice in new ways. Although all nurses are innovators but there are challenges. Healthcare nursing leaders’ should be role models to nurture nurses, empower them to bring out their potentials i.e. creative thinking; ideas development, and walk along side with nurses toward the journey of innovations.

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Innovative Workplace Culture in the Operating Room

𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅 𝐖𝐖𝐖𝐖𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝐅𝟏𝟏𝟏𝟏, 𝐇𝐇𝐇𝐇𝐇𝐇𝐇𝐇𝐇𝐇𝐇𝐇 − 𝐋𝐋𝐋𝐋𝐇𝐇𝐇𝐇𝐅𝐅𝐅𝐅 𝐋𝐋𝐋𝐋𝐇𝐇𝐇𝐇𝐅𝐅𝐅𝐅𝟏𝟏𝟏𝟏


Background and Purpose: National Taiwan University Hospital (NTUH) was founded in 1895. It’ a healthcare system with eight branches in Taiwan. There are 50 operation rooms in NTUH and we carry out approximately 56,000 operations each year. The scope of our services are various. In additional, our hostipal has made significant contributions to the development of medical treatment in Taiwan. For example, we have done the first case of kidney and heart transplantation and conjoined twins separation in Asia. Operating room is a huge, rushing, and complex organization as it focuses on speed, flexibility, quality and precision. Besides, it is a complex work unit with a wide distribution of ages. Merging different groups into a work team is crucial in organizational culture. We’re dedicated to create a pleasant working atmosphere because when they work in a relaxing environment, they can stop and think about how to improve their work and make an effort to implement their ideas.

Materials and Methods: Creative Problem Solving (CPS) is a process of searching for a novel solution to a problem, including fact-finding, problem-finding, idea-finding, solution-finding and acceptances-finding. We follow this process in our heads without thinking about it. By continuous developing our colleagues’ ability to find out the problem and inspiring them using their creative thinking to solve them, they can take place to move the solutions into implementation. Since they can tackle the situation by their own, they will have a sense of achievement and satisfaction.

Results: Since 2007, we have been participating the nursing innovation and invention competitions which were hold by Taiwan Union of Nurses Association (TUNA) and Taipei Nurses Association (TNA). We won awards for 18 times. Furthermore, we took out 5 patents from Intellectual Property Office, Ministry of Economic Affairs. We dedicate to applying for patents and protecting our creative thinking. Moreover, we mass-product and promote our devices worldwide through academia-industry collaboration. To our surprise, our innovative devices which were made in early years are used where vaccinations are made during the covid 19 outbreak. We hope these inventive conceptions, like our design “withdrawing medication”, can be extended to different uses and benefit to more humans.

Conclusion: We shared our experiences and management philosophy in operation room. During the outbreak of Covid-19, we still come up with 2 innovation devices to reduce exposure to infection. We should not underestimate ourselves. Rather, we should hold on to every creative thinking and take it into practice since we don’t know how will it astound the world. Most of all, there is no

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lmitation on the position. We hope we can convey the spirit— “Everyone can be an innovator” and be benefit to more human beings.

Keywords: nursing innovation, patent, creative problem solving (CPS)

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Bemarituzumab as a First-Line Therapy for FGFR2b+ Advanced Gastroesophageal Cancer – A Subgroup Analysis of East Asian

Patients from the FIGHT trial

Kensei Yamaguchi1, Akira Ooki1, Yoon-Koo Kang2, Keun-Wook Lee3, Li-Yuan Bai4, Helen Collins5, Yingsi Yang5, Khalid Mezzi5, Daniel Catenacci6, Peter Enzinger7, Zev

Wainberg8

Cancer Institute Hospital of Japanese Foundation for Cancer Research, Japan1, University of Seoul, South Korea2, Seoul National University Bundang Hospital ,

South Korea3, China Medical University, Taiwan4, Amgen Inc, United States5, University of Chicago, United States6, Dana Farber Cancer Institute, United States7,

University of California, Los Angeles, United States8 Email: [email protected]

Background and Purpose: The FIGHT (NCT03694522) study, a global phase 2, randomized, double-blind, study, showed that bemarituzumab, a first in class humanized IgG1 monoclonal antibody selectively binding to fibroblast growth factor receptor 2b (FGFR2b), improved progression-free survival (PFS) and overall survival (OS) in patients with FGFR2b+ gastric/gastroesophageal junction (GC/GEJ) adenocarcinoma. Here, we present data from a subgroup analysis of East Asian (Japan, South Korea, Taiwan) patients. Material and Methods: Previously untreated patients with HER2-negative, unresectable, locally advanced or metastatic FGFR2b+ GC/GEJ received mFOLFOX6 plus bemarituzumab (15mg/kg) or placebo once every two weeks. One additional dose of 7.5mg/kg bemarituzumab or placebo was given on day 8 of cycle 1. The primary endpoint was PFS; secondary endpoints included OS, overall response rate (ORR), and frequency of adverse events (AEs). Results: In total, 62 patients in the East Asian subgroup were eligible. Median PFS was 12.9 months (95% CI: 8.6–not reached) for the bemarituzumab arm vs 8.4 months (95% CI: 6.8–12.1) for the placebo arm (HR: 0.52 [95% CI: 0.26–1.03]) in the intent-to-treat population. Median OS was not reached (95% CI: 15.1–not reached) for the bemarituzumab arm vs 15.9 months (95% CI: 10.2–not reached) for the placebo arm (HR: 0.53 [95% CI: 0.22–1.28]). The ORR by immunohistochemistry staining score of 2/3+ in ≥10% cells was 57.9% (95% CI: 33.5%–79.7%) for the bemarituzumab arm vs 41.7% (95% CI: 22.1%–63.4%) in the placebo arm. Grade 3+ AEs were reported in 25

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(83.3%) patients in the bemarituzumab arm vs 23 (74.2%) in the placebo arm. Overall, 25 (41%) patients had corneal AEs, which were more common in the bemarituzumab arm (21 [70.0%] vs 4 [12.9%] in the placebo arm). Of those in the bemarituzumab arm who experienced corneal disorders, 10 (47%) patients reported grade 3. Among patients who received bemarituzumab and experienced corneal AEs, these were either resolved or downgraded to grade 1 in 16 (76%) patients. Conclusion(s): Consistent with the intent-to-treat population, addition of bemarituzumab to mFOLFOX6 led to clinically meaningful improvements in PFS, OS, and ORR in FGFR2b+ East Asian GC/GEJ patients with an acceptable safety profile, supporting a prospective phase 3 study. Keyword(s): gastric/gastroesophageal junction adenocarcinoma, bemarituzumab, East Asian patients, FIGHT study

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Results of the Modified Neoadjuvant Therapy on the Surgical Management of Advanced Gastro-oesophageal Junction Tumors

Attila Paszt, Márton Erdős, Krisztina Budai, Márton Vas, Zoltán Szepes, László

Torday, László Tiszlavicz, György Lázár

University of Szeged, Hungary Email: [email protected]

Background and Purpose: Nowadays the therapeutic treatment for advanced, stage T2-T4 gastro-oesophageal cancer and those adjacent to the lymph nodes involves neoadjuvant chemotherapy with subsequent surgical intervention. Material and Methods: Neoadjuvant oncological treatment for gastro-oesophageal junction cancer previously consisted of the intravenous administration of epirubicin, cisplatin and fluorouracil(ECF) or epirubicin, cisplatin and capecitabine(ECX) combination (Group I). In the term of the new protocol, patients were included with resectable gastro-oesophageal junction cancer who had a clinical stage T2 or higher lymphnodes positive disease (Group II). Between January 2016 and of June 2021 we retrospectively analyzed the effect of these ECF/ECX/FLOT oncological protocols in terms of surgical outcomes in cases of advanced tumors . We compared the results the randomly assigned patients from ECF/ECX protocol (Group I) and these same number patients(Group II) from FLOT group. The effectiveness of oncological therapy is best characterized by the Tumor Regression Grade. We evaluated the types and degree of possible side effects of different treatment arm, type and complications of surgery, and different pathological parametres. Results: Comparing the two groups we found that in cases of FLOT neoadjuvant chemotherapy (Group II) complete regression was achieved in significantly higher number than group one. Furthermore, in cases of FLOT treated patients, the average number of removed lymph nodes slightly increased from 29,6 to 32,7 pcs/pts. In terms of the safety resection margins (distal, circumferential) no significant difference was found between the two groups. Leukopenia, neutropenia and nausea occurred more frequently in cases of the ECF/ECX treatment. The chemotherapy related surgical complications were in same range. Conclusion(s): As a result of the FLOT neoadjuvant oncological protocol for advanced GEJ cancer, the number of cases with complete tumor regression has significantly

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increased. The present study results strongly suggest a significant advantages of the FLOT neoadjuvant treatment following surgery. Keyword(s): advanced GI cancer, neoadjuvant therapy

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Comparison of Robotic and Laparoscopic Distal Pancreatectomy

Hon-Fan Lai, Bor-Uei Shyr, Bor-Shiuan Shyr, Shih-Chin Chen, Yi-Ming Shyr, Shin-E Wang

Taipei Veterans General Hospital, Taiwan

Email: [email protected] Background and Purpose: Warshaw technique has gained the favor of some surgeons due to its simplicity. Outcomes and surgical risks after robotic distal pancreatectomy with spleen preservation (RDP-SP) by Warshaw technique and with splenectomy (RDP-S) were compared. Material and Methods: All the data for patients undergoing robotic distal pancreatectomy (RDP) were prospectively collected. The incidence and clinical significance of spleen infarction and gastric varices after spleen preservation by robotic Warshaw technique were also evaluated. Results: A total of 177 patients were included, including 65 RDP and 122 LDP. Conversion rate was 1.5% in RPD group and 3.6% in LPD, P = 0.653. Spleen-preservation by Warshaw technique was 45.9% in total, with 53.1% in RPD group and 41.7% in LPD, P = 0.157. RDP took less operation time than LDP, with median of 2.7 vs 3.5 hours, P = 0.005. Overall, DP with splenectomy took more operation time than that with spleen-preservation, P < 0.001, but the difference regarding the operation time between spleen-preservation and splenectomy was only significant in LDP group, P = 0.003, not in RDP, P = 0.072. Splenectomy was associated with higher blood loss, as compared with spleen-preservation in both RDP and LDP groups. There was no surgical mortality in both groups, and surgical morbidity was of no significant difference between RDP and LDP. Post-operative pancreatic fistula was 22% for overall patients, with 17 % in RDP, and 24% in LDP, P =0.340. There was also no significant difference regarding PPH, wound infection, chyle leakage, and hospital stay. The hospital cost in RDP was much higher than that in LDP, with median of 13,404 vs 7,765 USD, P < 0.001. Conclusion(s): Both robotic and laparoscopic surgeries work equally well for DP. LDP with spleen-preservation by Warshaw technique whenever possible and feasible for those benign or low malignant, is highly recommended in term of cost and blood loss.

Keyword(s): distal pancreatectomy, laparoscopic, robotic, spleen, preservation

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Significance of Multiple Tumor Markers Measurements in Conversion Surgery for Unresectable Locally Advanced Pancreatic

Cancer

Minako Nagai, Kenji Nakagawa, Satoshi Nishiwada, Tadataka Takagi, Taichi Terai, Daisuke Hokuto, Satoshi Yasuda, Yasuko Matsuo, Shunsuke Doi, Naoya Ikeda,

Masayuki Sho

Nara Medical University, Japan Email: [email protected]

Background and Purpose: Tumor marker (TM) has been widely used as a biomarker in conversion surgery (CS) for unresectable locally advanced pancreatic cancer (UR-LAPC). The aim of this study was to evaluate the significance of multiple TM measurements in determining the indication of CS during the multidisciplinary treatment for UR-LAPC. Material and Methods: A total of 104 patients with UR-LAPC who were treated between 2008 and 2020 were enrolled in this study. We routinely measured three TMs including CEA, CA19-9, and DUPAN2. Results: Twenty-seven patients (26%) underwent CS. The median preoperative treatment period was 7.9 months. Twenty patients (74%) had the histopathological effect of Evans grade IIb or higher. The median survival time (MST) from initial treatment for patients with CS was significantly longer than those without CS (33.3 vs. 18.9 months, P<0.001). Patients who had normal levels of each TM before CS showed better survival than those with elevated levels of TM (CEA; P=0.033, CA19-9; P<0.001, DUPAN-2; P<0.001). The number of elevated TMs before CS was 1 in 6 patients and 2 in 6 patients, while 15 patients had normal levels of all three TMs. Nobody had elevated levels of all three TMs. Importantly, the MST from surgery for patients with all three normal TM levels was favorable of 63.8 months. In sharp contrast, the patients with one or two preoperative elevated TM levels had a significantly worse prognosis (18.4 and 10.4 months, P<0.001). Furthermore, the relapse-free survival (RFS) of patients with three preoperative normal TM levels was significantly longer than that for those with one or two elevated TM levels (22.2 vs. 11.5 or 3.7 months, P=0.010). In prognostic factor analysis, multivariate analysis showed that three normal preoperative TMs are one of the independent prognostic factors. Taken together, the prognosis for

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patients with normal levels of all three TMs was favorable with current multidisciplinary treatment, while those with elevated levels of any TM before CS may need further systemic therapy rather than CS. Conclusion(s): The simultaneous measurement and assessment of three TM levels may be useful to determine the surgical indication for UR-LAPC after systemic anticancer treatment. Keyword(s): Conversion surgery, unresectable locally advanced pancreatic cancer, tumor marker

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Pancreatic Head Sparing Surgery for Solid Pseudopapillary Tumors in Patients with Agenesis of the Dorsal Pancreas

Bor-Shiuan Shyr, Bor-Uei Shyr, Shih-Chin Chen, Yi-Ming Shyr Shyr, Shin-E Wang

Taipei Veterans General Hospital, Taiwan

Email: [email protected] Background and Purpose: This study aimed to clarify the feasibility and justification of pancreatic head sparing (PHS) enucleation for patients with agenesis of the dorsal pancreas (ADP) associated with a solid pseudopapillary tumor (SPT). Material and Methods: Data of the SPT patients with and without ADP, including clinical presentations, surgical options, and surgical and survival outcomes, were recruited for comparison. Results: A total of 31 patients with SPTs were included, 3 of whom displayed ADP and underwent PHS enucleation. Surgical complications were comparable between the groups. Overall, the 5-year and 10-year disease-free survival rates were 100% and 90%, respectively. The 20-year and 25-year overall survival rates were 100% and 66.7%, respectively. Only one patient (3.2%) developed tumor recurrence 7.3 years after pancreatectomy for an SPT with lymph node involvement, and the patient survived 24.5 years after the initial operation. No tumor recurrence occurred in any patient with ADP after PHS enucleation. Conclusion(s): The association between tumorigenesis and ADP suggests that every congenital ADP patient should be observed for the early detection of pancreatic neoplasia. PHS enucleation seems to be feasible and justifiable for SPT patients with ADP in terms of surgical and survival outcomes, and this approach could be recommended to avoid pancreatic insufficiency. Keyword(s): dorsal agenesis, solid pseudopapillary tumors, pancreatic head, pancreas

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Simultaneous Hologram and IOUS Navigation in Laparoscopic Hepatectomy

Yasuji Seyama1, Hiroko Okinaga1, Rei Ogawa1, Mikiya Takao1, Keigo Tani1, Maki

Sugimoto2

Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Japan1, Teikyo University Okinaga Research Institute, Japan2

Email: [email protected] Background and Purpose: In laparoscopic hepatectomy, intraoperative ultrasonography (IOUS) cannot be performed as well as open hepatectomy because of limited mobility and inability to hold it directly in the hand. However, IOUS is essential for reliable resection of tumors on the dorsal side of the head. We have been applying VR technology to laparoscopic liver resection. In this presentation, we will demonstrate the IOUS technique using holograms in the surgical field and its usefulness. Material and Methods: VR images were created from the 3D analysis by preoperative CT. We use HoloLens 2 (Microsoft) to view hologram during the operation. Hologram images were used as a navigation map before the liver transection and at the reperfusion time during the liver transection. IOUS was performed from both phrenic and visceral surface of the liver. The hologram and IOUS were done at the same time to guide the IOUS. Results: Simultaneous hologram and IOUS were mainly performed for liver S7 resection and S8 partial resection, and it was effective in identifying the vascularization and tumor location in the liver. It is difficult to accurately grasp the intrahepatic vascular travel by IOUS, but by referring to the hologram at the same time, it became easier to grasp the anatomy. In addition, although deep tumors are difficult to observe from the liver surface, they could be easily identified by IOUS at the assumed location in the hologram. The laparoscopic liver resection was performed as planned. Conclusion(s): Simultaneous hologram and IOUS is useful for navigation in laparoscopic liver resection. Keyword(s): laparoscopic liver resection, hologram, IOUS, navigation

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Prognostic Significance of Lymph Node Status in Resected Ampullary Adenocarcinoma Followed by Adjuvant Therapy

Namyoung Park, Sang Hyub Lee, Joo Seong Kim, Jin Ho Choi, Min Woo Lee, In Rae

Cho, Woo Hyun Paik, Ji Kon Ryu, Yong-Tae Kim

Seoul National University College of Medicine, Seoul National University Hospital, South Korea

Email: [email protected] Background and Purpose: Lymph Node (LN) metastasis is considered an important prognostic factor in ampulla of Vater (AoV) cancer, and many parameters have been proposed to predict prognosis. The purpose of this study is to evaluate the prognostic importance of various LN parameters in resected AoV cancer followed by adjuvant chemotherapy. Material and Methods: From January 2005 to January 2018, 459 patients with surgically resected periampullary cancer were analyzed. In total, 81 patients with surgically treated AoV cancer followed by adjuvant chemotherapy were included. We evaluated the prognostic efficacy of N-stage, LN number (LNN), LN ratio (LNR), log odds of positive LNs (LODDs), neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio. The maximal chi-square method was used to determine the optimal cutoff points for each parameter. Results: Forty-six patients (56.8%) recurred within 5 years and the 5-year survival rate was 43.2%. The median of the dissected LNs is 15. We divided patients into 2 groups, LNN 0 vs. LNN ≥1, LNR ≤5% vs. >5% or LODD ≤-0.91 vs. >-0.91, based on maximal chi-square method. LNN, LNR, LODD as well as N-stage based on 8th edition of staging system of American Joint Committee on Cancer showed prognostic efficacy at 5-year survival rate, 5-year disease free survival rate, and 5-year distant metastasis free survival rate. Perineural invasion was also another independent predictor of overall survival, 5-year disease free survival, and 5-year distant metastasis free survival rate. Conclusion(s): In patients with radically resected AoV cancer followed by adjuvant chemotherapy, LN metastasis is one of the most significant prognostic factor. With appropriate cutoff points, many LN parameters including LNN, LNR, and LODDs showed good predictive performance on overall survival and disease free survival. Keyword(s): Ampullary adenocarcinoma, Lymph node metastasis, Prognosis

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Usefulness of In-Stent Radiofrequency Ablation after Occlusion of Self-Expandable Metal Stent in Unresectable Malignant Biliary

Obstruction: Multicenter Propensity-Score Matched Study

Namyoung Park1, Min Kyu Jung2, Woo Hyun Paik1, Jae Hee Cho3

Seoul National University College of Medicine, Seoul National University Hospital, South Korea1, Kyungpook National University Hospital, South Korea2, Gangnam

Severance Hospital, Yonsei University College of Medicine, South Korea3 Email: [email protected]

Background and Purpose: In patients with unresectable malignant biliary obstruction, endoscopic drainage with self-expandable metal stent (SEMS) is a well-established treatment, but its patency is still limited. In a recent study, in-stent radiofrequency ablation (IS-RFA) showed improved stent patency compared to plastic stent re-insertion within the occluded SEMS. This study aimed to compare the efficacy of IS-RFA plus additional SEMS insertion with additional SEMS insertion alone for management of occluded SEMS. Material and Methods: From 2014 to 2020, patients with pancreatobiliary cancer who had undergone biliary drainage in 3 tertiary hospitals were analyzed. Patients with biliary obstruction at or above the hilar level were excluded. Patients in the study group were treated with IS-RFA and uncovered SEMS placement, while patients in the control group were treated with uncovered SEMS placement alone. Patients in both groups were matched based on propensity scores in a 1:1 ratio. Time to additional SEMS malfunction and 90-day stent patency rate were analyzed as primary end points. Results: After propensity-score matching, a total 30 patients (15 in study group, 15 in control group) were analyzed. The median occlusion free survival was 117 days in study group, and 85 days in control group (P = 0.134). The 90-day stent patency rate was 60.0% and 20.0% in study and control groups, retrospectively (P = 0.06). No significant adverse events were reported after the second SEMS placement, but two cases of cholangitis manageable with additional biliary drainage were reported only in the control group. Immediate biliary drainage with additional SEMS was successful in all patients. In the IS-RFA group, ablation was interrupted in 5 patients (33.3%) because of in-stent contact.

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Conclusion(s): As treatment for occluded SEMS in pancreatobiliary cancer, IS-RFA with uncovered SEMS and uncovered SEMS alone showed comparable clinical outcomes. Reported adverse events were not different between two groups. Keyword(s): Radiofrequency ablation, Biliary obstruction, Malignancy, Self-expandable metal stent

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Hepatopancreatoduodenectomy with Hepatic Artery Resection/Microscopic Reconstruction Using Gastroduodenal Artery-

Our Challenges for Advanced Biliary Tract Cancer with Arterial Invasion

Shinya Hayami, Masaki Ueno, Manabu Kawai, Atsushi Miyamoto, Seiko Hirono,

Ken-ichi Okada, Motoki Miyazawa, Yuji Kitahata, Masatoshi Sato, Tomohiro Yoshimura, Hiroki Yamaue

Wakayama Medical University, Japan Email: [email protected]

Background and Purpose: Advanced biliary tract cancer (BTC) often invades right hepatic artery (RHA) and needs more than right hepatectomy for curative resection, postoperative liver failure has to be therefore concerned because of insufficient remnant liver volume. RHA resection/microscopic reconstruction is one of considered surgical techniques, although still a challenging surgical procedure even now. In this study, our surgical video of hepatopancreatoduodenectomy (HPD) with RHA resection/microscopic reconstruction using gastroduodenal artery (GDA) and outcomes for these highly advanced BTC were showed. Material and Methods: Between 2011 and 2021 September, major hepatectomy with RHA resection/microscopic reconstruction was performed for perihilar cholangiocarcinoma (n=7), distal cholangiocarcinoma (n=1), gallbladder carcinoma (n=1) and intrahepatic cholangiocarcinoma (n=1). This exhibited video case was perihilar cholangiocarcinoma located from the hepatic hilus to the lower bile duct (Bismuth type IIIB). RHA invasion was suspected, we therefore planned HPD with RHA resection/microscopic reconstruction using GDA. Operation time was 728 minutes and an amount of bleeding was 271 ml. He was discharged without postoperative complications at postoperative day 21. Results: Operative procedures were indicated as below; extended left hepatectomy (n=5), HPD (n=3), central bisectionectomy (n=1) and S4a+5 subsegmentectomy (n=1). As a proximal artery, we selected end-to-end anastomosis of RHA (n=4), right gastroepiploic artery (RGEA, n=4) and GDA (n=2). Portal vein resection were also carried out in four cases. Median operation time was 721 (range: 580-865) min and median intraoperative blood loss was 424 (range: 225-1,820) ml. There was no postoperative complication related to arterial reconstruction such as postoperative

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bleeding or reconstructed arterial obstruction. As pathologically findings, negative at surgical margin (R0) was obtained in seven cases (70%), especially six cases in perihilar cholangiocarcinoma (85.7%). Only three cases had arterial invasion, although all cases had neural invasion and these pathological results proved the need for arterial reconstruction. Their prognosis was not satisfactory and strict follow-up was thought to be needed, there were however some promising data; one patient however lived for more than five years and two patients lived more than two years. Conclusion(s): We could perform major hepatectomy with RHA resection/reconstruction including HPD in highly advanced BTC safely. Keyword(s): Hepatopancreatoduodenectomy, Hepatic artery resection/microscopic reconstruction, Gastroduodenal artery (GDA), Advanced biliary tract cancer

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Appropriate Cystic Duct Processing in Bailout Surgery for Patients with Difficult Laparoscopic Cholecystectomy

Mitsugi Shimoda, Yu Kuboyama, Toru Tanahashi, Shuji Suzuki

Tokyo Medical University, Ibaraki Medical Center, Japan

Email: [email protected] Background and Purpose: Bailout surgery (BOS) widely accepted for difficult laparoscopic cholecystectomy. There is not a clear criteria on the decision process on whether to continue laparoscopic or open BOS, and optimal procedure for treatment for the remnant cystic bile duct also awaits discussion. We comparted with open BOS and laparoscopic BOS, and compared with suture close and clipping or ligating of remnant cystic duct. Material and Methods: We have accrued 57 patients underwent BOS during study period. Seventeen cases underwent laparoscopic BOS, and 38 cases underwent open BOS. There were 22 patients were accrued in suture closing and 35 patients were accrued in clipping or ligating. Results: There was no BDI in Open BOS and Lap BOS. Suture close was higher in patients with preoperative endoscopic lithotripsy (EL). Conclusion(s): BOS can be sufficiently performed under laparoscopy. Patients underwent preoperative EL tended to be higher necessity to suture close of cystic duct Keyword(s): Subtotal cholecystectomy surgery, difficult laparoscopic cholecystectomy, reconstituting

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Body-first Approach in Surgery for Cholecystitis

Hiroko Okinaga, Seyama Yasuji, Rei Ogawa, Mikiya Takao, Keigo Tani

Tokyo Metropolitan Komagome Hospital., Japan Email: [email protected]

Background and Purpose: Tokyo Guidelines 2018 (TG18) recommend a bail-out procedure in case of difficult laparoscopic cholecystectomy. A bail-out procedure should be chosen if, when a critical view of safety cannot be achieved because of nondissectable scarring or severe fibrosis. In our institution, we use Body-first approach for safety in difficult cases with severe cholecystitis. We show the procedure of Body-first approach and evaluate outcomes. Material and Methods: We first identify the Rouviere's groove and start the serous incision from the neck of the gallbladder. Then we expose the inner layer of the subserosal layer from the neck to the body of the gallbladder. We tunneled the gallbladder at the body and tape the body of the gallbladder as needed. From this point, we proceed the dissection to the fundus and the neck. Taping the body is useful for developing a plane in the Calot’s triangle area and identify its boundaries. We choose a bail-out procedure if we can’t tunnel the body, or a critical view of safety cannot be achieved. We evaluated the short-term outcomes of laparoscopic cholecystectomies performed at out institution between May 2020 and July 2021. Results: A total of 54 laparoscopic cholecystectomies were performed. Of these, 32 were cases of acute or chronic cholecystitis. Body-first approach were performed in 25 cases (46%). Bail-out procedures were selected in 10 cases (19%). One patient underwent laparotomy and the other 9 underwent laparoscopic subtotal resection of the gallbladder. The mean operation time of 32 cases with inflammation was 180 minutes, and the mean blood loss was 78 grams. There were no vasculo-biliary injuries or complications of grade 3 or higher in the Clavien-Dindo classification. Conclusion(s): Body-first approach is a safe method in surgery for patients with severe cholecystitis, and can be a valid indicator to select a bail-out procedure.

Keyword(s): cholecystitis, Body-first approach, bail-out procedure

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Surgical Resection and Octreotide Efficacy in Patient with Neuroendocrine Carcinoma Intussusceptions at Hindgut : Case

Report

Wei Huang, Chou-Chen Chen, Joe-Bin Chen

Taichung Veterans General Hospital , Taiwan Email: [email protected]

Background and Purpose: Neuroendocrine carcinoma arised in many organs . The intussusception of hindgut neuroendocrine carcinoma (NEC) was never been reported, and functonal NEC also rare in oriental group. We would like reported such a NEC intussusception at hindgut. Material and Methods: This is a case of 54 years-old male patient , he suffered from acute low abdominal pain with significant body weight loss 14 kg within 1 year. He has no family history of colorectal cancers, no peranal bleeding history, no facial flushing. The patient came to our emergent room for help. The WBC and biochemistry did not show abnormality except anemia ( hemoglobin 9.2). The tumor can be palpable by digital rectal examination with push-back sensation. CT scan had a target sign mass lesion from sigmoid colon with intussusception downward to pelvis region, and hyper-density and hypo-density colon wall interweaved together. The huge mass was measured up to 15 cm diameter . Results: We arrange emergent Hartmann procedure , and operative finding showed large lobulated polypoid tumor at sigmoid colon with intussusception downwardly and a 9 cm ischemic change of sigmoid colon . The pathology report it as neuroendocrine carcinoma, high grade, grade 3 (mitotic rate 26/10 high powder field ). Postoperative monthly usage of octreotide long-acting regiment (LAR) have demonstrated either control in functional NEC tumor or tumor suppression over 50 months disease-free survival. Conclusion(s): The rare case of the neuroendocrine carcinoma intussusceptions at hindgut presented as acute abdomen and body weight loss . Primary tumor resection provided a definite diagnosis and octreotide LAR relieved the symptom and make disease-free survival longer than 50 months. Aggressive surgical resection and adjuvant

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octreotide LAR make curative treatment of high grade NEC possible. Keyword(s): Neurodnocrine, Octreotide, Hindgut, Intussusceptions, Carcinoma

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Ustekinumab and Surgical Resection in Synchronous Rheumatoid Arthritis , Sjögren's syndrome and Pan-Colitis of Crohn’s Disease

Yu-Kang Tseng, Chou-Chen Chen, Joe-Bin Chen

Taichung Veterans General Hospital, Taiwan

Email: [email protected] Background and Purpose: Biological agent has been used in various autoimmune diseases more than 15 years. Patients with rheumatoid arthritis (RA) , Sjögren's syndrome (SS), ulcerative colitis (UC) and Crohn’s disease (CD) could be beneficial for joint pain relief, gastrointestinal upset resolution, renal function preservation , and life quality improvement. New biological agents are rapidly being introduced years by years. Material and Methods: We presented treatment course on a patient with synchronous multiple autoimmune disease of RA, SS , and colonic CD . The previous biologics and corticosteroids did not suppress inflammatory status .The patient suffered a critical episode of colonic Crohn’s disease perforations . We resected the diseased segment of colon with temporary end ileostomy, then applied ustekinumab for maintenance her bowel function, and record a series of neurophil-lymphocyte ratio (NLR) as evaluation tool of biological effectiveness on multiple autoimmune disease. Results: This 58 years-old female patient had RA diagnosed at age 28, and subsequent SS and CD noted for more than 16 years with regular corticosteroids imuran and selective , B-cell depleting biologic agent treatment ( rituximab since 2017), failure 14 months later, then shifting to tocilizumab until now. She had acute on chronic abdominal pain, then visited emergent room, elevated WBC up to 11560 m/L and CT of abdomen showed multiple site colon wall thickening and moderate ascites. After emergent resection for skip lesion of pan-colitis Crohn’s disease and application of ustekinumab , the patient had well appetite , body weight gain, and life quality. The NLR had positive response after operation and ustekinumab with 2-months observation. We would like to reconstruct the bowel later. Conclusion(s): Same as safety and quality (SNQ) awarded experience, we emphasized the cooperation between gastrointestinal surgeons, ostomy and wound

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nursing care, nutritional supplement that made patient recovery soon in mood and physical field. The ustekinumab provided rapid and sustainable improvement in bowel function and symptomatic relief for patient with synchronous multiple immune disease , RA, SS and CD in every 8 weeks medication, safety profile and long term efficacy of ustekinumab is still going on evaluation in patients with multiple autoimmune disease. Keyword(s): Crohn's disease, Ustekinumab, Synchronous , Rheumatoid Arthritis , Sjögren's syndrome

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Colorectal Perforation Just Proximal of The Cancer Without Any Pathological Change

Tadao Kubota

Tokyo Bay Medical Center, Japan

Email: [email protected] Background and Purpose: Colorectal cancer is a one of major etiology of colorectal perforation. It is said that there are two mechanisms. One is direct invasion of the cancer known as onsite perforation. The other is diastatic rupture due to the colonic obstruction. In that type, cecum perforation is textbook example, however we some time encounter ascending, or transvers colon may be an involved area. Apart from them, we found the other type of colorectal perforation with cancer, in which the perforation site is just proximal and little away from of the cancer. In these cases, there was no direct invasion on the perforated site and no colonic obstruction. Material and Methods: We reviewed all case of colorectal perforation with cancer which was surgically treated in our institute from May 2015 to April 2019, and investigated history, the reason of perforation, tumor size, tumor location, the distance from tumor to perforation and pathology of the perforation site. Results: There were fifteen cases of colorectal perforation with cancer. Seven were onsite perforation in which direct invasion was seen at the perforation area. Two were diastatic perforation, both of which were distant from the original tumor. Six were just proximal perforation. In all six case, there were no macroscopic invasion at the site of the perforation and no colonic obstruction. The distance from the tumor and the perforation were 4 to 11cm(median:5cm). Pathological studies revealed there were no cancer tissue and other disease that cause perforation such as diverticulum, ulcer or inflammation. Conclusion(s): In our cases, just proximal perforation was more common than diastatic distant perforation. At that time, we don’t know the reason why the perforation was occurred in the normal wall without obstruction or other pathological change. In other word, we should keep in mind there might be a cancer just distal the colorectal perforation especially in case of unknown etiology intraoperatively. Keyword(s): colorectal perforation, on site perforation, diastatic perforation

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Effects of Different Routes and Forms of Vitamin D Administration on Renin-Angiotensin System-Associated Inflammation and Lung

Injury in Obese Mice Complicated with Polymicrobial Sepsis

Li-Han Su1, Chiu-Li Yeh1, Jin-Ming Wu2, Po-Jen Yang2, Po-Chu Lee2, Ming-Hsun Wu2, Kuen-Yuan Chen2, Chun-Chieh Huang2, Ming-Tsan Lin2

Taipei Medical University, Taiwan1, National Taiwan University Hospital/National

Taiwan University, Taiwan2 Email: [email protected]

Background and Purpose: Sepsis is a lethal complication occurs in critically ill that leads to multiorgan dysfunction. The lungs are the most frequently affected organ during sepsis and the balance of the renin-angiotensin system (RAS) is closely correlated with the severity of acute lung injury (ALI). Obesity is a pandemic with various metabolic disorders. The chronic inflammation and dysregulated immune response resulted from obesity may promote the progression of sepsis. Vitamin D is known to have the properties of immunomodulation, anti-inflammation, and organ protection. This study investigated different routes and forms of vitamin D administration on sepsis-induced ALI in obese mice. Material and Methods: A high fat diet was given to mice for 10 weeks, then cecal ligation and puncture (CLP) was performed to create a model of obesity with sepsis. The mice were divided to 4 groups: sepsis group without vitamin D (S), group with oral cholecalciferol (2000 IU/mice) gavage 1 d before CLP (G), group with intravenous calcitriol (410 ng /kg BW) 1 h after CLP (V), and group with both cholecalciferol before and intravenous calcitriol after CLP (GV). All mice were sacrificed 24 h after CLP. Results: The lung injury scores in the S group were significantly higher than the vitamin D-treated groups. Among the four groups, the V group had the highest renin, angiotensin-converting enzyme (ACE)2, angiotensin II receptor type 2 (AT2R), and Mas receptor (MasR) whereas the nuclear-factor-kB and interleukin-1b expressions were lowest in lung tissues. The V and GV group had lower AT1R expression than the S and G groups. Compared to the V group, the GV group exhibited lower ACE, ACE2, AT2R and MasR expressions in the lungs. There were no differences in these parameters between the G and the S groups.

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Conclusion(s): Although both forms of vitamin D reduce lung injury score, intravenous calcitriol administration after sepsis have more pronounced impacts on upregulating AT2R and ACE2/MasR-associated anti-inflammatory RAS signaling pathway and reduced inflammatory mediator expressions in the lungs. Combined oral cholecalciferol before and intravenous calcitriol after sepsis have no synergistic effect on attenuating sepsis-induced ALI in obesity. Keyword(s): cholecalciferol, calcitriol, angiotensin-converting enzyme, angiotensin II receptor, Mas receptor

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The Development of Newly-Generated Measure, the Trauma-10, to Assess Quality of Life for Rib Fracture Patients in Taiwan

Chia-Ying Lee1, Tzu-Hsin Lin1, Hsin-Ying Hsieh1, Chi-Cheng Yang2, Hsien-Chi

Liao1, Jin-Shing Chen1, Ming-Tsan Lin1, Rey-Heng Hu1

National Taiwan University Hospital, Taiwan1, National Chengchi University, Taiwan2

Email: [email protected] Background and Purpose: The 12-Item Short Form Health Status Survey (SF-12), a more concise version of the SF-36, has been proven to reproduce similar results to its longer counterpart in evaluating the quality of life (QoL) of patients with chronic diseases. However, studies on its applicability on specific types of trauma patients were scarce. Our goal was to develop a trauma-specific measure to provide reliable and valid QoL information in a rib fracture patient cohort. Material and Methods: Patients of rib fracture were enrolled from July 2017 to December 2019. Assessment for QoL were collected using the SF-36 at 5 time points (pre-operation / within 3 days of admission, post-operation / 1~2 days before discharge, 1 month, 3 months and 6 months). SF-12 scores were extracted from the SF-36 questionnaire. Generalized estimating equations method was used to evaluate longitudinal change of each item and ten items were selected to construct our originally-generated measure, the Trauma-10, based on its results. Confirmatory factor analysis (CFA) was performed to assess the factor structure of the SF-12 and the Trauma-10. Cronbach’s alpha and Spearman’s rho were utilized to measure the reliability of the SF-36, the SF-12 and the Trauma-10. Results: 71 total patients with rib fractures were enrolled in the study. Physical Functioning, Role Physical, Bodily Pain, and Role Emotional domains generally showed significant change over time, so these related items were selected for the construction of the Trauma-10. The SF-12 and the Trauma-10 both showed excellent internal consistency and test-retest reliability. A four-primary factor and one-secondary factor structure represented the SF-12 and the goodness-of-fit of this model for CFA was unsatisfactory (Chi-square statistic = 544.5612, df = 49, p < 0.0001, RMSEA = 0.2216, and CFI = 0.7632). The model of the Trauma-10 loaded on three factors, Physical ability, Functional limitation, and Pain and emotion, and showed excellent

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goodness-of-fit (Chi-square statistic = 40.8349, df = 29, p = 0.0712, RMSEA = 0.04451, and CFI = 0.9905). Conclusion(s): The newly-developed trauma-specific instrument, the Trauma-10, was able to assess long-term outcomes and increase the validity of measurement for the quality of life in trauma patients. Keyword(s): Trauma, Quality of Life, Measurement tool, Long-term outcomes

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Robotic Gastrectomy from My Experience

Jae-Moon Bae

Samsung Medical Center, Republic of Korea Email: [email protected]

Background and Purpose: We evaluated the learning curve and short-term surgical outcomes of robot-assisted distal gastrectomy (RADG) performed by a single surgeon who was experienced in open, but not laparoscopic gastrectomy. We aimed to verify the feasibility of performing RADG without extensive laparoscopic experience. Materials and Methods: Between July 2012 and December 2016, 60 RADGs were performed by a single surgeon using the da Vinci® Surgical System. Patient characteristics, the length of the learning curve, surgical parameters, and short-term postoperative outcomes were analyzed and compared between before and after the learning curve had been overcome. Results: The duration of surgery rapidly decreased from the first to the fourth case; after 25 cases, the duration of surgery was stabilized, suggesting that the learning curve had been overcome. Patients were divided into two groups: the 25 cases before the learning curve had been overcome (early cases) and the 35 later cases. The mean duration of surgery was 420.8 min for the initial cases and 281.7 min for the later cases (p<0.001). The console time was significantly shorter during the early cases (168 min) than during the later cases (247.1 min) (p<0.001). Although the volume of blood loss during surgery declined over time, there was no significant difference between the early and later cases. No other postoperative outcomes differed between the two groups. Pathology reports revealed the presence of mucosal invasion in 58 patients and submucosal invasion in two patients. Conclusion: RADG can be performed safely with acceptable surgical outcomes by surgeons with sufficient open gastrectomy experience. Keywords: : Robot-assisted distal gastrectomy; gastric cancer; learning curve; open gastrectomy; experienced surgeon.

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Indocyanine Green Tracer-Guided Lymphadenectomy in Laparoscopic Gastrectomy

Po-Chu Lee, Ming-Tsan Lin

National Taiwan University Hospital, Department of Surgery, Taiwan


Background and Purpose: Lymph node dissection using Indocyanine green (ICG) fluroescence for intraoperative mapping or sentinel lymph node imaging is globally administered in recent years. The real benefit of this technique for a gastric cancer surgery is still controversial. Results: Here we report the results of fluorencent guided gastrectomy of NTUH.We compare the fluorescent lymphography-guided lymphadenectomy group to the non-ICG laparoscopic or robotic D2 lymph node dissection of distal gastrectomy for gastric cancer. Conclusion(s): This technique has possible oncologic benefit in terms of high rate of metastatic lymph node removal. The result not only comes out the ordinary lymph node dissection but also the specific metastatic lymph node removal. Further randomized clinical trial for oncologic outcome should be launched. Keyword(s): Fluorescent, Indocyanine green, Gastric cancer

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The Immune Biomarkers of Metastatic Gastric cancer: Real World Experience

Ming-Huang Chen

Center for Immuno-oncology, Department of Oncology, Taipei Veterans General Hospital, Taiwan E mail: [email protected]

Background and Purpose: Immunotherapies are approved in few patients with gastric cancer (GC),

and durable response was observed in good responders. Several potential predictive biomarkers were

identified, such as microsatellite instability (MSI-H), Epstein-Barr encoding region (EBER), and

programmed death ligand (PD-L1). Currently, no consensus was achieved to predict the response.

Materials and Methods: Fifty-two GC patients who underwent immune therapy were enrolled from

June, 2016 to December, 2020 in Taipei Veterans General Hospital. The clinical features and

biomarkers were analyzed.

Results:

There were 8 patients with MSI-H, 5 patients with EBER positive, 29 patients with CPS ≥ 1, and 20

patients without any biomarker. The ORR of MSI-H, EBER positive, PD-L1 CPS ≥ 1 and all negative

group were 75%, 60%, 44.8% and 15%, respectively. Compared to all negative group, the PFS were

better in MSI-H (not reached vs. 3.2 months, p = 0.018), CPS ≥ 5 (not reached vs. 3.2 months, p =

0.012) and CPS ≥ 10 (not reached vs. 3.2 months, p = 0.006), but not in EBER positive ((not reached

vs. 3.2 months, p = 0.2) nor CPS ≥ 1 group (2.4 months vs. 3.2 months, p = 0.35). There were 10

patients with combined biomarkers, CPS ≥ 1 with either MSI-H or EBER positive. The ORR were

66.7% with CPS ≥ 1 and MSI-H and 75% with CPS≥ 1 and EBER positive. PFS were better in patients

with combined biomarkers (p = 0.01).

Conclusions:

MSI-H, EBER and CPS were useful biomarkers to predict the efficacy of immunotherapy. Keywords:

Microsatellite instability, Epstein-Barr virus, programmed cell death-ligand 1, gastric cancer,

immunotherapy

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Initial experience of proximal gastrectomy with double tract reconstruction for proximal gastric cancer

Wen-Liang Fang, Kuo-Hung Huang

Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taiwan


Background and Purpose: In recent years, the incidence of proximal gastric cancer has increased. Proximal gastrectomy is associated with a better postoperative nutritional status compared with total gastrectomy. There are various types of reconstruction methods following proximal gastrectomy. To date, double tract reconstruction following proximal gastrectomy has become more popular in Asian countries. Materials and Methods: A total of 21 patients diagnosed with proximal gastric cáncer were enrolled, and laparoscopic proximal gastrectomy with double tract reconstruction was performed. The clinicopathological characteristics and postoperative outcomes were prospectively collected and analyzed. Results: We performed 21 cases of proximal gastrectomy with double tract reconstruction for proximal gastric cancer. The male to female ratio was 10:11. The tumor size was 3.7+2.3 cm, The retrieved lymph node number was 31.1+18.1. The operative time was 320.2+68.4 mins. The postoperative hospital stay was 9.3+3.0 days. One patient needed reoperation due to intestinal obstruction and bypass surgery was performed. There was no surgical mortality. Conclusion: Laparoscopic proximal gastrectomy with double tract reconstruction is a safe and feasible procedure. Investigation of long-term outcomes including gastroesophageal reflux, nutritional status, and oncological outcomes are required. More patients enrollment and further randomized controlled trials are needed to compare the clinical outcomes of various reconstruction methods following proximal gastrectomy. Keywords: proximal gastric cancer, proximal gastrectomy, double tract reconstruction.

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ECJ cancer reconstruction : frozen first

Yu-Yin, Liu Department of General surgery, Kaohsiung Chang Gung Memorial Hospital


Purpose

ECJ cancer is difficult to manage due to controversial approach method. In general, trans-hiatus and

transthoracic approach were the two main method according to the tumor condition. In recent study, the

lower mediastinum LN metastasis were up to 10% in >= T2 lesion. The lower mediastinum dissection is

benefit for long term survival rate. For the reconstruction method is also controversial due to uncertain

margin. There several method were used such as esophago-jejunostomy, double tract or double flap

reconstruction in abdominal cavity, gastric tube formation in thoracic cavity or colon-interposition in

neck. The length of residual esophagus was important factor for reconstructive method. The frozen

section of esophagus margin was sent before the choice of reconstructive method We summarized our

cases and shared our experience how to manage those case by laparoscopic approach.

Material and method

Trans-Hiatus approach was chose. Stage I : proximal stomach was free including resection left gastric

artery, short gastric artery and total omentum including dissection LN group 1,2,3,4,7,8,9,11p,12a and 10

if tumor over greater curvature side or huge tumor but preserving right gastro-epipoloric vessel. Stage II:

LN dissection of lower mediastinum and partial remove of bilateral crus muscle. Stage III : transection of

esophagus and extraction the stomach via umbilicus wound. The margin of esophagus was sent for frozen

section. Stage IV : decision of reconstruction method including total gastrectomy with

esophago-jejunostomy, proximal gastrectomy with double tract or double flap method in abdominal

cavity; gastric tube formation with anastomosis in the thoracic cavity or total gastrectomy and

esophagectomy with colon-interposition method.

Results

Total 27 patients had tumor involving ECJ or Cardiac . 6 pts received total gastrectomy with

esophago-jejunostomy, 10 pts received gastric tube formation with anastomosis in the lower mediastinum

cavity, two pts with total gastrectomy and esophagectomy and colon-interposition method 8 pts with

proximal gastrectomy ( 4 for double flap , 1 for double tract). Two patients had anastomosis leakage in

esophago-jejunosotmyand and two for gastric tube formation. There was no mortality case.

Conclusions

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Lowe mediastinum LN dissection was feasible by laparoscopic approach and frozen first before

gastrectomy provided multiple choice of reconstruction.

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The effects of simultaneous splenectomy on hepatocellular carcinoma patients underwent liver transplantation

Teng-Wei Chen

Division of General surgery, Department of Surgery, Tri-Service General Hospital, National

Defense Medical Center, Taiwan, R.O.C. Email: [email protected]

Background and Purpose: Risk of hepatocellular carcinoma (HCC) recurrence after splenectomy remains controversial. The effects of splenectomy in de novo cancer development after liver transplantation (LT) had not been discussed in previous literatures. The purpose of this study was to compare the oncologic outcomes of those who received simultaneous splenectomy with those who did not in HCC patients underwent liver transplantation. Materials and Methods: The demographic and perioperative data, short-term surgical outcomes, and long-term oncological results of two hundred eighteen patients who had HCC within the UCSF criteria and received LT were collected. Patients received simultaneous splenectomy (n = 36) were compared with patients without splenectomy (n = 180). Univariate and multivariate Cox proportional hazard models were established. Kaplan-Meier survival curves were generated, and log-rank tests were performed to compare group survival status. Results: Patients who underwent simultaneous splenectomy had more HCV infection, had lower platelet counts, and had higher alpha fetoprotein level. Significantly more patients in the splenectomy group had died (31.4% vs 9.4%, P = 0.003) than patients in the non-splenectomy group. 5-year disease-free survival rates were 82.0% in non-splenectomy group and 57.8% in splenectomy group (P = 0.006). 5-year overall survival rates were 90.7% in non-splenectomy group and 68.1% in splenectomy group (P = 0.002). Splenectomy was an independent predictor in Cox proportional hazard model for HCC recurrence (HR 2.303, P = 0.023) and mortality (HR 3.163, P=0.018). Conclusions: HCC patients who received living donor liver transplantation with simultaneous splenectomy had worse oncologic outcomes. Simultaneous splenectomy should be avoided as possible in HCC patients receiving LT. Keywords: splenectomy, hepatocellular carcinoma, survival, liver transplantation

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Split liver transplantation with full right/left hemi-liver grafts for adult recipients

Kun-Ming Chan

Department of General Surgery and Chang Gung Transplantation Institute, Chang Gung Memorial

Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan Email: [email protected]

Liver transplantation has become a routine operation in many transplantation centers worldwide.

However, liver graft availability fails to meet patient demands. Split liver transplantation (SPLT),

which divides a deceased donor liver into two partial liver grafts, is a promising strategy for

increasing graft availability for transplantation and ameliorating organ shortage to a certain degree.

However, the transplantation community has not yet reached a consensus on SPLT because of the

variable results. Specifically, SPLT for two adult recipients using full right/left hemi-liver grafts is

clinically more challenging in terms of surgical technique and potential postoperative complications.

Therefore, this report summarizes the current status of SPLT, focusing on the transplantation of

adult recipients. Furthermore, the initiation of SPLT, donor allocation, surgical aspects, recipient

outcomes, and obstacles to developing this procedure will be thoroughly discussed. This

information might help provide an optimal strategy for implementing SPLT for two adult recipients

among current transplantation societies. Meanwhile, potential obstacles to SPLT might be overcome

in the near future with growing knowledge, experience, and refinement of surgical techniques.

Ultimately, the widespread diffusion of SPLT may increase graft availability and mitigate organ

donation shortages.

Keywords: split liver transplantation; adult recipient; deceased donor; hemi-liver graft; donor and recipient matching; outcomes

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Surgical treatment for portal hypertension

Hiroshi Yoshida, Tetsuya Shimizu, Masato Yoshioka, Akira Matsushita, Junji Ueda, Manpei Kawashima, Toshiyuki Irie, Atsushi Hirakata, Yoichi Kawano, Nobuhiko Taniai

Department of GI and HBP Surgery, Nippon Medical School


Abstract Various complications, such as esophagogastric varices, ectopic varices, ascites, and hepatic encephalopathy, can occur in portal hypertension. Bleeding from esophagogastric or ectopic varices is the most critical complication of portal hypertension. Portal hypertension can arise from any condition interfering with blood flow at any level within the portal system. Many years ago, surgery was the only treatment available for esophagogastric varices in Japan. A number of surgical procedures have been developed to manage esophagogastric varices. Broadly, these can be classified as shunting and nonshunting procedures. There are two types of shunting procedure, namely nonselective and selective. While nonselective shunt, such as portacaval or mesocaval shunt, effectively reduces the incidence of variceal bleeding, it is associated with a high risk of hepatic encephalopathy. A selective shunt, such as distal splenorenal shunt (DSRS) or left gastric venous caval shunt, were developed to preserve portal blood flow through the liver while lowering variceal pressure. The hope was that both bleeding and hyperammonemia would be prevented. DSRS effectively prevents rebleeding, but still carries a risk of hyperammonemia. We improved the DSRS procedure by additionally performing splenopancreatic disconnection and gastric transection. Historically, nonshunting procedures, such as the Hassab operation, esophageal transection (ET), splenectomy, or terminal esophago-proximal gastrectomy, were developed in an attempt to decrease the high rates of encephalopathy associated with portosystemic anastomoses. ET divides and reanastomoses the distal esophagus and devascularizes the distal esophagus and proximal stomach; splenectomy, selective vagotomy, and pyloroplasty are performed concomitantly. Recently, laparoscopic Hassab operation is performed as minimally invasive surgery.

We review surgical treatment for portal hypertension.

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Mechanism-Driven Precise Treatment for Primary Liver Cancer

Ming Kuang

Center of HPB Surgery, The First Affiliated Hospital, Sun Yat-sen University, China

Email: [email protected] Background and Purpose: Primary liver cancer including hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC) ranks the second in tumor related mortality worldwide. Targeted therapies and immune-checkpoint inhibitors are emerging as important treatment to improve patients’ outcome. We carried out a series of studies to investigate how to predict and improve efficacy of targeted therapies or immunotherapy for primary liver cancer through precision medicine. Materials and Methods: Whole genome sequencing (WGS), whole exom sequencing (WES) and RNA sequencing and single cell RNA sequencing were performed on HCC and ICC tumor samples. As for clinical translation, we started a clinical trial of cellular immunotherapy in 2017. Patients enrolled received adjuvant neoantigen dendritic cells / cytotoxic T lymphocytes therapy after surgery or ablation. Results: We found pVEGFR2 expression level predicts Sorafenib-benefited population. Only 20% of target drug-sensitive sites are shared by all metastases for multifocal HCC patients. The small tumors in multifocal HCC patients had more immune cell infiltration and upregulation of immune pathways as compared the large tumors. We further identified two types of recurrence: de novo cancer and true recurrence. Multiomic analysis revealed comprehensive tumor heterogeneity and distinct immune subtypes in multifocal ICC. We developed an immune classification based on the expression level of CD8B and ICOS for multifocal ICC. In the clinical trial of cellular immunotherapy, 70% of patients got neoantigen immune response, and the response group had longer overall survival. After treatment, patients could sustain the neoantigen-specific T cell response. Conclusion: The mechanism-driven precise treatment based on multi-omic studies helps boost the clinical responsiveness to targeted drugs and immunotherapy for primary liver patients. Keywords: Primary liver cancer, targeted therapy, immunotherapy, next generation sequencing, precision medicine.

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Post-hepatectomy liver failure after hepatic resection for hepatocellular carcinoma: a single center experience

Ahmed Shehta, Ahmed Farouk, Amgad Fouad, Ahmed Aboelenin, Ahmed Nabieh

Elghawalby, Rami Said, Mohamed Elshobary, Ayman El Nakeeb

Gastrointestinal Surgery Center, Mansoura University, Egypt


Background and Purpose: Post-hepatectomy liver failure (PHLF) is one of the most feared morbidities after liver resection (LR) for hepatocellular carcinoma (HCC). We aimed to investigate the incidence and predictors of PHLF after LR for HCC and its impact on survival outcomes. Materials and Methods: We reviewed the patients who underwent LR for HCC during the period between January 2010 and 2019. Results: Two hundred sixty-eight patients were included. Patients were divided into two groups according to the occurrence of PHLF, defined according to ISGLS. The non-PHLF group included 138 patients (51.5%), while the PHLF group included 130 patients (48.5%). Two hundred forty-six patients (91.8%) had hepatitis C virus. Major liver resections were more performed in the PHLF group (40 patients (30.8%) vs. 18 patients (13%), p = 0.001). Longer operation time (3 vs. 2.5 h, p = 0.001), more blood loss (1000 vs. 500 cc, p = 0.001), and transfusions (81 patients (62.3%) vs. 52 patients (37.7%), p = 0.001) occurred in PHLF group. The 1-, 3-, and 5-year Kaplan-Meier overall survival rates for the non-PHLF group were 93.9%, 79.5%, and 53.9% and 73.2%, 58.7%, and 52.4% for the PHLF group, respectively (log rank, p = 0.003). The 1-, 3-, and 5-year Kaplan-Meier disease-free survival rates for the non-PHLF group were 77.7%, 42.5%, and 29.4%, and 73.3%, 42.9%, and 25.3% for the PHLF group, respectively (log rank, p = 0.925). Preoperative albumin, bilirubin, INR, and liver cirrhosis were significant predictors of PHLF in the logistic regression analysis. Conclusion: Egyptian patients with HCC experienced higher PHLF incidence after LR for HCC. PHLF significantly affected the long-term survival of those patients. Keywords: Hepatitis C virus; Hepatocellular carcinoma; Liver resection; Post-hepatectomy liver failure.

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Current Status and Future Perspective of Liver Surgery in Taiwan

Rey-Heng Hu

National Taiwan University Hospital


Just as many Asian countries, Taiwan s one of the countries with high HCC occurrence rate. The HCC at Taiwan is mostly related to HBV, and less related to HCV. The universal HBV vaccination at Taiwan began since 1984. Populations born after that year will have low HBV carrier rate at about 0.6%. While those populations born before 1984 still have high HBV carrier rate around 10%. In Taiwan there is also national hepatitis C DAA treatment program since 2017. The peak incidence of HCC occurrence rate at Taiwan was in 2004, that is 20 years after HBV vaccination program. After 2004, the year number of HCC at Taiwan decreased gradually. Nationally, surgical resection, including transplantation) accounts for about 25 % of new diagnosed HCC. Ablation and TACE account for about 17% each. Local ablation outnumbered surgical resection at NTUH, even though evidence revealed that local ablation has inferior longterm overall and disease free survival than surgical resection. Minimally invasive hepatectomy accounts for about 30% hepatectomy at NTUH, but in some priivate hospital it accounts for more than 80% cases. Liver transplantation number at Taiwan reached a peak in 2015, and after that year, the number decreased gradually, due to less HBV or HCV related diasese. Conclusion: Before the fading out of HBV and HCV, there is still a lot liver surgery to be performed in Taiwan. Keywords: hepatocellular carcinoma, hepatitic B, hepatitis C, hepatectomy, ablation, TACE

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Current Status and Future Perspective of Liver Surgery in Japan

Susumu Eguchi

Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences Recent progresses in liver surgery includes 1. Introduction of minimally invasive technique (laparoscopy and robotic surgery), 2. Usage of novel molecular targeting agents (MTA) and immune check-point inhibitor (ICI) for conversion surgery or borderline resectable liver tumors for oncological fields. In addition, ALLPS procedure or stage hepatectomy could be one of the option of extensive surgery for extensive disease. On the other hands, in liver transplant field, we reached 10,000 cases of living-donor liver transplantation (LDLT) in our national registry. Our patient survival has been very stable as 5-year 79.2%, 10-year 74.1%, 12-year 65.6%, To obtain better control, induction of immunological tolerance using reguratory T cell therapy has attracted and currently under clinical research progress. In addition, preformed donor specific antibody (DSA) and de novo DSA has been formidable foe but now getting under control with usage of Rituximab and other specific immunosuppressive drugs.

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Multimodal Treatment in Patients With Pancreatic Ductal Adenocarcinoma

Satoi S, Yamamoto T, Hashimoto D, Yamaki S, Hirooka S, Sekimoto M.

Department of Surgery, Kansai Medical University, Osaka, JAPAN Email: [email protected]

Surgical resection has provided the only chance for a cure in patients with PDAC, but the 5-year survival rate is still low (approximately 20%) even in patients with margin-negative resection. The implementation of adjuvant chemotherapy or neoadjuvant therapy has increased the long-term survival of patients with resectable and borderline resectable pancreatic ductal adenocarcinoma (PDAC). Recent randomized control trials (RCT) clearly revealed that adjuvant chemotherapy using S-1 in Japan (Uesaka et al. Lancet 2016;388:248-57.) and modified FOLFIRINOX in the Western countries (Conroy et al. N Engl J Med 2018;379:2395-406.) improved overall survival (OS) after surgical resection in patients with PDAC. However, approximately 50% of patients develop disease recurrence within 2 years in patients who underwent surgical resection followed by adjuvant chemotherapy. Implementation of neoadjuvant therapy may be associated with higher proportion of R0 resection and negative lymph node metastasis, resulting in improved OS, but there has been less definite evidence in terms of favorable prognosis of neoadjuvant therapy so far. Interim analysis in the Korean RCT recently revealed that neoadjuvant chemoradiation improved OS better than upfront surgery in patients with borderline resectable PDAC (Jang et al. Ann Surg 2018;268:215-222.). PREOPANC trial of preoperative chemoradiotherapy versus immediate surgery in resectable or borderline resectable PDAC did not show a significant OS benefit of preoperative chemoradiotherapy but a predefined subgroup analysis showed superior OS after preoperative chemoradiotherapy for borderline resectable PDAC and no significant difference for resectable PDAC (Versteijne et al. J Clin Oncol. 2020;38:1763-1773.). The PREP-02/JSAP-05 in Japan clearly demonstrated that neoadjuvant therapy using Gemcitabine+S-1 in patients with resectable PDAC improved disease-free survival and OS with less frequencies of lymph node metastasis and development of liver metastasis (Unno et al. J Clin Oncol 2019;37:189, Satoi et al. J Clin Oncol 2019;37 (suppl; abstr 4126). Neoadjuvant therapy can be standard of care in patients with resectable and borderline resectable PDAC. JASPAC-04 study comparing OS between neoadjuvant chemoradiation using S-1 and neoadjuvant chemotherapy using gemcitabine + S-1 revealed that there was no difference in 2-year progression-free survival in patients with resectable PDAC (J Clin Oncol 38, 2020 (suppl 4; abstr 724). Surgical resection in patients with positive peritoneal washing cytology is still controvertial. Recently, large sclaed studies clearly revealed worse survival after surgical resection in patients with positive cytology, relative to negative cytology (Satoi et al. J Gastrointest Surg. 2015 ;19:6–14. Tsuchida et al. Surgery. 2019;166:997-1003.) It may be avoided to perform up-front surgery in patients with positive cytology. Recent evidence of neoadjuvant therapy is promising, and other RCTs using FOLFIRINOX or gemcitabine plus nab-paclitaxel as neoadjuvant therapy are going on. Multimodal treatment including margin-negative resection, but not surgical resection only, will be one of the standard treatment options in patients with R/BR PDAC.

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Conversion Surgery for Pancreatic Cancer

Itaru Endo

Yokohama City University, Japan Email: [email protected]

Recent 10 years, there were steep increases in the incidence and mortality rate from pancreatic cancer in most countries. In Japan, the number of deaths from pancreatic cancer shows a tenfold increase in the last 50 years. According to Japan Pancreatic Association Pancreatic Cancer Regstry, the number of resectable cases has increased. However, the number of Stage III/IV patients is not decreasing. It is essential to improve the outcome of this group to raise the level of pancreatic cancer treatment. In order to achieve conversion surgery, there are still some unanswered clinical questions, such as what kinds of regimens should be used, what are the indications for surgery, and how should postoperative adjuvant chemotherapy be used? Concerning to regimen selection, there was no difference in overall survival between FFX and GnP in most studies. In recent years, good outcomes of resection after chemotherapy or chemoradiation for locally advanced unresectable (UR-LA) pancreatic cancer have been reported, and some reports have shown good results with MST for more than 2 years. Especially, after the emergence of FFX and GnP, the resection rate of UR-LA pancreatic cancer has been increased to be 30 to 70% and the R0 resection rate to be 90%. In our case-series of conversion surgery, 75% of cases, vascular resection was performed. Postoperative complications were acceptable. In multivariate analysis, postoperative adjuvant chemotherapy was an independent favorable prognostic factor. These results suggest that it is essential to perform surgery that allows adjuvant chemotherapy to be administered after surgery. It is difficult to determine when and in which cases conversion surgery should be performed. Many cases are judged as Stable disease by conventional diagnostic imaging such as contrast-enhanced CT. Therefore, appropriate biomarkers are required. Preoperative high serum CA19-9 and elevation of DUPAN2 after neoadjuvant treatment may be good biomarkers. Furthermore, liquid biopsy (peritoneal washing cytology, circulating tumor DNA etc) has the potential to become a useful test method. Prospective studies using larger patient cohorts are needed to validate the usefulness for decision making and their clinical relevance for the optimal selection of conversion surgery.

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Conversion Surgery for an Initially Locally Advanced Unresectable Pancreatic Cancer After Multidisciplinary Treatment

Tsutomu Fujii, Isaku Yoshioka, Kazuto Shibuya, Katsuhisa Hirano, Toru Watanabe,

Takamichi Igarashi, Haruyoshi Tanaka, Yuuko Tohmatsu, Ayano Sakai, Nana Kimura, Takeshi Miwa, Isaya Hashimoto, Shozo Hojo, Koshi Matsui, Tomoyuki

Okumura

Department of Surgery and Science, Faculty of Medicine, Academic Assembly,

University of Toyama, JAPAN Email: [email protected]

The number of annual deaths due to pancreatic cancer is increasing every year, and a cure is achieved in less than 10% of patients. In pancreatic cancer, which is an incurable disease, improved results have begun to be reported due to the advancement of multidisciplinary treatment, including state-of-the-art chemotherapy regimens and improvements in perioperative procedures and management. In the treatment of unresectable (UR) pancreatic cancer, the most innovative recent change is the introduction of FOLFIRINOX and nab-paclitaxel as an effective protocol. By multidisciplinary treatment using them, there are increasing cases in which resection is possible in pancreatic cancer which was unresectable at the time of initial diagnosis. This additional surgical resection is called “Adjuvant surgery” or “Conversion Surgery”, implying strategy-conversion. There is still no clear evidence on the validity and usefulness of this option; however, good prognosis has been reported in locally advanced UR (UR-LA) pancreatic cancer patients little by little. However, a multidisciplinary treatment including regimen, duration of treatment, and timing of surgery require further study as well in UR-LA pancreatic cancer. In addition, surgery for UR-LA pancreatic cancer requires advanced techniques such as portal vein and arterial resection. In conversion surgery for metastatic (UR-M) pancreatic cancer, a thorough verification will be required in the future. I will review previous reports, especially about conversion surgery for initially unresectable locally advanced pancreatic cancer following multidisciplinary treatment, and state the experience including combined radiotherapy and surgical results in our institution. Keywords: pancreatic cancer, unresectable, conversion surgery, multidisciplinary treatment

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Surgical Outcome of Conversion Surgery for Initially Unresectable Locally Advanced Pancreatic Cancer: A Single-Center Experience

Ippei Matsumoto, Yuta Yoshida, Chihoko Nobori, Kohei Kawaguchi, Masataka Matsumoto,

Dongha Lee, Takaaki Murase, Keiko Kamei, Shumpei Satoi, Atsushi Takebe, Takuya Nakai, Yoshifumi Takeyama

Department of Surgery, Kindai University, Japan


Background and Purpose:

With recent advances and improvements of chemotherapy and/or chemoradiotherapy, reports of

conversion surgery (CS) for initially unresectable pancreatic cancer have been increasing. Here, we

report our experiences and results of CS for initially unresectable locally advanced pancreatic

cancer (UR-LA PC).

Materials and Methods:

This single center retrospective study included consecutive 88 patients with UR-LA PC receiving

treatment in our hospital from 2014 to 2021. Surgical outcome of CS and long-term results

comparing to the patients without CS. Surgical indication was decided in our multidisciplinary

meeting in all patients.

Results:

The patients consisted of 43 men and 45 women with a median age of 68 years. The median follow-

up time was 14 months after initial treatment. Twenty-eight (32%) patients underwent CS. Sixty-

seven patients received systemic chemotherapy and 21 patients received chemo-radiotherapy.

Response of preoperative therapy defined by RECIST were PR in 21 patients and SD in 7. The

median time from initial treatment to CS was 8 (3-22) months. The median values of CA 19-9

before initial treatment and CS were 93 (9-1147) U/ml and 19.0(3-124) U/ml, respectively. The

normalization rate of CA19-9 was 85.7%. Surgical procedures included with SSPPD in 13 patients,

DP-CAR in 12, DP in 2, and TP in 1. Portal vein resection and artery resection were performed in

14 patients and in 14, respectively. Five patients (18%) developed grade III or more complication

defined by Clavien-Dindo classification. Mortality (≤ 90 days) was zero. R0 resection was achieved

in 23 patients (82%). Evans grades shows grade I in 2 patients, IIa in 3, IIb in 11, III in 8, and IV in

2. There was no difference in patients characteristics (age, sex, tumor location, and major vessel

invasion) between the CS and Non-CS groups. The median survival times from initial treatment

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with and without CS were 41 and 14 months, respectively (p<0.0001). Prognostic nutrition index

and CS were identified as prognostic factors before treatment.

Conclusion:

CS for UR-LA PC may be useful for survival with an acceptable risk of surgery in selected patients.

Further study will be needed to evaluate the efficacy and selection of the patients who will really

have benefit with CS.

Keywords: Pancreatic cancer, Conversion surgery

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Multidisciplinary treatment for advanced pancreatic cancer

Hideyuki Yoshitomi

Dokkyo Medical University, Saitama Medical Center, Koshigaya, JAPAN Email: [email protected]

Pancreatic cancer remains a lethal disease with poor outcomes. Although surgical resection is the only hope for a cure, only a few patients undergo surgical resection as most patients are found at their advanced stage. In addition, even though with curative resection, most of the patients experience recurrence within a few years. In this decade, chemotherapy and radiotherapy have achieved huge advancement, and there are several treatment options other than surgical resection for pancreatic cancer. These advancements lead to the development of multidisciplinary treatment, which combines surgical resection and chemo(radiotherapy). Especially for advanced cancer, such as borderline resectable (BR) or unresectable (UR) cancer, neoadjuvant therapy has recently become a standard treatment. In this presentation, I review these advancements, mainly focusing on distal pancreatectomy with celiac axis resection (DP-CAR) for pancreatic body cancer and the combination of heavy carbon ion radiation and surgical resection. The purposes of neoadjuvant therapy are 1) treating patients when their performance status is stable, 2) treating widespread cancer cells to other organs by chemotherapy before surgery 3) decreasing the tumor size and involvement to adjacent organs, increasing the chance of curative resection. Recent research showed that circulating tumor cells were found in pancreatic cancer patients even with early-stage cancer. This indicates that curative resection does not mean removing all cancer cells from the body, and neoadjuvant therapy has a role. In addition, recent research showed that neoadjuvant chemotherapy improves the tumor's microenvironment by increasing tumor immunity and suppressing epithelial-mesenchymal transition of tumor cells. The pancreatic body cancer easily involves the common hepatic artery and celiac axis. For these tumors, we aggressively have performed DP-CAR. However, recent meta-analyses revealed the high incidence of complications of this procedure. We recently treated patients with neoadjuvant therapy. Thirty-one patients underwent DP-CAR followed by neoadjuvant treatment. The 90-days mortality occurred in one patient (3.2%). The median overall survival time of these 31 patients was 38.6 months. This result indicates that the combination with neoadjuvant treatment and DP-CAR The role of radiation in neoadjuvant treatment is controversial. Several reports showed the addition of radiotherapy in neoadjuvant therapy resulted in a high R0 resection rate and low lymph node involvement. On the other hand, several retrospective analyses could not show the survival benefit of neoadjuvant chemoradiationtherapy compared with neoadjuvant chemotherapy. This may depend on the power of radiation. The heavy-ion radiation has Bragg peak effect, which leads to target specific and increasing intensity of radiation. In our experience, 21 patients received heavy-ion radiation before the surgical resection and the median overall survival of these patients was 35.9 months after initiation of treatment and 28 months after surgery. The future clinical trials will reveal adequate radiation dose and area. Many points should be revealed in the future regarding multidisciplinary treatment for pancreatic cancer. What is the adequate regimen for each type of cancer? When is the best timing for surgery? These questions should be revealed in future studies. Keywords: Multidisciplinary treatment, neoadjuvant treatment, DP-CAR, heavy-ion radiation, Borderline resectable, unresectable

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Second-line chemotherapy for advanced pancreatic cancer

Sang Hyub Lee, MD, PhD

Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Se

oul, Korea Email: [email protected]

Pancreatic cancer is one of the fatal cancers, and will become the second leading cause of cancer deaths in 2030. Relatively better chemotherapy regimens and improvements in supportive care for patients receiving chemotherapy have increased the number of patients who maintain good performance status after disease progression. Although there are limited evidences, many guidelines recommend second-line chemotherapy based on the patient’s Performance status and the history of previous chemotherapy. During the past decade, the majority of patients with unresectable pancreatic cancer have received either gemcitabine-based therapy or fluoropyrimidine-based therapy. Therefore, when considering the second-line chemotherapy, there are two main scenarios: after the first-line gemcitabine-based treatment and after the first-line fluoropyrimidine-based treatment.

When the first-line gemcitabine-based therapy failed, it is recommended to use fluoropyrimidine-based therapy for patients with good performance status. In phase III NAPOLI-1 trial, the combination of nano-liposomal irinotecan, 5-fluorouracil (5-FU), and leucovorin showed improvements compared to 5-FU and leucovorin in overall survival (OS, 6.1 months vs. 4.2 months; P = .012) and progression free survival (PFS, 3.1 months vs. 1.5 months; P < .001). Other fluoropyrimidine-based regimens, including modified FOLFIRINOX (5-FU and leucovorin with reduced dose of irinotecan and oxaliplatin), OFF (oxaliplatin, 5-FU, and leucovorin), and FOLFIRI (irinotecan, 5-FU, and leucovorin), have also demonstrated promising efficacy in phase II and some retrospective studies.

For patients with unresectable pancreatic cancer that is resistant to first-line fluoropyrimidine-based therapy, gemcitabine-based therapy is recommended. Although there is lack of evidence from randomized controlled trials, the combination of gemcitabine and nanoparticle albumin–bound paclitaxel showed remarkable improvements in OS (5.7-9.8 months) and PFS (3.61-5.1). And a retrospective study demonstrated the efficacy of gemcitabine monotherapy after FOLFIRINOX failure with a median OS of 3.7 months and PFS of 2.1 months.

In patients with neurotrophin receptor kinase (NTRK) gene fusions, NTRK inhibitors, including larotrectinib and entrectinib, showed promising OS and PFS. And pembrolizumab showed remarkable survival benefits in patients with microsatellite instability or mismatch repair deficiency.

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Resistance to first-line therapy eventually develops in the majority of patients with advanced pancreatic cancer. Second-line treatment decisions should be made jointly by the patient and the provider after a thorough assessment of the oncologic value of treatment in terms of survival, therapeutic toxicity, and quality-of-life effects.

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PALLIATIVE CHEMOTHERAPY FOR PANCREATIC CANCER

Ji Kon Ryu, M.D, PhD

Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea

101 Daehak-ro, Jongno-gu, Seoul, 03080, South Korea Tel: +82-2-2072-2228, Fax: +82-2-762-9662, E-mail: [email protected]

Pancreatic cancer has a 5-year survival rate with less than 10% and less 20% of patients who can undergo surgery at first diagnosis. Unfortunately, even in resectable cancers patients, 5-yr survival rate also showed unsatisfactory. Pancreatic cancer is associated with the lowest survival rates of any major cancer type. By 2030, pancreatic cancer is expected to rise to the second leading cause of cancer-related mortality in the United States (after lung cancer). PRODIGE4 ACCORD11 in 2011 trial has been accepted as the most important progress in the chemotherapy of pancreatic cancer. This multicenter, randomized, phase 2–3 trial was conducted at 15 centers during phase 2 and expanded to 48 centers during phase 3. Patients were randomly assigned to receive FOLFIRINOX (FFX) or gemcitabine within 1 week after enrollment. FFX regimen has been showed the excellent clinical efficacy to overcome the limitation of previous standard gemcitabine chemotherapy. MPACT trial in 2013 is a multicenter, randomized, phase 2–3 trial which was conducted at 15 centers during phase 2 and expanded to 48 centers during phase 3. Patients were randomly assigned to receive gemcitabine with nab-paclitaxel (GnP) or gemcitabine. GnP regimen showed significantly better overall survival than gemcitabine therapy. Two Korean studies also demonstrated that GnP regimen resulted better overall survival (12.1 months and 14.2 months in metastatic pancreatic cancer. Our question is which one is better as the 1st line chemotherapy among FFX and GnP regimen. However, these two regimens have not been compared head to head. So, our group performed comparison study between FFX and GnP regimen including sequential treatment for metastatic pancreatic cancer. Data of 528 patients (FFX, n = 371; GnP, n = 157) with mPC were collected retrospectively. Propensity score matching was conducted to alleviate imbalance of the two groups. Overall survival (OS), progression free survival (PFS), and toxicity of patients were analyzed. After matching, PFS (7.2 months vs. 5.8 months, p=0.04) and OS (11.8 months vs. 10.3 months, p=0.02) were longer in the FFX group than Gem/nab-P group. Chemotherapy interruption due to adverse reaction was much higher in Gem/nab-P group than FFX group. However, for complete sequential treatment group, PFS and OS showed no significant difference between two groups. FFX first sequence would be tolerable in terms of a lower rate of interrupting chemotherapy due to AEs than GnP. FOLFIRINOX is a platinum-based chemotherapy regimen for patients with pancreatic cancer and is known to be more effective in the presence of the BRCA mutation, one of the DNA damage repair (DDR) gene mutations. However, BRCA mutations are less common in pancreatic cancer patients, accounting for only about 5% of cases worldwide, and are known to be even rarer in Asians. Therefore, our group studied to uncover new genetic variants of DNA damage repair (DDR) genes related to the response of FOLFIRINOX by analyzing variants of DDR genes using whole exome sequencing. The multivariate Cox model showed that rs2228528 in ERCC6 was significantly associated with improved PFS (hazard ratio 0.54, p = 0.001). The median PFS was significantly longer in patients with rs2228528 genotype AA vs. genotype GA and GG (23.5 vs. 16.2 and 8.6 months; log-rank p < 0.001). If validated

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through future large-scale studies, rs2228528 in ERCC6 could be used as a valuable biomarker to help determine whether to use FOLFIRINOX as the first-line therapy in pancreatic cancer patients. PARP inhibitors such as olaparib are newly approved molecular target drug by USA FDA in 2019 for the patients with germline BRCA mutation. According to NCCN guideline, olaparib can be considered as maintenance treatment for patients who have a deleterious germline BRACA1/2 mutation, good PS, metastatic disease, and no disease progression during >16 weeks of 1st line, platinum based chemotherapy.

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Interplays between genetic alterations modulate cancer behavior and tumor microenvironment

Tzu-Lei Kuo, Li-Tzong Chen, Wen-Chun Hung

National Institute of Cancer Research, National Health Research Institutes, Taiwan


Background and Purpose: Pancreatic cancer is a deadly disease with a 5-year survival rate less than 8%. Global genomic profiling has revealed a number of genetic alterations that might contribute to pancreatic tumorigenesis. Mutations in the K-ras gene have been found in more than 90% of patients, and the encoded oncoprotein plays an important role in the initiation and maintenance of pancreatic cancer. Mutation, deletion, truncation, or gene silencing of p53 has also been detected in more than 50% of pancreatic cancer patients. It is noteworthy that the deregulation of genes involved in cell cycle control, transforming growth factor beta signaling, and epigenetic modification frequently co-exist with K-ras mutation and p53 inactivation in patients with pancreatic cancer. Clinical evidence also suggested that patients with complex pathway deregulations tend to have poor prognosis. However, whether the interplay between the altered genes promote pancreatic tumorigenesis is still unclear. To clarify the crosstalk between the dysregulated genes in the initiation, promotion and progression in tumorigenesis, we generated genetically engineered mice with specific genetic defects in the pancreas and elucidated the molecular mechanism how the interplys between the alteraions modulate cancer behavior and tumor microenvironment. Materials and Methods: Genetically engineered mice with defects in the WNT signaling and chromatin remodling complex were generated. Tumor formation was monitored and cancer cell behavior was examined. In addition, alterations in tumor microenvironment was investigated by different experimental approaches. Results: Our results demonstrated that genetic alterations of the WNT signaling molecules induced constitutive activation of the pathway, leading to the enhancement of platlet-derived growth factor (PDGF)-mediated oncogenic signaling. Targeting PDGF receptor and downstream molecules could be a strategy to inhibit pancreatic cancer with K-Ras/p53/WNT defects. We also generated mice with specific alterations in chromatin remodefier and found the induction of epithelial-mesenchymal transition in cancer cells. In addition, tumor microenvironment was changed in the tumors with defects in chromatin modifier genes. Conclusion: The interplays between different genetic alterations can modulate cancer behavior and tumor microenvironment. Elucidation of the underlying mechnaisms of the interplay provides useful information to design targeted therapy for pancreatic cancers with specific genetic defects. Keywords: K-Ras; p53; WNT signaling, chromatin remodeling omplex.

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Mutational Landscape in Pancreatic Cancer

Li-Yuan Bai

Taiwan


Pancreatic cancer is the leading 4th cause of cancer death globally and 7th in Taiwan. The incidence and mortality of pancreatic cancer also increase gradually in Taiwan in recent years. Although the estimated time for pancreatic cancer formation is more than 20 years, most patients with pancreatic cancer are diagnosed at advanced or metastatic stage. With the advance of next generation sequencing technologies, more comprehensive genomic information is available. KRAS, TP53 and CDKN2A are the leading mutations in patients with pancreatic cancer in Taiwan as same as in western countries. KRAS is believed to be the most important and initiating factor but additional genetic alterations are necessary to the carcinogenesis of pancreatic cancer. Few of the identified genetic alterations have become the targets for pancreatic cancer therapy, including RAS G12C and BRCA1/2 mutations. There are several clinical trials assessing the activity of compounds targeting these alterations, and more effect is undergoing to develop novel agents for other potential druggable targets. However, the difficulty to successfully treat pancreatic cancer probably relates to the immunosuppressive tumor microenvironment which contains fibroblasts, tumor associated macrophage, myeloid-derived stem cell, pancreatic stellate cell, TGFb, HGF and IL-10. In this meeting, we will discuss the current understanding of genomic alteration, as well as therapies targeting these alterations in pancreatic cancer.

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The Update of Pancreatic Cancer Management

Nai-Jung Chiang

National Institute of Cancer Research, National Health Research Institutes National Cheng Kung University Hospital, Tainan, Taiwan

Email: [email protected] Pancreatic ductal adenocarcinoma (PDAC) is associated with dismal prognosis. Only about 10-20% of people diagnosed with pancreatic cancer are able to have surgery. Around 15-20% of patients presented with locally advanced (LA) PDAC at the time of diagnosis and mostly patients had metastatic PDAC with the incidence of 60-70%. For LA and metastatic PDAC, chemotherapy remains the standard first-line treatment. Neoadjuvant chemotherapy (NAT) is also suggested to be applied in borderline resectable (BR) and resectable PDAC instead of upfront surgery. The common regimens of salvage chemotherapy and NAT include FOLFIRINOX (oxaliplatin, irinotecan and 5-FU/LV), gemcitabine plus nab-paclitaxel, S-1 based treatment (mainly in JAPAN) with or without radiotherapy. We also developed some regimens applied in LA and metastatic PDAC through investigator-initiated clinical trials (IITs), such as GOFL (gemcitabine, oxaliplatin and 5-FU/LV), SLOG (S-1/LV, oxaliplatin and gemcitabine), and modified gemcitabine and S-1 in elderly subpopulation. In this talk, I will briefly review the current evidence of chemotherapy in resectable, BR, LA and metastatic PDAC, focusing on pivotal global and results from our IITs.

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Salvage Proton Beam Therapy for Failure of First Staged Laparoscopic ALPPS

Chee Chien Yong

Kaohsiung Chang Gung Memorial Hospital, Taiwan Email: [email protected]

Background and Purpose: Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) can effectively induce the rapid hypertrophy of future liver remnant (FLR) within a short time to avoid post hepatectomy liver failure. However salvage therapy for failure of stage I ALPPS due to tumor progression or insufficient of increase FLR is need.

Materials and Methods: we present a case of huge right liver tumor with insufficient FLR underwent laparoscopic first stage of ALPPS. However failure to increase FLR to 40% of SLV. Salvage proton Beam therapy was successful for tumor control and second stage ALPPS was safely performed.

Results: The 60 year old male without hepatitis history. Unresectable huge liver tumor at right liver with middle hepatic vein and right hepatic vein compression was noted, need right tri- sectionectomy, however FLR only 159cm3 (13% of standard liver volume, SLV) and alpha fetal protein (AFP) was 1605ng/ml. He underwent laparoscopic first stage ALPPS. The kinetic growth rate was 24.1cm3/d in first week, FLR was increased to 328cm3 (27% of SLV). But the FLR was no further increased in following 5 weeks. Salvage proton beam therapy with 7260cGy/22 fractions) was underwent during day-51 to day-89 after first stage ALPPS. The AFP was drop to normal (9ng/ ml) and the FLR was increased to 679cm3 (56% of SLV). And the 2nd stage ALPPS was successful performed on day-125. And length of stay was 10 days without complication. Pathology revealed near complete pathology response (99% of tumor necrosis).

Conclusion: salvage proton beam therapy was not only optimize in tumor control but also increased the FLR, there can be a suitable therapy for failure of first stage ALPPS.

Keywords: ALPPS, hepatocellular carcinoma, salvage proton beam therapy.

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Laparoscopic surgery for advanced gastric cancer

Jiann-Ming Wu

Far Eastern Memorial Hospital, New Taipei City, Taiwan Email: [email protected]

Background and Purpose: Gastric cancer is still the 8th cancer death in Taiwan. About 60% of gastric cancer pateints are diagnosed at stage III or IV disease. The role of laparoscopic surgery for advanced gastric cancer is not well defined. Materials and Methods: We reviw the literature and share our experience about laparoscopic sugery 1. For early gastric cancer (cT1) or early stage gastric cancer (cT1-2N0), 2. For advanced gastric cancer, 3. Laparoscopic gastrectomy and paraaortic LN dissection, and 4. Laparoscopic gastrectomy and HIPEC for limited peritoneal carcinomatosis or prophylaxis of peritoneal recurrence. Results:: Laparoscopic surgery 1. Could be a standard procedure for EGC (cT1) or early stage GC (cT1-2N0), 2. Could be a standard treatment choice for AGC (cT2-4), 3. Laparoscopic gastrectomy + PAND following NAC is technically feasible in experienced hands for highly selected patients, 4. Laparoscopic gastrectomy + HIPEC could be considered for limited peritoneal seedings, or prophylaxis of peritoneal recurrence for high risk patients. Conclusion: Laparoscopic surgery is feasible for both early and advanced gastric cancer. However, careful selection is crutial for patient safety and better outcome. Keywords: Laparoscopic gastrectomy, advanced gastric cancer, paraaortic lymph node dissection, hyperthermic intraperitoneal chemotherapy (HIPEC)

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The role of minimal invasive surgery of colorectal liver metastases

Te-Hung Chen Department of Surgery, China Medical University Hospital, China Medical University, Taichung,

Taiwan Email: [email protected]

Abstract: Liver resection is the standard therapy for patients with colorectal liver metastases (CRLM) and the only potentially curative treatment approach. The 5-year overall survival rate after resection of CRLM has been reported to be 33–55%, whereas the median overall survival time of patients with untreated CRLM is less than 1 year. CRLM can be resected using an open or laparoscopic approach. For resection of CRLM, studies have shown that LLR results in superior perioperative outcomes and similar oncological outcomes (recurrence-free and overall survival) in selected patients compared to OLR. We will report the result of laparoscopic liver resection for colorectal liver metastases in a single center. Keywords: laparoscopic, hepatectomy, colorectal liver metastases

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Mycetoma Belt, Madura Foot in Baidao City, Somalia - Clinical Diagnosis

Hussain Ghorab

El-Sahel Teaching Hospital, Cairo, Egypt Email: [email protected]

Background : Mycetoma is a chronic, granulomatous, subcutaneous, inflammatory disease caused by true fungi (eumycetoma) or filamentous bacteria (actinomycetoma) . The foot is the most commonly affected. Mycetoma commonly affects adults aged 20 to 40 years, predominantly male. The causative microorganisms probably enter the body by a thorn prick “Mycetoma: a thorn in the flesh, AH Fahal.“. It was described in the modern literature in 1694 but was first reported in the mid-19th century by Gill,J (1842)in the Indian town of Madura, and hence was initially called Madura foot. “'Mycetoma” (meaning: fungal tumor) was proposed by Carter HV,(1860), he classified his cases by the color of the discharged grains. Today, the infection remains difficult to diagnose, difficult to treat, and still a major socioeconomic burden. Mycetoma was recently added to the WHO list of Neglected Tropical Diseases (NTD) following the Geneva meeting in May 2016. This recog-nition has brought much more attention to this badly ignored disease. However, the global burden of mycetoma is still unknown. Unfortunately, Mycetoma is not a reportable disease yet. The causative organisms are distrib-uted worldwide but are endemic in tropical and subtropical areas in the ‘Mycetoma belt’, between latitudes 15° south and 30° north, in hot and rather dry climates. Clinical Diagnosis: Somalia is an endemic country where Mycetoma cases are under-or misdiagnosed due to the lack of health education and awareness among health workers and the community. A total of 54 patients, visited the surgery outpatient clinic, Baidaoo hospital, Bay region, Somalia, in 18- month period (1982-1983).The patients were between 20 and 70 years-old, the male: female ratio was a 8:1; and most were manual workers. The most frequent presentation was massive limb deformity and sever disability, 50% of patients were asking for amputation. In a situation where diagnostic tools are expensive, limited or unavailable, little is left but to clinically diagnose these patients. Clinically, diagnosis can be established through the: "Baidao Hos-pital three-step diagnostic plan" : Step 1- Good clinical interview and general clinical examination, The clini-cal triad of a painless subcutaneous mass, sinuses, and granular discharge, seen in patients from an endemic area, is pathognomonic of Mycetoma. On direct examination, the discharged grains vary in size, color and consistency depending on the causative organisms. Step 2- differentiation of eumycetoma from actinomyceto-ma. To treat, clinicians need to distinguish between the bacterial and fungal form of Mycetoma. Step 3- Myce-toma also has to be differentiated from various infectious and non-infectious pathologies which mimic it in the same endemic area. (i.e. differential diagnosis) Conclusion: 1- In Somalia, patients delayed too long in consulting their doctors and health education is vital if amputation are to be avoided. 2- Mycetoma needs to be given more attention in research and funding. 3- There is an urgent need for the establishment of a surveillance system, early, recognition and initiation of appropri-ate treatment is needful in reducing the disability.4- Preventing infection is difficult, but people living in or travelling to endemic areas should be advised not to walk barefooted.

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Telemedicine for medical students and doctors in surgery

Taiki Moriyama

Kyushu University, Japan


Since the pandemic of COVID-19, human movement has been severely restricted not only in the world but also in domestic. This time, I would like to introduce the education of medical students and surgeons using remote technology, which we have been working on since before the pandemic. 1) Education for medical students: International tele-education class with live surgery has been performed by Kyushu University (Japan) and Seoul National University Hospital (Korea) for pre-clinical medical students since 2008. a moderating surgeon in Korea explains about surgical procedures and various instruments in the operation room. Most Japanese students have their first experience of observing surgery, and their first opportunity to communicate with foreign surgeons. They also had the chance to ask the surgical moderator some questions and for discussion with Korean medical students in their clinical class of the operating theater. 2) Education for surgeons using surgical images: More than 50 medical staff come to Kyushu University Hospital for training every year. In particular, there are many trainees of gastrointestinal endoscopy doctors and surgeons. As a summary of the training, they are implementing a program to connect with their own facilities and announce the results. In addition, taking this as an opportunity, even after returning to their countries, we have organized remote learning programs to continue sharing information and international exchange. TEMDEC, one of International Medical Department in our hospital, is in charge of these remote conferences. In the field of surgery, especially regarding laparoscopic surgery, it is useful to sharing information with a telemedicine system. Telemedicine and distance education are indispensable in the future, even after COVID-19, especially in the field of surgery. However, I think that direct international exchange also remains very important. I hope that the day will come when we can go back and forth between each other's countries as before. Keywords: telemedicine, surgery

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Telecare for Surgical GI Cancer Patients

Jin-Ming Wu, MD & PhD

Department of Surgery, National Taiwan University Hospital Email: [email protected]

Digestive system consists of the gastrointestinal tract plus the accessory organs of digestion, including pancreas, liver, and gallbladder. The indication for major digestive system surgery is cancer. According to the cancer registry of 2018 population in Taiwan, colon cancer, liver cancer and gastric cancer is the most common digestive system cancer. Among them, surgical modality for gastric cancer carries the highest rate of complication. Moreover, gastric cancer patients may suffer from nutritional deterioration, which consequently increases the risk of morbidity and mortality due to surgical stress, malnutrition or complications.

After radical gastrectomy, the patient would stay in the hospital for one to two weeks under the care of professional surgical staffs. During this time, it is easy for the patient and patient’s family to stay. However, it would switch to a heavy task when the patient was discharged and take care of them at home. They should do self wound cares, cook post-gastrectomy meals, mange gastrointestinal discomforts. Even worse, some patients need to care the retained intra-abdominal drain. Due to the care gap between the hospital and the home, we design one telecare system to help eliminate this barrier.

Telecare is the term for offering remote care of elderly and physically less able people, providing the care and reassurance needed to allow them to remain living in their own homes. In 2013, we start to design the first-generation APP and focus on the functions of body weight recording, patient education, drain recording, self-management of discomforts, and uploading wound images. Daily body weight is a simple parameter to assess nutritional status. The second- generation APP we implement the wearable device to our system. Surgical cancer patients often have deteriorated physical activity (PA), which in turn, contributes to poor outcomes and early recurrence of cancer. This APP is to determine the feasibility and clinical value of using 1 wearable device connected with the mHealth platform to record PA among patients with gastric cancer (GC) who had undergone gastrectomy. In third generation APP, we focus on the surgical wound cares. The telecare staff will customize the wound care plan for each patient, and the patient get aforementioned information in APP about the interval of wound cares and dressing method.

In conclusion. our early study supported the feasibility of a tablet PC-based application for the perioperative care of gastric cancer cases to promote a lower body weight loss and the collection of patient-generated data. Second, incorporating the use of mobile phone apps with wearable devices to record PA in gastric cancer patients undergoing gastrectomy in this study. With the support of the mHealth platform, this app offers seamless tracing of patients’ recovery with a little extra burden and turns subjective PA into an objective, measurable parameter. Third, AI-

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supported algorithm is a feasible tool to recognize the wound infection characteristics. Implementation of automatic algorithm may help the surgical professionals in charge of telecare. In the future, with the support of government and funding support, the application of telecare will play an important role in perioperative cares.

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Telemedicine in Gastroenterology during COVID 19 pandemic

Kalayarasan R

JIPMER, Puducherry, India [email protected]

Telemedicine refers to the use of information and communication technologies to provide medical services from a distance. India, one of the worst affected nations due to the COVID-19 pandemic, announced a complete lockdown in mid-March 2020. The lockdown had a severe impact on health care as the patients could not reach Hospital due to lack of public transport. Also, the Hospitals had started to restrict the number of outpatient consultations and routine services to reduce the spread of COVID-19. Thus, alternative methods to reach these patients have become necessary. This is where telemedicine played a significant role. We developed a custom-made video consultation application using Active Server Pages (ASP.NET) framework with Visual Basic (VB) as the code behind the language. The application uses a very minimal bandwidth of 500 kbps to facilitate low bandwidth video consultation so that any patient with inadequate network coverage too can utilize the teleconsultation service. When a clinician initiates a call, he has features like zooming in and out the patient’s video for better medical observation. The system also ensures that the secure channel for video consultation is closed, and the patient cannot use the same channel again once the clinician marks the call has ended. The two-way communication can also be used for audio consultation only, and the clinician has the freedom to choose between audio and video. Of the 252 patients with gastrointestinal disorders who received teleconsultation, 62% rated the consultation process as good whereas 22% and 16% rated it as average and not satisfied. Technical issues were the vital cause for suboptimal satisfaction. While the COVID-19 pandemic provided an opportunity to explore the role of telehealth, more innovations are required to improve patient satisfaction. . Keywords: Telemedicine, telehealth, Gastroenterology, COVID-19.

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Late Complication of Bariatric Procedure

Valter Nilton Felix , Ioshiaki Yogi, Nayara Santos, Rafael Rodrigues, Karen Terra

Nucleus of General and Specialized Surgery and HCFMUSP , Brazil Email: [email protected]

Background and Purpose: Adenocarcinoma of the esophagus associated to morbid obesity, also has been highlighted. However, association between weight-loss operations on the stomach and post-operative esophageal cancer must be better studied. We present herein one case of esophageal undifferentiated cancer that occurred longtime after bariatric procedure and that went unnoticed until reaching advanced stage Material and Methods: A 74-year-old man, non-smoker or alcoholic, underwent gastric bypass with stapled division of the stomach and Roux-en-Y gastrojejunostomy 20 years ago. A band was used to limit the emptying of the gastric pouch. A preoperative endoscopic evaluation did not show any esophagogastric problem and H. Pylori infection was discarded by biopsies. In the post-operative period, he experienced expected persistent symptoms of regurgitation, particularly after overeating, and lost 52 Kg. Two surveillance upper endoscopies discarded any esophageal, gastric pouch or jejunal disease, except mild esophagitis, until ten years ago, when the follow-up was abandoned. Actually,body mass index was 16.5, hemoglobin, 8.6 g/dL and serum albumin, 2.7 g/dL. The passage of the endoscope through the distal esophagus was made impossible by the presence of an obstructive tumor, and undifferentiated carcinoma was confirmed by endoscopic biopsies submitted to anatomopathological and immunohistochemi-cal studies. On the contrast-enhanced radiographs, extensive tumor was seen from the distal esophagus, and PET-CT showed the tumoral mass and several compromised lymph nodes, in addition to evidence of hepatic metastasis. Due to the impossibility of endoscopic passage of transtumoral prosthesis or even of nasoenteric alimentary tube, gastrostomy was performed in the excluded stomach by videolaparoscopy. Patient was forwarded to chemotherapy (docetaxel and vinblastine) after a multidisciplinary consensus Results: The patient remains alive eighteen months later, receiving immunotherapy with pembrolizumab and maintaining a regular quality of life index (whoqol-old 3.9). The cancer decreased in size, liver metastases also regressed, and the ganglia disappeared

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Conclusion(s): Because many of these patients have ongoing regurgitation, surveillance endoscopies seem to be mandatory to avoid too late diagnosis of associated esophagogastric cancer. However, even in cases of inoperable cancer, chemotherapy, immunotherapy and feeding can keep them alive and with a regular quality of life Keyword(s): esophageal cancer , bariatric surgery, endoscopy

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Significance of Glasgow Prognostic Factor in Stage IV Colorectal Cancer

Kosuke Fujimoto, Fumikazu Koyama, Hiroyuki Kuge, Takayuki Nakamoto, Shinsaku Obara, Yosuke Iwasa, Takeshi Takei, Tomomi Sadamitsu, Suzuka Harada, Masayuki

Sho


Background and Purpose: ystemic inflammation would have been proved to play a crucial role in promoting cancer progression and metastasis in colorectal cancer. The aim of this study was to clarify the significance of Glasgow Prognostic Score (GPS) as a prognostic factor in Stage IV colorectal cancer. Material and Methods: We retrospectively investigated the data from 175 patients with Stage IV colorectal cancer patients who diagnosed at our hospital between 2010 and 2018. The stage of the disease was based on the Third English edition of the Japanese Society for Cancer of the Colon and Rectum. The relationship between prognosis and clinical pathological factors including GPS was examined by univariate analysis and multivariate analysis. Moreover, we compared the prognosis of patients who underwent resection of the primary tumor and chemotherapy with that of patients who did not undergo resection or chemotherapy by dividing them into GPS 0,1 and GPS 2 groups, respectively. Results: Of a total of 175 patients with the median age was 67 years (range 23- 85years), 111 men and 64 women. The 3-year overall survival rates by GPS 0/1/2 were 36.8/27.9/23.5%, respectively. Patients in the GPS 0 and GPS 1 groups who underwent resection of the primary tumor and chemotherapy had a better prognosis than those in the non-resection and non-chemotherapy groups, but there was no significant difference in the GPS 2 group. In univariate analysis, age 67 years or older, liver metastasis H2/H3, peritoneal dissemination, CEA level more than 5.0, and GPS 2 were extracted as poor prognosis factors, and the same factors were extracted as independent factors in multivariate analysis. Conclusion(s): In Stage IV colorectal cancer, GPS may be a prognostic factor, suggesting that primary resection and chemotherapy may improve the prognosis in patients with GPS 0,1.

Keyword(s): colorectal cancer, Stage IV, GPS

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The Middle Rectal Artery Detected by Contrast-Enhanced Magnetic Resonance Imaging Predicts Lateral Lymph Node Metastasis in

Lower Rectal Cancer

Yosuke Iwasa, Fumikazu Koyama, Hiroyuki Kuge, Takayuki Nakamoto, Shinsaku Obara, Takeshi Takei, Tomomi Sadamitsu, Suzuka Harada, Kosuke Fujimoto,

Masayuki Sho


Background and Purpose: Lateral lymph node (LLN) metastasis is one of the leading causes of local recurrence in patients with lower rectal cancer. Unfortunately, no diagnostic biomarkers are currently available that can predict LLN metastasis preoperatively. Accordingly, we investigated the relationship between the middle rectal artery (MRA) detected by contrast-enhanced magnetic resonance imaging (ceMRI) and LLN metastases. Material and Methods: Data from 102 patients with lower rectal cancer who underwent surgery, and were evaluated by preoperative ceMRI, between 2008 and 2016 were reviewed retrospectively. Two expert radiologists evaluated the MRA findings. The diagnostic performance of MRA for LLN metastasis was evaluated by a multivariate analysis with conventional clinicopathological factors. Results: The MRA was detected in 67 patients (65.7%), including 32 (31.4%) with bilateral MRA and 35 (34.3%) with unilateral MRA. The tumor size, presence of the MRA, and clinical LLN status were significantly correlated with LLN metastasis. A multivariate analysis demonstrated that the presence of MRA (P = 0.045) and clinical LLN status (P = 0.001) were independent predictive factors for LLN metastasis. Furthermore, the sensitivity and negative predictive value of MRA for LLN metastasis were 95% and 97.1%, respectively. Conclusion(s): We successfully demonstrated that MRAs could be clearly detected by ceMRI, and the presence of MRA robustly predicted LLN metastasis in patients with lower rectal cancer, highlighting its clinical significance in the selection of more appropriate treatment strategies. Keyword(s): rectal cancer, lateral lymph node metastasis, middle rectal artery

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Risk Factors for Stage Underestimation in Patients with cT1N0 Gastric Cancer

Tomohiro Kunishige, Sohei Matsumoto, Kohei Wakatsuki, Hiroshi Nakade, Shintaro

Miyao, Takanari Tatsumi, Akinori Tsujimoto, Masayuki Sho


Background and Purpose: Although radical gastrectomy with D2 lymph node dissection has been utilized as a standard procedure for gastric cancer, gastrectomy with D1/D1+ lymph node dissection and function-preserving gastrectomy are generally performed in clinical T1N0 disease. Therefore, An accurate preoperative staging is essential to perform such surgical procedure safely. The aim of this study was to identify risk factors for stage underestimation in clinical T1N0 gastric cancer. Material and Methods: This study reviewed the medical records of 566 patients who underwent gastrectomy for clinical T1N0 gastric cancer between 2001 and 2017 in Nara Medical University Hospital. A multivariate analysis was performed to determine the risk factors for stage underestimation. Results: The tumor stage was underestimated in 122 (21.6%) patients. The overall survival rate was significantly lower in patients with pathological stage II (P = 0.034) and III (P = 0.001) than in patients with pathological stage IA. In the multivariate analysis, the location of the upper third of the stomach (P = 0.039), tumor size of 30 mm or greater (P <0.001), undifferentiated adenocarcinoma (P = 0.001) and clinical tumor depth of SM (P = 0.002) were identified as independent risk factors for pathological stage II and III. The rate of the pathological stage II and III was 0% in patients with no risk factor, 3% in one risk factor, 10.5% in two risk factors, 19.8% in three risk factors and 50% in four risk factors. Conclusion(s): Location, tumor size, undifferentiated adenocarcinoma and clinical tumor depth were independent risk factors for pathological stages II and III in clinical T1N0 gastric cancer. Surgical procedure should carefully be determined in patients with multiple risk factors for stage underestimation. Keyword(s): gastric cancer, stage underestimation

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Development of a miRNA Panel for Predicting Clinically-Relevant Pancreatic Fistula After Distal Pancreatectomy

Satoshi Nishiwada, Kenji Nakagawa, Minako Nagai, Taichi Terai, Shunsuke Doi,

Yasuko Matsuo, Satoshi Yasuda, Daisuke Hokuto, Takahiro Akahori, Naoya Ikeda, Masayuki Sho

Nara Medical University, Japan

Email: [email protected] Background and Purpose: Clinically relevant postoperative pancreatic fistula (CR-POPF) is an important cause of post-operative morbidity and mortality following pancreatic surgery. Despite the advances in surgical techniques, the incidence of CR-POPF after distal pancreatectomy (DP) still ranges between 10-30 %. Since it requires immediate interventions, development of a risk-predictive models for CR-POPF have been investigated. Herein, we for the first time, performed a genome-wide analysis to identify a miRNA panel for the prediction of CR-POPF after DP. Material and Methods: We analyzed a total of 241 non-cancerous normal pancreatic tissues from patients who underwent DP. This included a cohort of 45 patients (7 with/38 without CR-POPF) that were subjected to small RNA sequencing for the identification of miRNA panel, as well as 196 patients from two independent clinical cohorts. The predictive performance of the miRNA panel was independently validated in two clinical cohorts (training cohort: n = 93; 9 with/84 without CR-POPF, validation cohort: n = 103; 14 with / 89 without). Results: The small RNA sequence profiling from CR-POPF positive and negative patients following DP led to the identification of a miRNA panel for the prediction of CR-POPF. Using logistic regression analysis, we optimized and trained a 6-miRNA panel in the training cohort, which robustly discriminated patients with CR-POPF (AUC: 0.91). Subsequently, the performance of this panel was successfully validated in an independent validation cohort (AUC: 0.76). Most importantly, in multivariate analysis including conventional clinical factors, the panel emerged as an independent predictor for CR-POPF in both cohorts (P < 0.01, < 0.01). Conclusion(s): We identified a novel miRNA panel that predicts CR-POPF following DP. Such a biomarker panel is of important clinical significance for risk-stratification

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and selection of more appropriate patient managements and designing future genome-guided prospective clinical trials. Keyword(s): miRNA panel, clinically-relevant pancreatic fistula, distal pancreatectomy, small RNA sequencing

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Body-first Approach of Laparoscopic Cholecystectomy: A Safety Technique to Avoid Biliary Injury

Rei Ogawa, Yasuji Seyama, Mikiya Takao, Keigo Tani, Hiroko Okinaga

Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital,

Japan Email: [email protected]

Background and Purpose: Difficulty of laparoscopic cholecystectomy (LC) for acute cholecystitis increases as time passes from onset. Although Tokyo guidelines 18 recommends LC performed within 96 hours for acute cholecystectomy, LC is often needed even during a period of strong inflammation depending on situation. We introduce a safe technique of LC named “body-first approach” for acute cholecystitis with an operative video. Material and Methods: A patient is 83-years-old female. She diagnosed with acute cholecystitis and LC was recommended. She and her family refused surgery at that time and underwent percutaneous transhepatic gallbladder drainage (PTGBD). PTGBD was successfully performed. However, continuation of drainage became difficult due to deterioration of delirium, therefore, we decided to perform LC on 6 days after PTGBD. Results: Adhesion among gallbladder and greater omentum was divided. After bilateral serosal incision, we started division between dorsal part of gallbladder and gallbladder bed from right side. Border of Subserosal layer inner and outer have obscured by inflammation. We proceeded division on external layer of subserosal layer outer from right side and left side, and successfully encircled the gallbladder body with tape. As traction of the tape improved development of Calot`s triangle, cystic duct and cystic artery were safely exposed and divided under securing critical view of safety. The specimen was resected after dissection of gallbladder bed. Operation time was 2:41, amount of blood loss was 20g. Conclusion(s): Body-first approach of LC is effective and safety technique to avoid biliary injury for acute cholecystitis with strong inflammation.

Keyword(s): laparoscopic cholecystectomy, acute cholecystitis

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Central Pancreatectomy for Pancreatic Cancer

Taichi Terai, Kenji Nakagawa, Satoshi Nishiwada, Minako Nagai, Takahiro Akahori, Naoya Ikeda, Masayuki Sho


Background and Purpose: Recently, Central pancreatectomy (CP) are generally indicated as a pancreatic function-preserving procedure for benign or low-grade tumors. In our institution, we have performed CP for limited cases of pancreatic cancer. We report 4cases of pancreatic cancer treated with CP. Material and Methods: Of the 199 patients who underwent pancreatic resection after NACRT for pancreatic cancer from January 2008 to March 2017, 4 patients who underwent CP were enrolled. The indication for CP was limited to those in which the lesion was located the body of pancreas and was cT1 (UICC 8th). The pancreatic resection margins and lymph nodes were negative on intraoperative pathological examination. Results: The median operation time and the amount of blood loss were 239 minutes (161-288 minutes) and 13 ml (10-35 ml), respectively. Postoperative complications were Grade BL pancreatic fistula in 1 case, but there were no complications of Clavien-Dindo classification IIIa or higher, and the median postoperative hospital stay was 12 days (10-15 days). Postoperative adjuvant therapy could be completed in 3 cases. Lymph node recurrence was found near the left renal artery 17 months in 1 case. All 4 cases are alive to date (median 57 months: 18-68 months). Conclusion(s): With strict patient selection performed, CP could be a surgical procedure that can achieve curative treatment for pancreatic cancer. Keyword(s): central pancreatectomy, pancreatic cancer

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Optimal Pancreatodigestive Anastomosis for Laparoscopic and Robotic Pancreaticoduodenectomy

Aleksandr Petrovsky, Vladimir Lischishin, Aleksandr G. Barishev, Aleksey

Lischenko, Arsen Y. Popov, Denis Zamsha, Vladimir A Porhanov

Ochapovsky Regional Clinical Hospital № 1, Russia Email: [email protected]

Background and Purpose: To evaluate the reproducibility and safety of the patented pancreatic-gastric anastomosis technique formed with various surgical approaches during pancreaticoduodenectomy. Material and Methods: The experience of surgical treatment of 47 patients with malignant neoplasms of the periampullary zone, who underwent pancreaticoduodenectomy, was considered. The proposed pancreaticpgastrostomy was performed to 14 patients (29.8%): in 7 cases with a minimally invasive approach to perform pancreaticoduodenectomy; and in 7 cases with an open, laparotomic approach. The retrospective study was performed to compare 33 (70.2%) patients with pancreaticogastrostomy according to the Bassi technique, formed after pancreaticoduodenectomy by various approaches: 9 minimally invasive and 24 open procedures. When evaluating the results of surgeries, the following were taken into account: the frequency of pancreatic fistula occurrence, the need and number of repeated interventions, postoperative in-hospital mortality. Results: In the open surgery group, the new anastomosis showed a statistically significant advantage in terms of operative time compared to the Bassi technique. There were no significant differences in blood loss with different types of anastomoses (p> 0.05). When using the proposed technique, both in the minimally invasive and in the open version, the formation of pancreatic fistulas was not revealed. The development of postoperative complications in the form of pancreatic fistula was observed in 4 patients after open surgery (16.7) and in 7 patients (77.8%) after minimally invasive approach according to the Bassi technique. Repeated interventions were performed after open surgery in 3 patients (12.5%) and in 4 patients (44.4%) who had minimally invasive surgeries surgery according to the Bassi technique, respectively. There were 2 deaths (22.2%) in the miniinvasive group.

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Conclusion(s): The proposed pancreaticogastroanastomosis technique is suitable for further application in clinical practice. This method is reliable, relatively fast and less challenging, including but not limited to a minimally invasive approach. The use of this technique makes it possible to reduce mortality and the number of postoperative complications in case of a "complex" pancreas. Keyword(s): Pancreaticoduodenectomy, Pancreatogastrostomy, Postoperative pancreatic fistula

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A Study on the Effectiveness of Preventive Measures for Pressure Injuries Administered in the Operating Room During General

Surgery

Chiung-Fun Chang, Fang Wang, Hui-Lin Lin


Background and Purpose: Pressure-related injury prevention is an important indicator of clinical care, as patients with pressure injuries may experience pain, extended hospitalization, increased nursing care hours, and medical costs; in 2019, the rate of postoperative pressure injuries among general surgery patients in the operating room was 2.85%, an analysis of the causes revealed that only 63% of preoperative pressure injury preventive measures were implemented by nurses in operating room. The purpose of this study is to investigate the effectiveness of preventive measures implemented by operating room nurses on general surgical patients to prevent pressure injuries. Material and Methods: The study was conducted as a retrospective study, with a total of 3,935 general surgical patients from a medical center in 2020 for the incidence of pressure injuries. Results: Pre-operative screening was conducted using the Pressure Injury Assessment Scale, and for high-risk surgical patients, measures were given to (1) maintain the flatness of the surgical bed, (2) reduce the pressure of non-essential equipment and piping, (3) reduce non-essential movement to minimize friction, (4) prevent the formation of humidity, (5) appropriate application of pressure-reducing aids, and (6) special protective measures for each surgical position. After implementing the preventive measures related to pressure injury, the completion rate of measures aimed at preventing pressure injury by operating room nurses increased from 63% to 94%, while the incidence of pressure injury in patients after general surgery decreased from 2.85% to 2.51%. Conclusion(s): Inclusion of pressure injury prevention measures in operating room education and training as well as implementation of protective measures can reduce the incidence of pressure injury and promote patient safety.

Keyword(s): Surgery, General Surgery, Pressure Injury

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Factors Related to Incisional Hernia Recurrence - A Tertiary Center's Experience

Kai-Hsing Chang, Chi-Chuan Yeh


Email: [email protected] Background and Purpose: Incisional hernia is a significant complication after abdominal surgery. The recurrence after incisional hernia repair also costs patient’s life quality. However, the current surgical intervention to incisional hernia varies and there is no clear guideline so far. We analyzed the incisional hernia repair performed in National Taiwan University Hospital (NTUH) in recent 3 years to find the factors influence the outcomes after incisional hernia repair. Material and Methods: We retrospectively collected the patients who had received ventral incisional hernia repair in our institution since January 1st, 2016 to December 31st, 2018. The patients’ demographic, surgery data, and the outcome, including recurrence and complication were analyzed. Results: A total of 227 patients were included. Among them, 172 patients (75.8%) received incisional hernia repair with mesh. The average follow up time was 19.05 month. The recurrence rate was 30.4%. The postoperative complication rate was 16.3%. The average time since incisional hernia repair to recurrence was 11.68 months. We compared the mesh and suture group, and the mesh group showed significant lower recurrence rate (26.7% vs 41.8%, p=0.034) and higher postoperative complication rate (19.2% vs 7.3%, p=0.037). As for the location of mesh, the sublay mesh showed no significant difference in recurrence rate when compared to onlay mesh (20.0% vs 25.9%, p=0.454). Meanwhile, the synthetic mesh showed trend of less recurrence rate, though not significant, when compared to biological mesh. (13.5% vs 35.7%, p=0.055). Conclusion(s): The mesh placement in incisional hernia repair showed lower hernia recurrence rate and higher postoperative complication rate in our study. Further research is necessary to find the long term outcomes and its relation to patient’s demography and the method of surgical intervention. Keyword(s): Incisional hernia, Recurrence, Mesh

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Establishing the Dynamic Information System of Cancer Medical Records

Ying-Lun Chen, Ching-Ping Liu, Shou-Hui Hsu, Ying-Lun Chen

MacKay Memorial Hospital, Taiwan

Email: [email protected] Background and Purpose: Hospitals actively cooperate with the Ministry of Health and Welfare (MOHW) to promote electronic medical records, which can facilitate medical teams to better understand the status of patients’ disease treatment through the electronic medical records. However, because all medical records have been scattered in various information systems and input at different time points, which inevitably lowers the willingness of physicians to fill in records regularly, the completion rate of medical record review is thus quite low.To allow the medical teams to simplify the difficulty of cancer medical record inquiry and reduce the query time. Material and Methods: We established a dynamic information system of cancer medical records, used ICD-10 to conduct the required examinations, treatment plans, treatment histories, and the related side effects, and collected all data chronologically using the same platform. Results: Following establishing the dynamic information system of cancer medical records, the completion rate of hospital’s medical quality review increased from 72% to 87%, physicians’ satisfaction reached 84.2%, and the review of completion for each medical record saved 30 minutes in average. Conclusion(s): Since medical teams can check patients’ relevant treatment information more efficiently using our newly established information system when treating patients, they can provide immediate responses to patients’ questions, and thereby improve the quality of medical services and the completeness of medical records. Keyword(s): the dynamic information system of cancer medical records, cancer medical record inquiry, quality review of cancer medical records

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Peri-liver Transplantation Nursing Experiences in a Cirrhotic Patient with Hemodialysis-Related Hepatitis C Virus Infection

Ching-Yi Chen

Tungs’ Taichung MetroHarbor Hospital, Taiwan

Email: [email protected] Background and Purpose: This article described that the perioperative nursing experiences for a 63-year-old female patient who underwent living-donor liver transplantation who was infected with hepatitis C related liver cirrhosis when she received hemodialysis under long-term dialysis and unwilling to burden family members. We hoped that the case can go through the operation safely and smoothly. We maintained and provided the individual needs of the case and her family during the period before, during and after the operation.To achieve the goal of care for the whole period of the operation, we expected that the experiences of nursing care in this case to share with others. Material and Methods: We use Gordon's eleven health function assessment guidelines to establish questions through interviews, observations, physical assessments, and participation in surgery to collect data. "Anxiety before surgery" is evaluated by the Mood Thermometer Simple Health Scale. We use listening skills, listening to music, abdominal breathing, and essential oil aroma to transfer anxiety. "Potentially dangerous injuries" :we use aseptic prevention of infection, and we ensure the safe use of the instrument and we avoid foreign bodies remaining in the body , "Acute pain" application measures: relaxation techniques, support pain and "acute confusion" improvement includes: reducing noise, getting out of bed as soon as possible and familiar objects to help memory. Results: In BSRS-5, preoperative was ranked five. Potential damage was all identified and removed, and we checked his skin intact without foreign bodies remaining in vivo. In managing acute pain symptoms, pain scale changed from eight to three after our management. In perioperative period, his consciousness was clear without self-talking.

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Conclusion(s): The sense of trust allowed us to give him individualized physical cares and psychological supports, Therefore it was important to give preoperative psychological support and inform the surgical details, and home care after discharge was promoted by connecting integrated resources such as psychologists and hepatobiliary project managers. The goal of holistic health care was fulfilled. Between the receipts and donor patients, We often ignored the psychological and physical health of received. We suggest to care the donor patients more detailly. Keyword(s): Living Donor Luver Transplant, Perioperative nursing, Liver cirrhosis, Dialysis, Htpatitia c

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Response and Safety of the Bevacizumab-awwb in Patients with Metastatic Colorectal Cancers: A Single Surgical Oncology Team

Experience

Chou-Chen Chen, Joe-Bin Chen

Taichung Veterans General Hospital, Taiwan Email: [email protected]

Background and Purpose: Anti-vasculoendothelial growth factors has been used to metastatic colorectal cancers with relative better progression-free survival and overall survival since 2004.There are three kinds of anti-VEGFs applied for mCRC, they are bevacizumab, aflibercept, and ramucirumab. But the accumulated clinical experience of bevacizumab has been well documented by many journals, its relative high price impaired the budget of reimbursement application in Taiwan, also in many nations. Therefore, bevacizumab-awwb become a cost-effective target therapy, but it’s extrapolation was still a problem. Thus, we would like to present our real world experience of bavecizumab-awwb to understand response rate and safety for mCRC patients. Material and Methods: We collected patients in mCRC from May, 2020 up to September,2021 received bavecizumab-awwb, recorded sex and age, the primary colorectal cancers location, primary tumor resection or not, metastatic-organ resection, chemotherapy backbone, response condition, and possible adverse effect. Results: We had 20 patients received bavecizumab-awwb , median age 58, male:female= 10:10, 17 patients in left side colon ( 85 %) and 3 patients in right side ( 15 %), 19 patients received primary mCRC resection (95 %) ,only one not .There are 6 patients received mets-organ resection (30%) , and chemotherapy are 14 patients with FOLFIRI , 3 patients with FOLFOX and 3 patients with oral regiment. There are 5 patients with stable disease, 13 patients with partial response, response rate was 90%, disease control rate was 65 % .The median treatment of duration was 5.5 months. Five patients switched from bavecizumab to bavecizumab-awwb revealed similar outcomes. Conclusion(s): Bavecizumab-awwb launched to provide an additional ,economic choice, efficacy and more affordable option to improve mCRC patient treatments. From our clinical experience, patients tolerate Bavecizumab-awwb very well and their

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treatments had acceptable response and less adverse effect, and the clinical treatment is still ongoing. Keyword(s): Mvasi, Bevacizumab-awwb, Metastatic , Colorectal , Response

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Periostomy Bullous Pemphigoid With Generalized Progression in Older Colon Cancer Patient

Chou-Chen Chen1, Chen-Yu Tsai2, Joe-Bin Chen1, Pin-Chuan Yao2

Taichung Veterans General Hospital, Taiwan1, Dayeh University, Taiwan2

Email: [email protected] Background and Purpose: Periostomy dermatitis was taken reason of skin erythematous change and epidermis irritation around colostomy or enterostomy wound. Bullous Pemphigoid would cause large and fluid-rich blisters at abdomen, and extensor side of trunk, and most common in older adult. Periostomy bullous pemphigoid is rare blister around ostomy in patient with colorectal cancer, that physician might mistake as dermatitis.We reported a rare case of periostomy bulloud pemphigoid. Material and Methods: This is a 84y/o male patient has a S-colon carcinoma obstruction, he received emergent Hartmann procedure. Pathology revealed T4aN1bM0 . Postoperative outpatient follow up is smooth until peri-ostomy skin lesion happened .The patient had multiple bullous erythematous painful sensation around end colostomy 17 months later, and he visited other physician taken NSAID medication or anti-histamine without significant improvement. The bullous skin lesion progressed to both sides of abdomen, face, upper arm. We arranged admission for ostomy care and consult dermatologist. Results: After consultation, dermatologist’s diagnosis was bullous skin disease , it was not usual common peri-ostomy allergy problem, they performed skin biopsy, and lesion had subepidermal blister formation containing numerous eosinophils, and superficial perivascular lymphoeosinophilic infiltration in the dermis, concluded as bullous pemphigoid. The patient received imuran 50mg QD , prednisolone 20 mg QD, and topical ointment 10g-Clobetasol cream. The general skin lesion got better and better after treatment 5 months later. Conclusion(s): Periostomy Bullous pemphigoid could be mistaken as dermatitis. We need more attention to treat in older adult patient with colorectal cancer. Keyword(s): Bullous pemphigoid, dermatitis , periostomy, colon , cancer

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The Effect of Maintaining Body Temperature During the Laparoscopic Surgery

Yu-Ting Chen, Ya-Ling Shen, Yen-Hua Huang


Email: [email protected] Background and Purpose: For patients receiving general anesthesia, maintaining a normal temperature is a necessity. Studies have suggested that about 50%-90% of surgical patients might have unexpected hypothermia every year. Hypothermia can lead to delay of patients’ recovery from anesthesia uncomfortable, increased surgical wound infection rate, comorbidities, hospital costs, and the risk of death. Our medical center noticed that many patients undergoing laparoscopic surgery had hypothermia. However, most of the studies so far have focused mainly on hypothermia during laparotomy surgery. For this reason, we want to know patients received laparoscopic surgery under general anesthesia whether causes body temperature changes when we used hot air blanket as an intervention. Material and Methods: The study population consisted of patients who underwent laparoscopic surgery performed by a medical center in North Taipei City Hospital from July 2020 to June 2021. The study is Quasi-experimental research, in which patients were divided into two groups. The research group had 34 patients and 62 patients were in the control group. Patients in the research group used hot-air warm blankets during the surgery and in the recovery room. We conducted an analysis by using patients’ data including patients’ basic information, surgery time, anesthesia ASA evaluation, Aldrate score, and measuring the body temperature before and after in recovery period. Results: The current results showed that the incidence rate of hypothermia in the research group was 8.82%, which was lower than the control group that had 14.52%. Furthermore, the research group and the control group had significant differences among body temperature, surgery time, and anesthesia ASA assessment. Conclusion(s): We concluded that maintaining body temperature during laparoscopic surgery is as important as in laparotomy surgery. Moreover, we suggested conducting pre-assessment of relevant variables before performing laparoscopic surgery and development of equipment which can maintain body temperature, such as a gas-

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warming system, could be added to reduce the rate of hypothermia after surgery, improve the care quality and increase patient comfort. Keyword(s): hypothermia, laparoscopic surgery, gas warming system

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ACLY Inhibitors Induce Apoptosis and Potentiate Cytotoxic Effects of Sorafenib in Thyroid Cancer Cells

Shih-Ping Cheng1, Chi-Yu Kuo1, Yi-Chiung Hsu2, Chien-Liang Liu1

MacKay Memorial Hospital, Taiwan1, National Central University, Taiwan2

Email: [email protected] Background and Purpose: ATP-citrate lyase (ACLY) is a critical enzyme at the intersection of glucose and lipid metabolism; we aimed to explore the possibility of utilizing ACLY inhibition as a new strategy in the treatment of thyroid cancer. Material and Methods: Bioinformatic analysis of public datasets was performed. Thyroid cancer cell lines were treated with two different ACLY inhibitors, SB-204990 and NDI-091143. Results: Bioinformatic analysis revealed that ACLY expression was increased in anaplastic thyroid cancer. ACLY expression in The Cancer Genome Atlas thyroid cancer database was positively correlated with epigenetically regulated mRNA stemness index. In thyroid cancer cell lines FTC-133 and 8505C, ACLY inhibitors suppressed monolayer cell growth and clonogenic ability in a dose-dependent and time-dependent manner. Flow cytometry analysis showed that ACLY inhibitors increased the proportion of sub-G1 cells in the cell cycle and the number of annexin V-positive cells. Immunoblotting confirmed caspase-3 activation and PARP1 cleavage following treatment with ACLY inhibitors. Compromised cell viability could be partially rescued by co-treatment with the pan-caspase inhibitor Z-VAD-FMK. Additionally, we showed that ACLY inhibitors impeded three-dimensional growth and cell invasion in thyroid cancer cells. Isobolograms and combination index analysis indicated that ACLY inhibitors synergistically potentiated the cytotoxicity rendered by sorafenib. Conclusion(s): Targeting ACLY holds the potential for being a novel therapeutic strategy for thyroid cancer. Keyword(s): ATP-citrate lyase, apoptosis, thyroid cancer

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The Effectiveness of Applying Situational Simulation Teaching Strategies on Reducing Sharp Injuries among Medical Staffs in the

Operating Room

Sih-Yu Guo, Fang Wang, Hui-Lin Lin


Background and Purpose: The research was designed for the discussion of the effects of relevant interventions on preventing injuries from sharp substances of doctors and nurses in operating room by the application of situational simulation teaching strategies. Material and Methods: This study was conducted in a retrospective manner. 77 cases, which were with injuries from sharp substances of doctors and nurses, reported in “Report on Occupational Disaster Caused by Sharp Substances and Instruments” issued in 2019 by a medical center were investigated and analyzed in a statistical way. Results: Based on the analysis of current situation as well as the application of situational simulation teaching strategies, the relevant measures to prevent injuries from sharp substances for doctors and nurses in the operating room taken by the medical center includes: (1) Design the neutral zone and indirect tool transfer of situational simulation teaching to improve correct cognition; (2) Simulate the dangerous acts likely to lead to injuries from sharp substances and conducting repeated demonstration teaching; (3) Shoot the teaching videos of preventing the injuries from sharp substances and establishing multimedia teaching database; (4) Organizing surgical animal workshop camp; (5) Establish the standard specifications for the prevention of injuries from sharp substances of doctors and nurses and treatment of sharp substances; (6) Hold the case discussions regularly; (7) Establish a sustainable process improvement mechanism. After the intervention, the result showed that the cases of injuries from sharp substances reduced from 77 in 2019 to 70 in 2020, especially surgeons, dropped from 54 cases to 45 cases, a decrease of 16.6%. Conclusion(s): Sharp injury prevention is important to front-line medical personnel. The intervention of the preventive measures proposed in this study can effectively reduce the occurrence of sharp injuries. We suggest that the prevention of sharp injury should be included in the education and training content of the operating room. To ensure the workplace safety of medical staff in the operating room.

Keyword(s): Sharp injuries, Needle stick, Situational simulation teaching

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Improving the On-Time Rate of The Daily First Surgery in a Regional Hospital

Miao-Qin Hong, Shu-Wen Yang, Meng-Ling Chung

Tung's Taichung MetroHarbor Hospital , Taiwan

Email: [email protected] Background and Purpose: The on-time rate of the first surgery in our operating room in the first quarter of 2020 was in an average of 84.43%, as compared with the average of 85.72% in the fourth quarter of 2019. The decrease in the on-time rate is due to the failure of the first surgery reaching the operating room on schedule and the subsequent delay in operation time. This situation leads to a decline in the utilization of operating rooms and an increasing hospital cost. Therefore, the objective of this study to establish a systemic protocol to improve the on-time rate of the daily first surgery with an inter-professional team. Material and Methods: According to the analysis of the current data, the main reasons of delaying the operation included the defective surgical scheduling system, inefficient patient transportation, and insufficient manpower. For example, there was no particular elevator for transporting patients which leads to a traffic jam for the surgery schedule. Results: With the cooperation of inter-professional surgery teams, the implementation of countermeasures improved the setting of the surgical scheduling system. Moreover, the new delivery tools helped staffs to transport patients in an efficient way with special ladders. Besides, the human resource increased more manpower to support patient transportation during a rush hour. Therefore, the on-time rate of the first surgery was improved from 80.81% to 92.09%. Conclusion(s): Improving the on-time rate of the daily first surgery effectively reduced the waiting time of patients, increased the utilization rate of operating rooms, and lowering the overtime rate of nursing staff. Our outcomes are enhancing the surgery team's efficiency and the quality of medical care. Keyword(s): operating room, first operation , punctuality rate

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Muscle Repairing Effects of Glutamine and Leucine Administration in Sepsis-induced Myopathy

Yu-Chen Hou1, Yu-Chen Hou1, Man-Hui Pai1, Jin-Ming Wu2, Po-Jen Yang2, Po-Chu

Lee2, Ming-Hsun Wu2, Kuen-Yuan Chen2, Chun-Chieh Huang2, Ming-Tsan Lin2

Taipei Medical University, Taiwan1, National Taiwan University Hospital, Taiwan2 Email: [email protected]

Background and Purpose: Sepsis is a severe systemic inflammatory response caused by extreme infections, commonly seen in critically ill patients. Despite the high mortality, abundant evidence indicates that many sepsis survivors suffer from myopathy, characterized by erosion of muscle mass and muscle weakness. Sepsis-induced myopathy is linked to excessive local accumulation of proinflammatory cytokines and free-radicals, increasing enzymatic protein breakdown but suppressing muscle regeneration. Glutamine (Gln) has been found to have immunomodulatory, anti-inflammatory and anti-oxidative properties in catabolic conditions. Leucine (Leu) is an essential amino acid that has been proved to enhance protein synthesis and suppress proteolysis in skeletal muscles. In this study, we propose to investigate the effect of Gln and/or Leu administration on sepsis-induced myopathy. Material and Methods: Eight-week-old male C57BL/6J mice were divided into one sham control (C) group and four septic groups which underwent cecal ligation and puncture to induce polymicrobial sepsis. Septic mice were given a daily intraperitoneal injection of Gln (G), Leu (L), or Gln combined with Leu (GL) whereas mice in the C group and the septic control (S) group received identical amount of saline. All mice were sacrificed at day 4 post operation and skeletal muscle tissues were collected for analysis. Results: Body weights were decreased in all septic mice. Compared to the S group, M2 macrophage population in the skeletal muscle was elevated in both G and GL groups without affecting M1 macrophages. Muscle calpain activity was also inhibited in the G and GL groups whereas lipid peroxidation was not affected in the muscle of amino acid treated groups. Muscle expressions of tumor necrosis factor-α and interleukin-1β mRNA were suppressed by amino acid administration, and MyoD and Myog mRNA expressions were elevated in the G and L groups, respectively.

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Conclusion(s): These results suggested that septic mice treated with Gln and/or Leu could attenuate inflammation, reduce proteolysis and promote muscle regeneration in skeletal muscles, which may have beneficial effects on muscle repair. Keyword(s): skeletal muscle, M2 macrophage, inflammation, calpain, muscle regeneration

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Examining the Differences of Pain Management Issues between Patients with Gastrointestinal and Non-gastrointestinal Cancer

Diagnoses

Pei-Yi Hsu1, Chiou-Fang Liou2, Yu-Hsuan Shih3, Cheng-Wei Chou3

Taichung Veterans General Hospital/Chung Shan Medical University, Taiwan1, Chung Shan Medical University, Taiwan2, Taichung Veterans General Hospital,

Taiwan3 Email: [email protected]

Background and Purpose: Cancer has been the first leading cause of death for 30+years in Taiwan. Both incidences and mortality rate are high among patients with Gastrointestinal cancer diagnoses, such as pancreatic cancer and colon cancer. About 60%-90% patients with cancer have reported pain experience. These patients tend to have a negative emotional response to a poor pain management. Experiencing pain has a unique meaning to patients with cancer diagnoses. In addition, patients with various cancer diagnoses also have difference interpretation of their pain experience. For example, pain experience for patients with Gastrointestinal Cancer diagnoses often cause by much more complex etiologies. With a thorough pain assessment, the clinicians will provide a sophisticated and unique pain management plan. It is therefore important for nurses have a in depth understanding what does pain experience mean to patients with cancer diagnoses. The research questions are :will experiencing pain has a different meaning between patients with Gastrointestinal and non-Gastrointestinal cancer diagnoses? Material and Methods: After IRB approval, this cross-sectional exploratory study has taken place in both in-patient and out-patient settings at a Medical center in Middle Taiwan since 2020/11. Up to date, we recruit a total of 98 patients with cancer diagnoses experiencing cancer pain. 59 of them were diagnosed with Gastrointestinal cancer. Survey questionnaires, pain inventory with VAS on most severe, most easy and most of time while experiencing pain, along with the Perceived Meanings of Cancer Pain Inventory consisting of loss, threat, challenge, and spiritual awareness, were employed one time. Results: To prevent type I error from multiple uses of independent t-test, the statistical method, one-way ANOVA with multiple outcomes, pain inventory and 4 dimensions

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of Perceived Meanings of Cancer Pain Inventory was employed to compare the differences between patients with Gastrointestinal and non-Gastrointestinal cancer diagnoses. Results indicated that the experience of pain was not different between the two groups. However, experiencing pain as a challenge has a higher meaning in the patients with Gastrointestinal cancer, p=0.02. Conclusion(s): The protocol for pain assessment and management should take patients’ perceived meaning of cancer pain into consideration. Further investigation is recommended. Keyword(s): Chen,M.L(1999)Validation of the PMCPI, Gastrointestinal cancer, Pain management, Pain meaning

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A Rare Case of Unicentric Castleman’s Disease

Gaday Htay, Tzu-Hung Chen, Sheng-Chun Wang, Fur-Jiang Leu

Cardinal Tien Hospital, Taiwan Email: [email protected]

Background and Purpose: Castleman disease (CD) is a rare lymphoproliferative disease. The etiology and pathogenesis of CD are still unclear, making diagnosis difficult. CD was first described by Benjamin Castleman in 1954. There are two types of CD: unicentric CD (UCD) which involves a single enlarged lymph node or region of lymph nodes, and multicentric CD (MCD), which involves multiple lymph node stations. It is divided into three types: hyaline vascular type, plasma cell type and mixed type. UCD occurs most commonly in the mediastinum (70%), cervical regions (15%), and abdominal/pelvic cavity (12%). Mesenteric localization of UCD is relatively rare and a differential diagnosis between UCD and other disorders is very difficult to achieve. Material and Methods: A 52-year-old woman was admitted due to abdominal nodule found by radiologic examination without clinical symptoms. Her abdominal ultrasound taken 2 weeks ago before admission revealed a well-defined hypoechoic nodule about 1.8 x 1.4 cm in epigastric region. The subsequent abdominal CT showed a solid nodule about 2cm in subpyloric region. Physical examination was normal with no lymphadenopathy. The laboratory findings were unremarkable and tumor markers showed within normal limits. Results: The patient underwent a laparoscopic procedure and the intraoperative findings showed one 2cm tumor between gastric antrum and pancreas. Laparoscopic excision of the tumor was done. Histopathology revealed multiple nodules of lymphoid tissue with abnormal germinal centers separated by hypervascular interfollicular tissue. The lymphoid nodules contain concentric arrangement of small lymphocytes, small germinal centers depleted of follicular central cells, and penetration by hyalinized vessels. Immunochemistry study showed CK -, CD3 ++, CD20+++, CD5 +, CD23 +, CD10 -, Bcl-2 +++ and Bcl-1 -. The final diagnosis was unicentric Castleman’s disease, hyaline-vascular subtype. Conclusion(s): Unicentric Castleman´s disease is a diagnostic challenge and it must be included in the differential diagnosis of intra-abdominal tumors. Preoperative diagnosis

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is difficult due to a lack of specific radiologic markers and the poor performance of biopsy. Complete resection is the gold standard treatment for UCD. Further studies are needed to establish recommendation for the management of MCD. Keyword(s): Dispenzieri A, Fajgenbaum DC. Overview of Castleman disease. Blood. 2020 Apr 16;135(16):1353-1364. doi: 10.1182/blood.2019000931. PMID: 32106302., Castleman’s disease, Laparoscopy

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Improving the Skills of Perioperative Nurses to Perform Unexpected Cardiac Surgery

Chia-Ju Huang, Wan-Yu Chang, Wen-Hui Wang, Geng-Yao Chen, Li-Lin Kuo,

Hsueh-Chen Ku

MacKay Memorial Hospital, Taiwan Email: [email protected]

Background and Purpose: The professional skills of perioperative nurses affect the safety and quality of surgical patients. When facing unexpected heart surgery, the operation time may be increased due to lack of preparation of surgical materials and unfamiliarity to surgical procedures, which affect the safety of patients, working atmosphere of the surgical team and lowering the team spirit. Therefore, this programme aims to improve the skills of perioperative nurses who have been trained in cardiac surgery to perform unexpected operations of such flied. Material and Methods: In the preliminary questionnaire survey, the complete rate of performing unexpected cardiac surgery skills was only 50.1%, mean self-evaluated confidence scored 5.1 points out of 10, anxiety scored 8.1 points out of 10; the reasons included unfamiliarity to extracorporeal circulation procedures and instrument, complexity of equipment and materials which may increase the difficulty of manipulation, lack of experience and auxiliary tools to facilitate the procedures, etc. To improve the skills of nurses performing unexpected cardiac surgery, after discussion, possible solutions included customized cardiac surgery medical materials and equipment, detailed lists of physicians’ preference, visualized color-labeled instrument explicating operation procedures, substantial reward scheme, revised and updated education and training programme for new trainee, regular continuous medical education, processes surveillance, posters illustrating procedures for usage of extracorporeal circulation in brief, and teaching videos with QR code. Results: After implementing improvement plan, the completion rate of performing cardiac surgery skills increased to 93.7%, mean self-evaluated confidence increased to 8.1 points out of 10, and anxiety dropped to 6.4 points out of 10.

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Conclusion(s): Therefore, appropriate methods and incentive scheme can enhance the professional skills and self-confidence of perioperative nurses and can be served as an example for other hospital units with shared purpose. Keyword(s): perioperative nurse, cardiac surgery, learning outcome

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Using Situational Simulation Teaching to Improve the Learning Effectiveness of New Nurses in the Operating Room on the Cognition

and Skills of Laparoscopic Surgery

Yen-Hua Huang, Yi-Chien Lee, Hui-Lin Lin

National Taiwan University Hopital , Taiwan Email: [email protected]

Background and Purpose: Nurses in the operating room must have keen observation, resilience, and professional knowledge and skills. How to make quick and logical judgments and teamwork for new nurses to make the operation smooth and maintain patient safety, so new nurses have basic knowledge and skills are very important. Material and Methods: With 10 new nurses participants in 2020 to 2021, use situational simulation teaching to compile teaching plans. Before the activity, the teaching concept was simulated by the situation, leading the students to communicate and discuss with the team members and cooperate with each other. Before the activity, the cognition accuracy rate was 64.9%, the skills were only 70.1%, and the evaluation of the mind map. Results: After situational simulation teaching workshops, making mind maps and material preparation manuals for laparoscopic surgery, adding teaching aids for practice, constructing learning objectives and assessment forms, cognition increased to 96.3%, skills increased to 95.3%, and evaluation of the mind maps has a significant effect. Conclusion(s): It is recommended that the situational simulation teaching workshop can be extended to complicated procedures in the future, instead of traditional classroom lectures, and after the mind maps data is sorted, the knowledge of preoperative and postoperative review will be increased. Integration of abilities to enhance the professional knowledge and clinical skills of new nurses in the operating room. This article provides a reference for students, teachers, researchers and health care education trainers to encourage them to try new teaching and learning methods. Keyword(s): Situational simulation teaching , mind maps

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Effectiveness Analysis of Cleanliness Testing of Manual Cleaning Surgical Instruments

Yu-Ling Huang, Tsuey-Ru Lin, Bao-Hua Huang

NTUH, Taiwan

Email: [email protected] Background and Purpose: The pass rate of the cleanliness test of manual cleaning surgical instruments in our hospital in 2019 was 91.9%. Based on the analysis, the reasons are: Simplify the process by themselves when staff of central supply room are busy, Insufficient cleaning equipment, Manual cleaning equipment standard operation guidelines are not clear, Unfamiliar with the principles of manual cleaning of instruments, No relevant audit system, etc. which cause poor cleaning effect of surgical instruments. Therefore, the purpose of this study is to make the effectiveness analysis of the pass rate of instrument cleanliness testing after the personnel in the central supply room perform manual cleaning of surgical instruments. Material and Methods: To improve the quality of manual cleaning surgical instruments, supplemented by adenine triphosphate biofluorescence analysis to detect the pass rate of the cleanliness of manual cleaning instruments, the evaluation method is to clean the instruments once per week, and sampling inspection based on 8 pieces of manual cleaning instruments each time, to check the cleanliness with naked eyes, supplemented by Adenosine TriPhosphate (ATP), and the value of the test is less than 150RLU to pass. Results: Implementation of improvement measures related to manual cleaning of surgical instruments, including: (1) adjustment of working load, (2) re-planning of special cleaning equipment, (3) revision of standard operating guidelines for manual cleaning of instruments, (4) holding relevant education and training, (5) formulation with measures such as the audit system. With good results, the pass rate of manual cleaning equipment cleanliness testing has been increased from 91.9% to 95.8%, thereby ensuring the safety of surgical patients.

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Conclusion(s): The central supply room is responsible for the cleaning and sterilization of surgical instruments, providing sterile instruments to effectively prevent infection of the surgical site, which is an important core of infection control. If the equipment does not meet the cleaning standard, it will not only damage the normal function of the equipment, but also hinder the sterilization effect, which will affect the life safety of surgical patients. Therefore, this study can provide a reference for the cleaning quality management of equipment in various hospitals. Keyword(s): Surgical instruments, Adenosine TriPhosphate, Cleanliness of surgical instruments

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Use the Watson theory to perform Perioperative Nursing for Cases with Mastectomy and Immediate Reconstruction

Yun-Jhu Huang

Tungs' Taichung MetroHarbor Hospital, Taiwan

Email: [email protected] Background and Purpose: A 37-year-old woman who consciously had a lump on her right breast and went to the hospital for medical treatment.The diagnosis was third stage of breast cancer.The modified radical mastectomy on the right side and immediate reconstruction of the breast with deep inferior epigastric perforator flap were performed to reduce the impact of losing a breast. Material and Methods: Use the Maslow Pyramid Theory of Needs and the Baker Anxiety Scale to assess the needs of the patient, collect data and nursing evaluation according to the framework of perioperative nursing, and use the Watson theory as the conceptual basis of nursing measures providing nursing care for those who is undergoing breast reconstruction surgery because of losing their breast. Results: Use the Watson care theory to explain pre-operative preparations, surgical procedures, and post-operative care and health education to the patient, and build trust and provide relevant reference materials and resources to increase the sense of security through family strength and make the patient feel accompanied and supported. Using the Baker Anxiety Scale to assess the degree of anxiety of the patient was reduced from 25 points to 8 points during the preoperative visit. Conclusion(s): The preoperative visit revealed that the patient was anxious about the surgical procedure and breast reconstruction surgery, facing the operation was about to lose the femininity which had a great impact on the patients' psychosocial and triggered the motivating for discussion. With the Watson's theory and perioperative nursing, we provide continuous and comprehensive care to help alleviate anxiety about surgery and adapt to changes in body structure, so that the patient can return to the family as soon as possible and improve the quality of life. Hope to benefit from this nursing experience and colleagues Share it as a reference for care during the whole period of the perioperative nursing.

Keyword(s): Watson care theory, Mastectomy, Breast cancer reconstruction, Perioperative nursing, Mastectomy and immediate reconstruction surgery

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Arise the Preparation Rate and Handover Completion of Operation Professional Nurses in Living Donor Liver Transplantation

Operation

Cheng-Ting Ku, Luan Hsieh

Chi Mei Medical Center, Taiwan Email: [email protected]

Background and Purpose: In this hospital, there are less than 10 living donor undergoing liver transplant operations every year. If the staffs are not familiar with the operation procedure, will leads to incomplete preparation of the surgical and low completion rate of handover. Material and Methods: From January to December 2020, there are _5_patients who underwent living donor liver transplantation operation. The completion rate of preoperative preparation was only 87.2%. The completion rate of handover was 78.5%. Root cause analysis: too many surgical instruments are used, unfamiliar with surgical aseptic drape procedures, unfamiliar with surgical procedures, and lack of education and training. Results: Through the project implementation plan: 1. Make a checklist of instruments before surgery 2. Make a teaching videotape for aseptic surgery 3. Launch a training course of living donor liver transplantation procedures 4. Make a flow chart of surgical procedures 5. Make a handover card. After the implementation of the project, from January 2021 to August 2021, there are _4_patients underwent living donor liver transplantation. The completion rate of preoperative preparations increased to 100% and the completeness rate of handover increased to 98.6%. Conclusion(s): It reduces the preoperative preparation abnormalities effectively. Our staff can learn from multimedia and checklist through self-study. The patient’s condition should fully explain through the handover card, which not only improves their confidence, but also enhance patients’ safety throughout the operation. Keyword(s): living donor, operation professional nurses, liver transplantation operation, preparation rate , handover completion

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Using “Flipped Classroom Method” to Improve the Completely Prepare Rate for Nursing Staff During Operation of Mini-

PerCutaneous NephroLithotripsy (Mini-PCNL)

Cheng-Ting Ku

Chi Mei Medical Center, Taiwan Email: [email protected]

Background and Purpose: Completly preoperative preparation is closely related to the safety and success rate for the operation. In 2017, Chi Mei Medical Center introduced the hybrid operating room which equip integrating imaging technology. And surgeons can real-time locate the lesion that perform precise surgical resection or any interventional treatment. Material and Methods: From January to July 2018, total of 18 patients accept operation of mini-PCNL. The pre-operative preparation completeness rate was only 80.2%. The reasons for the analysis included: The nurse staff are not acquainted with surgical procedures, no standard peri-operative procedures, many surgical instruments and incomplete training for staff education. Results: From January to July 2018, total of 18 patients accept operation of mini-PCNL. The pre-operative preparation completeness rate was only 80.2%. The reasons for the analysis included: The nurse staff are not acquainted with surgical procedures, no standard peri-operative procedures, many surgical instruments and incomplete training for staff education. Conclusion(s): Through project implementation plan: 1. Production of pre-operative preparation checklist 2. Production of nursing staff multimedia teaching 3. Using flipped classroom method in education courses. After the project implementation, total of 43 patients accept operation of mini-PCNL since August to December 2018. The pre-operative preparation completeness rate increased to 98.3%. Keyword(s): mini-PCNL, flipped classroom method, Mini-PerCutaneous NephroLithotripsy , pre-operative

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A Perioperative Nursing Experience of a Flail Chest Patient with Locking Plate Fixation Surgery

Yu-Yen Kuo

CHi Mei hospital, Taiwan

Email: [email protected] Background and Purpose: Thorax protects the heart, lungs, blood vessels. If human body suffers severe impact, it may cause multiple fractures of the rib. Around 20% chest trauma patient caused by rib fractures and always combined with pneumohemothorax. Undergoing the locking plate fixation surgery can help the patient returning to normal life, investigating postoperative self-perception and reviewing respiratory effects. Material and Methods: Searching PubMed, Airiti library, and medical books as reference. Three keywords and articles which are within five years are used as criteria, seven articles are remained. Based on the perioperative nursing, major aspects such as physiology, psychology, society, and spirituality are used as for evaluation. Caring, listening, interviewing and referring to medical record are used in the evaluation process to conduct an overall evaluation to confirm the nursing problems before, during and after the operation. Then we establish our nursing goal and measures for evaluate the effectiveness. Results: There are three nursing problems during the perioperative nursing care: 1.Anxiety: listen and accept the patient’s opinion; the health problem with patient. 2.Injury: prepared appropriate surgical instruments, position and knowledge to prevent surgical hazards; 3.Pain: Build up a good relationship with the patient and discuss the appropriate pain control when acute pain occur. Recovery exercise is also important for them to get their life back to normal. Conclusion(s): This is the first case of our hospital. Therefore, I try to figure out the patient’s problems through preoperative visits. I draw up care plans and measures for the operation, and conduct an individual treatment for the patient with the medical team. Under our care, the patient has recovered from the operation. We suggest the operation

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room to design leaflets about these surgical care so that patients can understand the relevant knowledge easily. Also we believe establishing an on-the-job education can increase the professional nursing experience of staff and enhance the quality of care. Keyword(s): A Perioperative Nursing Experience, Flail chest patient, Locking plate

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Nursing Project of Improving the Completeness of Postoperative Pain Care in the Recovery Room

Chen-Ni Li

National Taiwan University Children Hospital, Taiwan

Email: [email protected] Background and Purpose: Postoperative pain is the most important health problem in recovery room. However, the lack of clear pain assessment guidelines make nurses often underestimate postoperative pain scores or use wrong pain assessment tools. In addition, when nurses conduct pain assessments, most of them don’t directly communicate with the patient. Therefore, the purpose of this project is to improve the completeness of postoperative pain care in the recovery room. Material and Methods: A descriptive cross-sectional study including questionnaires and observations were conducted to understand nurses’ knowledge, attitudes towards pain, and how they execute postoperative pain assessments in the recovery room. According to these results, we developed a series of intervention including formulating pain assessments steps, giving formal in-service education for pain assessments, modifying pain care checklists, and designing pain aid tools to improve the completeness of pain care. Results: The completion rate of postoperative pain care increased from 45.4% to 62.6%. (The goal is 89.1 %.). There are also some meaningful secondary results: The accuracy rate of pain knowledge increased from 78.5% to 83.3%. In addition, the overall analgesics concept and pain situation simulation of recovery room nurses improved from 46.2% to 90.0% and 47.7% to 73.3% respectively. Conclusion(s): Although the project did not achieve its goal, it continued make progress after the project has finished. The developed pain care checklist can be extended to other recovery rooms for pain assessment, teaching and evaluation. We are looking forward to improving the completeness of postoperative pain care in the recovery room, thereby improving pain care quality in recovery room. Keyword(s): postoperative pain care, pain assessment checklist, pain assessment tools , recovery room

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Improve Primary Caregivers to Perform Home Intravenous Nutrition Care

Chia-Yu Lin, Hisu-Chin Cheng, Hsin-Chieh Chou, Sin-Yi Chen

Kaohsiung Medical University Hospital, Kaohsiung Medical University, Taiwan

Email: [email protected] Background and Purpose: Patients with gastrointestinal cancer often have gastrointestinal obstruction and cannot eat by mouth, causing malnutrition. They need to use home intravenous nutrition therapy to provide good nutritional support and care. Material and Methods: 1. Using mobile devices, use multimedia pictures and videos to be played repeatedly according to needs and convenience, so that learners are deeply impressed. 2. Simulate the tools needed for the care process, make the home vein health education mold, and lead the actual operation drill. 3. Make a flow chart and written materials for health education, put common problem handling methods into the health education manual, and learn about home intravenous nutrition care through the manual. Results: The recognition accuracy rate of home intravenous nutrition increased from 69.6% to 100%. The correctness of home intravenous nutrition care is increased from 77.2% to 100%. Conclusion(s): In the later stage of treatment, cancer patients cannot obtain nutrition in a normal way. They must use home intravenous nutrition to maintain their vitality. The use of home intravenous nutrition care videos and simulated health education molds can reduce the occurrence of comorbidities and improve the quality of home intravenous nutrition care. Keyword(s): home intravenous nutrition care, gastrointestinal cancer

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Nursing Experience of a Rectal Cancer Patient Undergoing Surgery

Chiu-Hsun Lin

MacKay Memorial Hospital, Taiwan Email: [email protected]

Background and Purpose: This article describes taking care of a rectal cancer case, undergoing tumor resection and placement of the colostomy when admitted to the hospital. The nursing period is from August 21, 2019 to September 1, 2019. Material and Methods: The author used Gordon's 11-iteams functional health patterns assessments during the hospitalization of the case, and collected relevant information by direct nursing, observation, interview, listening, and medical record review. Results: The main nursing problems of the case were: anxiety, acute pain, body image disturbance. During the nursing period, the author established a therapeutic relationship with the case, formulated overall, individual and appropriate nursing measures for the nursing problems, and used the pain assessment scale to give appropriate nursing measures to alleviate the symptoms; at the same time, the author cared, supported positively and accompanied to help the case accept the change of body and mind bravely, also guided the case to speak up his worry and anxiety. Conclusion(s): The author played the role in supporting and consultation to help the case re-adjust to the impact of the change in body and mind, and then made the case willing to learn colostomy self-care related knowledge and self-care skills to improve the quality of life and re-adapt the future life. Keyword(s): Singh, P,＆Chaturvedi, A. (2015). Complementary and alternative medicine in cancer pain management: A systematic review. Indian Journal of Palliative Care, 21 (1), 105-115, rectal cancer, anxiety, acute pain, body image disturbance

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Improve the Quality of Endoscopy Instrument by using PDCA Methodology

Tsuey-Ru Lin, Ruei-Yun Chen, Bao-Hua Huang

National Taiwan University Hospital , Taiwan

Email: [email protected] Background and Purpose: In 2015, a working group has been set up to improve the quality of endoscopy instrument due to the high failure rate of endoscopy instrument which have reduced the efficiency of related surgery. Until 2020, the statistics result show that the performance of all endoscopy instrument comply with the requirement and the efficiency of surgery also has been enhanced. Material and Methods: In 2015, to enhance the quality of endoscopy instrument, a working group has been set up by senior CSSD staff to improve following two issue - 1. Implementation the SOP of instrument examination before package. 2. Maintenance of old endoscopy. By using PDCA methodology, the working group focus on following improvement plan- 1. Hold training courses for endoscopy instrument quality examination. 2. Prepare checklist to inspect the compliance rate of endoscope instrument quality examination. 3. Provide continuous education for staff that didn’t meet the requirements. 4. Start a routine instrument maintenance program by its manufacture to examine and maintain all instrument weekly. 5. Repair and replace instrument timely. Results: In 2015, only 95.6% endoscopy instrument passed the quality requirement. After improvement, 99.9-100% of endoscopy instrument have passed the quality requirement from 2016 to 2020. Conclusion(s): This project use PDCA methodology and takes several actions, such as holding

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continuous education, set up instrument inspection checklist and routine instrument maintenance to improve the quality of endoscopy instrument. After improvement, all instruments pass the quality of requirement. Endoscopy surgery has several advantages such as shorten the operating time and reduce the risk of patient, therefore laparoscopic surgery already become a trend in recent year. However, the complexity of endoscopy is higher than others surgical instrument. Therefore, CSSD need to pay more attention on instrument inspection and maintenance to provide qualified instrument and ensure the safety of patient during operation. Keyword(s): Laparoscopic surgery, Endoscopic surgical instruments

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Nursing Experience of Patient with Psoriasis in Hemodialysis Room by Applying Swanson’s Caring Theory

Yung-Hui Liu

National Taichung University of Science and Technology, Taiwan

Email: [email protected] Background and Purpose: Swanson's caring theory is a middle range theory. It embraces five caring process, includes knowing, being with, doing for, enabling and maintaining beliefs. The purpose of this report is to assist a 37-year-old male patient with Psoriasis and hemodialysis in the process of physiological s and psychological symptoms by Swanson's caring theory. Material and Methods: From May 21 to July 7, 2020, data collection is carried out by means of observations, interviews, physical assessments, medical records and Gordon's 11 functional health assessments. The health issues are presented by "concept mapping". The nursing problems of the impaired skin integrity, the social isolation and the sexual life style changes are established. Results: We provide his individual care by the Swanson’s caring theory. His physical and psychological needs, social and the sexual problems are found. Hereafter, we continue to accompany, listen and respond his problems during dialysis. In terms of medical treatment, Evidence-based Medicine of Herbs therapy and monitor serum potassium and avoid the complications. Moreover, we provide knowledge of lifestyle change from Evidence-based Nursing so that he can apply correct diet in daily life, and strengthen self-care skills. He understands hemodialysis care, physical and psychological symptoms improved, more open mind to hug persons and satisfying his sexual needs . The five care processes of the Swanson’s caring theory can be used to effectively reduce the physical and mental symptoms. Conclusion(s): In the nursing process, in addition to providing direct nursing activities, we played a role as a counselor, instructor, and a coordinator. I hope to cooperate with team works in cross-professional fields according to him, and then use sharing decision-making method to make choices. The patient understands the pros and cons of Western

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medicine treatment and makes the final decision. Keyword(s): Ko, S.H., Chi, C.C., Yeh, M.L., Wang, S.H., Tsai, Y.S., Hsu, M.Y. (2019). Lifestyle changes for treating psoriasis(review). Cochrane Database of Systematic Reviews 2019. 7, 1-65. DOI: 10.1002/14651858.CD011972.pub2., Psoriasis, social isolation, sexual life style changes, Swanson’s caring theory

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The Hazards and Protection of Operating Room Personnel during Hyperthermic Intraperitoneal Chemotherapy

Chi-Chi Lu, Chia-Chieh Wu, Shu-Wen Yang, Ping-Chen Chen

Cardinal Tien Hospital, Taiwan

Email: [email protected] Background and Purpose: Hyperthermic intraperitoneal chemotherapy (HIPEC) was developed in the 1970s and has been widely used in the treatment of patients with cancer cell metastasis in recent years. The operating room was the first case in 2019. Chemotherapeutic drugs are high-risk drugs. In order to reduce the risk of exposure of the medical team, strengthen the administration safety of nurses and the treatment process of chemotherapeutic drug sprinkling, Provide a safe care environment for operating room personnel. Material and Methods: The operating room has planned preparation for Hyperthermic intraperitoneal chemotherapy, including sealed delivery box and sprinkling treatment box. Personal protective equipment includes N95 mask, goggles, waterproof isolation clothing, gloves, long foot cover, genotoxic waste bag and air purifier with large capacity granular activated carbon to effectively remove a wide range of chemical gases and unpleasant odors, Simultaneously strive for the supporting projects of annual relevant health examination of the medical team. Results: At the initial stage of implementation, chemotherapy drugs were sent to the operating room by ward nursing staff, which increased the risk of spilling during transportation and prolonged the waiting time. At present, pharmacists dispensed drugs and specially assigned personnel directly transported them to the operating room. The operating room personnel lack the overall concept of harm and protection. Through the sharing of experts from other hospitals and specialized education and training, they are used in the operation, post-operative materials and environmental treatment, and implement the technical standards step by step, so that the medical team can complete the operation in a safe environment.

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Conclusion(s): Hyperthermic intraperitoneal chemotherapy is a new choice for cancer patients and a new operation for the operating room. Although it is difficult from scratch, with the cooperation of all colleagues, Hyperthermic intraperitoneal chemotherapy has completed the formulation of education, training and technical standards, and improved the occupational safety and professional care quality of the medical team under the standard protective equipment. Keyword(s): Hyperthermic intraperitoneal chemotherapy（HIPEC）

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AC-0 Induced Cytoprotective Autophagy in Human Promyelocytic leukemia (HL60) Cells

Chiu-Pei Yuan

Chiayi Hospital, Taiwan

Email: [email protected] Background and Purpose: For decades, Cancer is known to be the first cause of mortality and morbidity in Taiwan. Statistical data from the Department of Health, Taiwan showed that Acute Myeloid Leukemia (AML) (blood cancer) has the highest incidence among all leukemia cancers in Taiwan. Hence, understanding the mechanisms involved in AML is the need of hour. In one of our previous study. The objective of this study was to see if treating with AC-0 (a key fermented compound from the mycelial suspension of A camphorata) can induce autophagy in HL60 cells. Material and Methods: In the present study, we evaluated the key fermented compound from the mycelial suspension of A camphorata, in blood cancer in vitro. AC-0(0–7 μM) treatment significantly reduced HL-60 cell viability. AC-0 treatment triggers intracellular ROS generation. Results: Data from this study showed that, AC-0 treatment (0,2,5,7 μM) upregulated the autophagy inducing protein marker LC31-II protein levels in HL60 cells. Pretreatment with NAC(1 mM)(ROS inhibiter),results show that reducing protein marker LC31-II protein levels in HL60 cells..Pretreatment with 3-MA (2 mM)(an autophagy inhibitor) aggravated the HL60 cell viability and further induced the apoptosis.AC-0 induced apoptosis was suppressed in HL60 cells that were pretreated with an apoptotic inhibitor Z-VAD-FMK (10 μM). Subsequently, this has also downregulated the autophagy in these cells.Finally, we transfection of VDAC1 protein in HL60 ,measure the mechanism will be enhanced or not.The data show that it will be upregulated the autophagy inducing protein marker LC31-II protein levels.It pove that VDAC1 protein can enhance the autophagy mechanism of HL60

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Conclusion(s): The data show that the mycelial suspension of A camphorata will be upregulated the autophagy inducing protein marker LC31-II protein levels via ROS.And VDAC1 protein can enhance the autophagy mechanism of HL60 Keyword(s): Blood cancer, Lekumia, A camphorata

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The Incidence of Rectal Cancer Patients Undergoing Sphincter Preservation Surgery Complains about Low Anterior Resection

Syndrome

Chia-Lin Shu, Ying-Siou Lin, Fang-Miao Lin, Chien-Ju Lin, Ming-Ying Hong, Yueh-Jiau Hwang


Email: [email protected] Background and Purpose: According to the Cancer Registry Annual Report, 2018 Taiwan, the incidence of colorectal cancer ranks second among the top ten cancers. Thirty-six percent of colorectal cancer patients were diagnosed with rectal cancer, of which 75% underwent sphincter preservation surgery. While this surgery may preserve the sphincter, patients suffer from low anterior resection syndrome that affects quality of life. The purpose of this study is to investigate the incidence of rectal cancer patients undergoing sphincter preservation surgery who complain of low anterior resection syndrome and determine the potential factor associated with low anterior resection syndrome. Material and Methods: Electronic health records from the system used by case managers were reviewed retrospectively for rectal cancer patients who underwent sphincter preservation surgery at a medical center in northern Taiwan between January and December 2020. The patients with a deviating stoma were excluded. We examine the electronic health record, which records patients with low anterior resection syndrome, to determine whether the patient has low anterior resection syndrome. The descriptive analysis was used to analysis patient characteristics and the rate of patients complains about low anterior resection syndrome. Results: Of the sixty-eight patients that met the inclusion criteria, thirty-seven were male, with mean age of 59.4 years. Among the 68 patients, the 5-10 cm above anal verge was the most numerous (63.2%) and nearly eighty percent of patients do not receive radiation. Fifty-one point five percent of the patients complain of low anterior resection syndrome. However, the sex, age, the location of above anal verge, and whether patients received radiotherapy were no different from their low anterior resection syndrome complaint.

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Conclusion(s): While we identify patients with low anterior resection syndrome from the electronic health record, more than half of the patients have this syndrome. It shows that low anterior resection syndrome significantly affects the daily lives of patients. To improve the quality of life of rectal cancer patients undergoing sphincter-preserving surgery, we recommended that case managers use assessment tools to actively monitor low anterior resection syndrome and provide patients with adequate measurements based on the different level of low anterior resection syndrome. Keyword(s): Low anterior resection syndrome, sphincter-preserving surgery, case managers

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Nursing Experience for an End-Stage Colon Cancer with Lung Metastasis Patient

Chia-Huei Su

Kaohsiung Medical University, Kaohsiung Medical University Hospital, Taiwan

Email: [email protected] Background and Purpose: This paper mainly describes a middle-aged woman with end-stage colon cancer who had undergone chemotherapy treatment several times, but owing to rapid disease deterioration, the medical team had decided on referral to palliative care, and the author endeavored to help the patient spend her final days with family in palliative care, despite facing shock and sadness at this time. Material and Methods: By observation, accompanying talks, and team communication, the heart, spirit, family, and social levels were all evaluated and analyzed. It was confirmed that the patient had "difficulty in breathing", "death anxiety", and " anticipatory grief " presenting as nursing problems. Results: To alleviate these conditions, 1) communication and coordination as adjuvant therapy was applied to relieve the uneasiness and fear of breathing difficulties in a multidisciplinary integrated care model; 2) in the face of death anxiety, the patient was prompted to realize intrinsic family support, affirm self-worth, and understand the meaning and connotation of life; and 3) with the intervention of expressive media, facilitating the expression and experience of sorrow and loss, the patient was enabled to reach a therapeutic treatment effect. This preparation for death in a limited time frame could satisfy the patient’s anticipatory grief. Conclusion(s): It is recommended that clinical nursing staff confirm and attach importance to spiritual care, cultivating a proactive attitude and strengthening grief-counseling skills to enhance individual abilities in the quality of cancer care. It is expected this nursing experience can provide a reference to care staff for end-stage care of cancer patients. Keyword(s): colon cancer, palliative care, multidisciplinary integrated care

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Factors Related to Unplanned Return to Operating Room – A study of a Major Medical Center in Northern Taiwan

Chih-Ting Su, Hung-Da Dai, Ciou-Rong Yuan, Hsiao-Ching Lee, Ling-Fu Shaw,

Mao-Che Wang

Taipei veterans general hospital, Taiwan Email: [email protected]

Background and Purpose: Unplanned return to the operating room (UROR) during hospitalization is one of the most important quality indicators for surgery. Surgeons and hospital administrators are both strive to reduce UROR rate. However, reported influencing factors are varying and few large scale studies conducted in Taiwan. The purpose of the study is to explore the factors related to the UROR in a 3000-bed medical center in Northern Taiwan. Material and Methods: A cross sectional study utilized the data provided by a medical center in Northern Taiwan. Data was collected during January 1st, 2015 to September 30th, 2019. Demographic characteristics, disease severity, surgical wound classification, anesthesia type, and the surgery department were analyzed as well as time attributes. Surgical in-patients were included except emergency cases. Those who did not have previous operation related complications or adverse reactions, and those who died during operation and organ donators were also excluded. We further selected patients who had 2 or more UROR during the hospitalization period. Results: The results showed that the overall UROR rate was 1.25%. Male was 1.65 times higher than female (p < 0.001). UROR rate of patients with high age-adjusted Charlson comorbidity index before surgery(ACCI≧7）was 1.69 times than low （ACCI 0-3）cases (p < 0.001). However, there was no difference in age. General anesthesia cases were 1.50 times higher than regional anesthesia cases, and contaminated wounds/dirty wounds were 2.61 times/5.61 times higher than clean surgical wounds (p < 0.001). UROR rate was higher as the surgical wounds was dirtier. The surgical departments including gynecology, dentistry, neurology and surgery department was 3.19 times , 2.95 times , 2.64 times and 1.56 times higher than orthopedic department(p < 0.001). In addition, the trend of UROR was significantly higher in the fourth season than the third season (p=0.020) and showed a linear decreasing trend as the year progressed (p<0.001)

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Conclusion(s): The incidence of UROR was related with gender, preoperative ACCI, surgical wound classification, type of anesthesia, surgical department, and season/year of surgery. However, more details may still need to clarified. Keyword(s): Unplanned return to the operating room, Medical quality, Medical center, Age-adjusted Charlson comorbidity index, Unplanned return trend

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Using Big Data to Analyze Cancer-Related Pain

Chiu-Ping Su


Background and Purpose: Pain is a common clinical symptom of cancer. There are many alternative analgesics available, but also many patients still have pain and not to relieved. In this study, big data was used to analyze the current status of cancer pain. Material and Methods: This study uses the Medical Integration Database, which will use removed link data, retrospective design, and cross-sectional and descriptive research. Study Object and Number of Samples: Based on the data available in Medical Records, patients with pain scores greater than 3 during hospitalization in the 2017 vital sign pain assessment records. This study was include 20-year-old cancer patients admitted Hospital since 2017 (diagnosis was ICD-9-CM 140.0-208.91, ICD-10-CM was C00-C97), exclude less than 20 years old. Results: There were a total of 5504 cancer patients and a total of 7,789 hospitalizations with pain scores greater than 3 points during hospitalization in the 2017. According to the analysis of the number of hospitalizations, there were 4566 (58.6%) males and 3223 (41.4%) females. Most are 60-80 years old, married, the education level is mostly high school, and have religious believers, most patients have no history of allergies. The primary site of cancer is gastrointestinal tumors (Gastrointestinal tract)(37.4%), and liver cancer(30.4%) is the primary diagnosis. Bone metastasis is the most common site of metastasis. According to the analysis of pain assessment records, abdominal pain is the most common part of moderate to severe pain(40.5%), secondly is lower back pain(16.5%). Intermittent pain was the main type of pain for 63.7%; the duration was less than 1 hour ( 55.5%), secondly was 1-3 hours (40.1%). Patients with moderate to severe pain mainly affect sleep (55%), followed by daily activities (31.5%).

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Conclusion(s): Patient with gastrointestinal tumor or bone metastasis often have moderate to severe pain. Keyword(s): cancer pain, moderate to severe pain

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Satisfaction of Nurses in Operating Room for the Operating Procedures and Protective Measures against COVID-19

I-Ting Tsai, Fang Wang, Hui-Lin Lin


Email: [email protected] Background and Purpose: Coronavirus disease has been a challenge for medical staffs from the end of 2019 to date (World Health Organization, 2020); the challenges have been also imposed to nurses in operating room while they’re providing full-term operating cares for patients. After the first suspected case was admitted to the unit, the operating room developed the operation process, in order to have a knowledge of the nurses’ views on relevant measures, which has inspired the study. It is expected that this study can contribute to the actual operation. This study was designed to discuss over the satisfaction of nurses in operating room on the operating room procedures and protective measures against COVID-19. Material and Methods: The study was performed in the operating room in a medical center in Taipei in a retrospective manner. The self-designed structural questionnaires were used, with Likert Scale for evaluation. 30 nurses in operating room with the experience in caring COVID-19 suspected / confirmed cases were investigated. The questionnaires were distributed in May 2021 and analyzed after being collected back. Results: According to the results, the average satisfaction rate of nurses in operating room on the operating process reached 95.3%, among which the online courses and PPT files with processes and photos scored the highest and the support rules for caring the suspected or confirmed cases scored the lowest. Conclusion(s): Developing SOP enables the teams to jointly promote safe working processes and environment, improve the satisfaction of nurses on the work. The negotiation can be processed in terms of support rules for caring the suspected or confirmed cases to reach the greatest consensus. Keyword(s): Nurses in operating room, COVID-19, Operating procedures, Satisfaction

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Prevention of Pressure Injury in Operating Room and Application of Dressing for Prevention of Pressure Injury in Taiwan

Ching-Yi Wang

Tungs' Taichung MetroHarbor Hospital, Taiwan

Email: [email protected] Background and Purpose: Studies have pointed out that operating patients lying still on the operating bed for a long time can easily increase the risk of pressure injury. Therefore, Taiwan Clinical Performance Indicator includes the incidence of intraoperative pressure injury as a monitoring item to avoid unexpected injuries during the operation. It is an important issue for the patient. Material and Methods: Analyzing the common causes of surgical stress injury are the low cognition and nursing ability of the nursing staff in the operating room, the low accuracy of positioning skills, and the lack of use of preventive pressure injury dressings. The task force used flipped teaching to improve cognition and nursing skills during surgery. Assess people at high risk of pressure injury to use preventive pressure injury dressings. Results: According to statistics, after the implementation of the improvement strategy from October 2020 to March 2021, the total number of surgical operations was 11,821, the incidence of pressure injury decreased from 0.05% to 0.04%, and 29 people participated in flipped teaching, with an average score of 46.8 points before education and 99.3 points after education. The average pre-test score is 46.8 points, and the average post-test score is 99.3 points, an increase of 52.5 points. Conclusion(s): Improve the awareness of nurses in the operating room to prevent pressure injuries,help correctly assess the factors that cause pressure injuries during surgery, and formulate relevant preventive measures and improvement plans, reduce the incidence of intraoperative pressure injuries, and improve surgical safety and the quality of medical care . Keyword(s): Operating Room, Pressure Injury, Preventive dressing

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Improving the Safety and Quality of Intraoperative X-ray in Children-Advanced and Improved Cassette-Type Carbon Fiber

Medical Bed Board

Pei-Ru Wang, Chia-Lan Chen, Yu-Wei Fu, Pei-Chi Chuang

Changhua Christian Hospital, Taiwan Email: [email protected]

Background and Purpose: In children undergoing intravenous device surgery, portable X-ray is often needed under anesthesia to check the position of the catheter to ensure that the catheter is placed correctly to avoid the risk of complications such as re-operation anxiety and catheter displacement. It is made of carbon fiber material "Advanced Improvement" Cassette-type carbon fiber medical bed board" reduces the risk of moving the patient during the operation, thereby improving the safety and quality of medical care. Material and Methods: Place the "advanced modified cassette carbon fiber medical bed board" under the patient's body, and just put on a fat pad and a layer of bed sheet. When taking X-ray to check and confirm the catheter position during the operation, it only needs to lift the bed sheet and directly insert the "X-ray film" into the cassette. The imaging film is then taken out directly after snapping, without turning the patient, reducing the risk of turning and moving the patient during the operation and infection of the surgical wound. Results: From March 2020 to August 2021, the infection rate of surgical site for intravenous device placement in children was 0%, and there was no accident of falls during the operation. Conclusion(s): After general anesthesia, patients may have "physical dysfunction" and "potentially dangerous infection" nursing problems. Using of advanced modified cassette-type carbon fiber medical beds can reduce the risk of turning and moving the patient during the operation and the risk of surgical wound infection. Make the entire operation process smoother and improve the quality of surgical medical safety care. Keyword(s): Intraoperative image irradiation, Cassette type carbon fiber medical bed board

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Explore the Active Warming System to Effectively Maintain the Patient's Body Temperature and Improve the Incidence of

Complications in Surgical Patients

Shu-Mei Wang1, Yi-Ru Lai1, Chiu-Hsiang Lee2

Chung Shan medical university hospital , Taiwan1, Chung Shan Medical University, Taiwan2

Email: [email protected] Background and Purpose: Surgery patients often suffer from hypothermia, and hypothermia can easily cause chills, decreased comfort, increased bleeding, prolonged or changed drug effects, delayed recovery from anesthesia,and increased risk of surgical complications. Therefore, the purpose of this study is to translate through empirical evidence and prove that the active warming system is really more effective than traditional ways. Material and Methods: Use PICO to establish Chinese and English keywords, and conduct literature review based on CASP for 2 systematic review studies. Results: The incidence of wound infection and complications: Active warming (FAW) than transmission control group and there is significant difference (statistically FIG. 1. 2). Bleeding volume: Active warming (FAW) is better than the control group, there is a statistically significant difference (Figure 3). Statistics 2020/06/01-06/30, a total of 54 open surgery patients were collected, FAW group: 30, control group 24, the average temperature in the second hour of the operation, the last temperature in the operating room, and the last temperature in the operating room were all high At 36 ℃ and higher than the control group. Recovery room one hour surgery after the patient consciously comfortable than the control group, while shivering was less than the control group. Conclusion(s): Active heating can provide continuous thermal insulation, no scalding concerns and reduce surgical complications. However, since patients with active warmers have to pay for themselves, it is recommended that they can be included in the health insurance payment in the future to provide comfort for surgical patients and

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reduce postoperative complications, as well as reduce the cost of hospitalization. Keyword(s): Hypothermia, active warming system , open surgery patients

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Improve the Completeness of the Nursing Staff in the Operating Room During Liver Tansplantation

Chi-Ming Wu, Shu-Jen Wong, Ting-Yun Yu, Chi-Wang, Su-Lan Wu

Chang Gung Memorial Hospital, Linkou, Taiwan

Email: [email protected] Background and Purpose: Improving the integrity of nursing staff to perform the surgical care for the steady progress of the transplantation operation is critical. Liver transplantation, especially, is extremely difficult because not only equipment and materials are various but also preparation process is complicated.Analysis of the current situation revealed that the staff's completeness of care for liver transplantation is only 45%; the accuracy rate of liver transplantation nursing care is 75%; there is no positioning for the placement of instruments and equipment; there are many instruments and often missed during the operation; the surgical nursing process is complicated; standard operations There are differences between norms and practical operations, which triggers the motive of the task force to improve. Material and Methods: The improvement fields include simplifying the nursing process of liver transplantation, integrating equipment and instruments, providing liver transplant surgery handbooks, holding specialized on-the-job education workshopThe improvement fields include simplifying the nursing process of liver transplantation, integrating equipment and instruments, providing liver transplant surgery handbooks, holding specialized on-the-job education workshop, etc. This study revealed that the integrity of surgical care Results: This study revealed that the integrity of surgical care increased from 45% to 98% and the cognitive accuracy rate increased from 75% to 98%. Conclusion(s): Such a result showing that this enhancement is concrete and feasible and provide practical improvement in the integration and quality of surgical care, and patients’ safety. Keyword(s): Garcia, C. S., Lima, A. S., La-Rotta, E. I. G., & Boin, I. S. F. (2018). Social support for patients undergoing liver transplantation in a Public University Hospital. Health and Quality of Life Outcomes, 16(1), 35.

https://doi.org/10.1186/s12955-018-0863-5, Liver Transplantation, Liver Transplantation Surgery Care, Completeness of Surgical Care

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Evidence-based Nursing on the Use of Prophylactic Dressings to Reduce the Incidence of Pressure Injuries in Surgical Patients: A

Preliminary Study

Shu-Wen Yang

Tungs’ Taichung MetroHarbor Hospital, Taiwan Email: [email protected]

Background and Purpose: The incidence of pressure injuries in patients during surgery has been increasing in the past five years. In 2020, twelve cases of pressure injuries happened at our hospital. This incidence has increased significantly to 112% comparing to that in 2019. Pressure injuries will cause postoperative pain and discomfort, which also increase the risk of infection, longer hospitalization, and possibilities of death which will increase of nursing care and medical costs. We expect to find relevant evidence-based nursing literature reviews to support the usage of prophylactic dressings which can effectively reduce the incidence of pressure injuries. Material and Methods: The Cumulative Index to Nursing and Allied Health Literature and PubMed system are used with keywords of “Pressure injury,” “Pressure ulcer,” “Prophylactic dressing,” and “Prevention,” for articles searching. The randomized controlled trial and systematic review articles that published from 01/09/2014 to 31/01/2021 were searched and 14 articles were found suitable to the topic. However, only one has relativity to the topic with higher evidence-base after careful reading through the article content. This systematic review were Search of four electronic bibliographic databases. 21 studies were included in synthesis, 3 randomized controlled trials (2 were no report of randomization procedure) and 18 non-randomized controlled trial studies (7 cohort and 11 case series). Results: Through evidence-based nursing verification, the use of prophylactic dressings has reduced pressure injuries related to medical equipment and long-term immobilization of patients. However, There is no clinical evidence to commend that which dressing type is more effective. Conclusion(s): Based on evidence-based nursing results, the other literature reviews were reserched that the use of sacral prophylactic dressings can reduce the risk of pressure injuries by about 70%; The use of Mepilex® Border Sacrum five-layer foam dressing could effectively prevent pressure injuries in sacral areas of

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surgical patients who suffered from high risk of pressure injuries. We hope this type of injury can be reduced under this manual and promote to build up new standards for prevention of pressure injuries in our hospital. By doing so, we hope to improve the quality of nursing care in our surgical patients. Keyword(s): Pressure injury, Pressure ulcer, Prophylactic dressing, Prevention

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Intravenous Arginine Administration Attenuates the Inflammatory Response and Improves Dysregulated Hepatic Lipid Metabolism in

Diet-Induced Obese Mice after Sleeve Gastrectomy

Chiu-Li Yeh1, Wan-Hsuan Wang1, Jin-Ming Wu2, Po-Jen Yang2, Po-Chu Lee2, Ming-Hsun Wu2, Kuen-Yuan Chen2, Chun-Chieh Huang2, Ming-Tsan Lin2

Taipei Medical University, Taiwan1, National Taiwan University Hospital/National

Taiwan University, Taiwan2 Email: [email protected]

Background and Purpose: Obesity is a pandemic with many metabolic disorders. Excessive adipose tissue accumulation results in chronic inflammation, insulin resistance, dysregulated lipid metabolism and other metabolic dysfunctions. Weight reduction can effectively attenuate obesity-associated complications. Sleeve gastrectomy (SG) is a bariatric surgery commonly used. Although SG is considered safe and effective for improving disease outcomes for long term, surgical stress itself intensifies the inflammatory reaction and imbalanced metabolic profiles. Arginine (Arg) is an amino acid with immunomodulatory and anti-inflammatory properties. Arg was reported to reduce central adiposity, improve nitrogen balance and metabolic profiles in obesity. The availability of Arg is found to have reduced in stress conditions that may be associated with increasing inflammation and oxidative stress. This study used an obese mouse model to evaluate intravenous Arg administration on hepatic fat metabolism and adipocyte inflammation short-term after SG. Material and Methods: C57BL6 male mice were divided into normal control and high-fat diet (HFD) groups. The HFD provided 60% of energy from fat for 10 weeks. Mice fed the HFD were then assigned to a sham (SH) or SG with saline (SS) or Arg (SA) groups. The SS group was injected with saline, while the SA group was administered Arg (300 mg/kg body weight) via tail vein postoperatively. Mice in the experimental groups were sacrificed at day 1 or 3 after SG. Results: Obesity resulted in fat accumulation, elevated glucose levels and adipokines production. SG enhanced the expressions of inflammatory cytokine, macrophage markers, CD68 and EMR-1, in adipose tissues. Also, adipocyte glucose transporter-4 (GLUT-4) as well as hepatocyte gene expressions associated with lipid b-oxidation including peroxisome proliferator-activated receptor-a, acyl-coenzyme A oxidase-1, carnitine palmitoyltranferase-1 and sterol regulatory element binding protein-1c were

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downregulated. Treatment after SG with Arg reversed the expressions of b-oxidation-associated genes and reduced lipid peroxides production in the liver. Also, adipose tissue expressions of inflammatory chemokines reduced while GLUT-4 and M2 macrophage marker, arginase-1 increased after the surgery. Conclusion(s): These findings suggest that postoperative Arg administration elicits a more balanced hepatic lipid metabolism, polarizes macrophages toward the anti-inflammatory M2 type and attenuates adipocyte inflammation shortly after the bariatric surgery. Keyword(s): macrophage polarization, adipocyte inflammation, hepatic lipid metabolism

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Intravenous Calcitriol Administration Modulates Mesenteric Lymph Node CD4+ T Cell Polarization and Attenuates Intestinal

Inflammation in Obese Mice Complicated with Polymicrobial Sepsis

Chiu-Li Yeh1, Jin-Ming Wu2, Po-Jen Yang2, Po-Chu Lee2, Ming-Hsun Wu2, Kuen-Yuan Chen2, Chun-Chieh Huang2, Ming-Tsan Lin2

Taipei Medical University, Taiwan1, National Taiwan University Hospital, Taiwan2

Email: [email protected] Background and Purpose: Sepsis is a lethal clinical syndrome with multiorgan injury. Insults of bacteria and their toxins initiate the cascade that lead to T cell dysregulation, imbalanced pro- and anti-inflammatory reactions and gastrointestinal dysfunction. The impaired gut integrity may enhance bacterial translocation and aggravate systemic inflammation. Obesity is a condition with chronic inflammation and metabolic disorders. Obesity coexist with sepsis deteriorate the outcomes of diseases. Vitamin D is a nutrient with properties of immunomodulation, anti-inflammation and maintaining intestinal homeostasis. This study used an obese mouse model to investigate the treatment of active form vitamin D, calcitriol, on mesenteric lymph node (MLN) CD4+ T cell polarization and intestinal injury in sepsis. Material and Methods: There were normal control and high-fat diet groups. High fat diet was provided to the mice for 10 weeks to induce obesity, then mice were separated to OB group without sepsis and sepsis groups with cecal ligation and puncture (CLP). Obese mice with sepsis were subdivided to groups either injected with saline (SS) or calcitriol (SD) via tail vein 1hr after CLP and sacrificed at 12 or 24 h post-CLP, respectively. Results: The findings demonstrated that sepsis resulted in increased percentages of T helper (Th)2, Th17 and T regular (Treg) cells in MLN. Also, lipid peroxide levels and inflammatory-associated genes were upregulated whereas the tight junction genes (ZO-1, occludin) were downregulated in the intestines after CLP. Compared to the SS group, the SD group exhibited reduced Th2, Th17 and Treg percentages in MLN. The expressions of intestinal inflammatory chemokine were lower while MUC2, ZO-1, occludin were higher in the SD groups than those expressed in SS group after CLP. Lower inflammatory cytokine levels in peritoneal lavage fluid and decreased lipid peroxide production in ileum were also noted in the SD group.

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Conclusion(s): These findings suggest that intravenous calcitriol treatment after sepsis elicits a more-balanced CD4+ T cell subsets in lymph nodes nearby intestines and alleviates intestinal inflammation and injury in obese mice complicated with sepsis. Keyword(s): T helper cells, T regular cells, MUC2, tight junction, lipid peroxide

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Experience of Perioperative Nursing in a Teenage Patient with Ovarian Cancer

Hsiu-Fen Yu

MacKay Memorial Hospital, Taiwan

Email: [email protected] Background and Purpose: This report presents the author’s experience of perioperative nursing in a teenage girl who has ovarian cancer, the role of perioperative nursing on the challenging time when facing possibility of malignancy histopathology in frozen section, and pursuing fertility sparing operation after thoroughly consultation and family support. Material and Methods: During the period from April 10, 2016 to April 18, 2016, nursing diagnoses based on Gordon’s 11 Functional Health Patterns was adopted through patient interview, clinical observation, and literature review. Results: The author divides the whole caring period into three stages and summarized a few health problems correspondingly as 1.) anxiety and uncertainty of the female teenage in preoperative stage; 2.) potential risk of injury during the operation; 3.) surgical wound and pain in postoperative stage. The first stage is before the surgery, the author provides the treatment information and also concerning the patient’s psychological aspects, by encouraging her to speak out the feelings to make her feel safe and comfortable and by helping her to overcome the anxiety and uncertainty. The second stage is when the surgery is processing to keep the theater environment clean and safety to decrease the potential risk of surgical complication. The third stage is after surgery, using the professional knowledge and skills to assist her recovery as soon as possible. Conclusion(s): The author hopes that this experience could provide to colleagues as a reference in caring for relevant diagnosed. Keyword(s): ovarian cancer, the uncertainty of adolescent patient, perioperative nursing, pain

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Combination of Two-hour Post-ERCP Serum Amylase Levels with Clinical Risk Factors for Predict Pancreatitis After Procedure

Pongsakorn Srichan

Surin Hospital, Thailand

Email: [email protected] Background and Purpose: Pancreatitis is the most common adverse event of endoscopic retrograde cholangiopancreatography (ERCP). Clinical risk factors are not reliable for early detect post-ERCP pancreatitis (PEP). The aim of this study is to assess 2 hour post-ERCP serum amylase levels combine with clinical risk factors for predict PEP. Material and Methods: A total of 355 ERCP procedures were enrolled in this study from February 2017 to December 2019. The receiver operator curve (ROC) analysis was used to determine the cutoff level of 2 hour serum amylase and predicted PEP. Results: PEP occurred in 41 patients (11.5%). 2 hour serum amylase levels was higher in patients with PEP (421 vs 104 IU/L, P < 0.001). The cutoff level of 2 hour serum amylase was 124 IU/L with area under ROC curve (AUC) 81.7%. By multivariate analysis, significant risk factors was 2 hour serum amylase > 124 IU/L (Odd ratio, OR 14.78, 95%CI 5.66 – 38.59, P < 0.0001 ). The AUC for predict PEP was significantly increase when using 2 hour serum amylase combine with clinical risk factors compare with clinical risk factors alone (AUC 84.9% VS 68.2%, P < 0.0001). Conclusion(s): Combination of 2 hour post-ERCP serum amylase levels with clinical risk factors is a reliable test for predict PEP. Keyword(s): Post endoscopic retrograde cholangiopancreatography pancreatitis, 2 hour serum amylase, Predict

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Survey of Challenges in Access to Diagnostics and Treatment for Neuroendocrine Tumor Patients (SCAN): The Diagnostic Process of

GEP-NETs in Asia, Europe, North America and Oceania

Teodora Kolarova1, Mark McDonnell2, Catherine Bouvier3, Elyse Gellerman4, Dirk Van Genechten5, Sugandha Dureja6, Christine Rodien-Louw7, Simone Leyden8

International Neuroendocrine Cancer Alliance (INCA), United States1, NET Patient

Network, Ireland2, Neuroendocrine Cancer UK, United Kingdom3, NET Patient Foundation, United States4, vzw NET & MEN Kanker Belgium, Belgium5, Carcinoid

and Neuroendocrine Tumour Society India, India6, APTED, France7, NeuroEndocrine Cancer Australia, Australia8

Email: [email protected] Background and Purpose: SCAN assessed the global delivery of NET diagnostics and treatment. This analysis focused on the diagnosing process in gastroenteropancreatic (GEP) neuroendocrine tumor (NET) patients in a comparative perspective – Asia (AA), Europe (EU), North America (NA) and Oceania (OA). Material and Methods: During Sept-Nov 2019, 2359 NET patients & carers, and 436 healthcare professionals (HCPs) completed a self-report online survey, available in 14 languages, disseminated via NET patient groups and medical society networks. Results: 71% (1670/2359) were GEP-NET patients: 48% from EU (802/1670), NA – 29% (485/1670), AA – 13% (211/1670), OA – 8%, (141/1670). Primary GEP-NETs were predominantly small intestinal (SI) and pancreatic (PNET), with similar proportions in EU, NA and OA, significantly more PNET vs. SI in AA (SI: AA [14%, 29/211]; EU [50%,397/802]; NA [57%, 276/485]; OA [57%, 81/141[ p<0.001, Chi-squared, (PNET: AA [47%, 100/211]; EU [29%,235/802]; NA [23%, 113/485]; OA (25%, 32/141) p<0.001). The majority of patients were misdiagnosed at least once but most commonly multiple times: (AA [33%, 70/211]; EU [43%, 342/802]; NA [45%, 219/485]; OA [57%, 80/141]). Mean time to correct NET diagnosis was five (SD 5) years, shortest in AA (2.3 years, N=70), EU (4 years, N=341), 6.4 years in NA (N=219), OA (4.7, N=80). The most frequent misdiagnoses were gastritis AA [53%, 37/70]; EU [38%, 131/342]; NA [47%, 102/219]; OA [44%, 35/80]) and irritable bowel syndrome (AA 16%, 11/70]; EU [35%, 119/342]; NA [48%,

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104/219]; OA [56%, 45/80]). Over 40% of patients had stage IV NETs at the time of diagnosis: AA [40%, 84/211]; EU [45%, 357/802]; NA [61%, 294/485]; OA [53%, 74/141]), significantly higher in NA. On average three HCPs were involved in the diagnosing process with no difference among the regions. Leading diagnosticians were gastroenterologists: AA [34%, 71/211]; EU [27%, 218/802]; NA [24%, 115/485]; OA [16%, 23/141], and GPs: AA [10%, 20/211]; EU [20%, 162/802]; NA [21%, 103/485]; OA [28%, 40/141], less in AA. Conclusion(s): Delayed GEP-NET diagnosis remains a significant challenge globally. Increasing the number of knowledgeable HCPs, especially gastroenterologists and GPs, must be a key priority in order to drive forward improvements in global NET care. Keyword(s): GEP-NETs, misdiagnosis, neuroendocrine, cancer, gastroenteropancreatic

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Clinical Practice Exploration of Gastric MALT Lymphoma Under the Multidisciplinary Diagnosis and Treatment Pattern

Yaru Yaru Li

West China Hospital of Sichuan University, Sichuan University–Oxford University Huaxi Gastrointestinal Cancer Centre. West China Hospital, Sichuan University,

China Email: [email protected]

Background and Purpose: Gastricmucosa-associated lymphoid tissue ( MALT) lymphomas is an indolent marginal zone B-cell lymphoma . Nevertheless, it's of vital significance to make early confirmation, accurate evaluation, individualized treatment strategy. Multidisciplinary Teams（MDT）pattern has a great application prospect in gastric MALT lymphoma. This article will summarize the process (presented in the form of flow charts) and practice effect of multidisciplinary diagnoses and treatment of gastric MALT lymphoma patients in West China Hospital of Sichuan University. Material and Methods: Individual treatment strategies were made by combining clinical stages, the status of Helicobacter Pylori,themanifestations of mucosal lesions under endoscopy and pathological diagnosis,eradication of H.pylori, radiotherapy, chemotherapy and immunotherapy were given according to the personal condition respectively. Our pattern focuses on H.pylori eradication for early stages (ⅠE, ⅡE) patients, especially those whose HP is negative. Results: From December 2018 to January 2020, there were 20 patients for MDT of gastric MALT lymphoma in West China Hospital of Sichuan University.Among the 20 patients , All patients were confirmed as MALT lymphoma by pathology, of which 55% were male, with an average age of 58.2 years old. The predominant symptoms were epigastric discomfort and gastrointestinal bleeding, both accounting for 40%. 70% of the patients were in the early stage when diagnosised and 75% of the patients were HP positive. endoscopic presentations were Exophytic Ulceroinfiltrative and diffuse type accounted for 35%, 40% and 25% respectively. 90% patients have gastric body involvement，70% texture of biopsy specimens was soft，and API2/MALT1 gene fusion was detected in 7 patients. Treatment: 2 cases adopted“wait-and watch” strategy ,

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The other 18 cases were treated with antibiotic treatment, 5 cases were treated with radiotherapy additionally and 4 cases with chemotherapy. all of them have developed individualized diagnosis and treatment plans. 5 patients achieved remission by endoscopy follow-up after treatment, while the rest werestill in the follow-up. Conclusion(s): The pattern of gastric MALT lymphoma MDT in general hospital can highlight the specialties' specialties, and it can improve thesituation that repeated medical treatment in the same specialist, lack of data connection between different specialties, inappropriate transitional treatment anddifferences in understanding of frontiers and guidelines in various specialties. Keyword(s): Multidisciplinary Teams, gastric MALT lymphoma

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Machine Learning Prediction based on Recurrent Neural Network (RNN) Algorithm to Determine Colorectal Cancer Stage

Rifaldy Fajar

Yogyakarta State University, Indonesia

Email: [email protected] Background and Purpose: Colorectal cancer or also known as colon cancer is a malignant tumor found in the colon or rectum. One way to detect colorectal cancer is by using colonoscopy. Once colorectal cancer is detected, a classification is performed to determine the stage of cancer. In this study, the Recurrent Neural Network (RNN) model was used for the classification of colorectal cancer stages. This study aims to explain the procedure and the accuracy of Elman tissue RNN modeling in the classification of colorectal cancer stages from colonoscopy photographs. Material and Methods: The process carried out is to convert the image of red green blue (RGB) to a grayscale image on the colonoscopy data. After that, the image was extracted with Gray Level Co-occurrence Matrix which was designed using Graphical User Interface (GUI) with Matlab. There are 14 features, namely energy, contrast, correlation, the sum of a square, inverse different moment, sum average, sum variance, sum entropy, entropy, differential variance, differential entropy, maximum probability, homogeneity, and dissimilarity. The feature is used as input, which is then divided into training data and testing data. Results: The results of the best model of training data and testing data were measured using sensitivity, specificity, and accuracy. So that from 74 training data obtained 92% accuracy rate, 96% sensitivity level as a reliable indicator when the results show colorectal cancer, and 79% level of specificity as a good indicator when the results show normal colorectal. While in 18 data testing showed 94% accuracy, 100% level of sensitivity, and an 80% level of specificity. Conclusion(s): The machine learning classification based on the RNN model algorithm can be said to be good enough to determine the stage level of colorectal cancer. Keyword(s): Classification, Colorectal Cancer, Machine Learning, RNN Model

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Metagenomic Analysis to Determine the Potential of Viral Infection in Intestinal Tissue as a Cause of Intestinal Inflammation Based on

the Bioinformatics Pipeline

Rifaldy Fajar, Nana Indri Kurniastuti, Dewi Mustika Sari

Yogyakarta State University, Indonesia Email: [email protected]

Background and Purpose: Current models for predicting the causes of inflammatory bowel disease suggest that genetically susceptible patients develop intolerance to the intestinal microflora, and chronic inflammation develops as a result of environmental factors. Most studies focus on genetic variants and gut bacterial flora, but little is known about the potential for viral infection as a cause of this disease. Therefore, this study conducted a metagenomic analysis to document baseline virome in a bowel biopsy sample of patients with inflammatory bowel diseases (IBD) to assess the contribution of viral infection to IBD. Material and Methods: The library contains gut RNA data designed in a 2 GB sequence database. Using a bioinformatic pipeline designed to detect viral sequences, more than 1000 viruses are detected directly in intestinal tissue without culture or isolation procedures. This study describes the complexity and abundance of viruses, bacteria, and bacteriophages, as well as human endogenous retroviral sequences from 10 patients with IBD and 5 healthy subjects who underwent colonoscopic surveillance. Results: Differences in the gut microflora and abundance of mammalian viruses and human endogenous retroviruses are easily detectable in the metagenomic analysis. In particular, patients with herpesviral sequences in their colon showed increased expression of human endogenous viral sequences and differences in their gut microbiome diversity. This study offers a promising metagenomic approach to delineating the gut microbiome that can be used to further understand the host-virus and phage-bacteria interactions in IBD. Conclusion(s): The presence of detectable viral sequences in intestinal samples of patients with IBD appears to have a marked impact on microbial diversity. The interaction of viral infection with enteric microbiota has recently been shown to be an important driver of the causative model for IBD. In the future, additional studies will

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be needed to more firmly link the metagenomic findings with the clinical picture of IBD disease. Keyword(s): Bioinformatics, IBD, Metagenomic Analysis, Viral infection

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Surgical Treatment for Portal Hypertension

Hiroshi Yoshida1, Tetsuya Shimizu1, Masato Yoshioka1, Akira Matsushita1, Junji Ueda1, Manpei Kawashima1, Toshiyuki Irie1, Atsushi Hirakata2, Yoichi Kawano3,

Nobuhiko Taniai4

Nippon Medical School, Japan1, Nippon Medical School Tamanagayama Hospital, Japan2, Nippon Medical School Chibahokusoh Hospital, Japan3, Nippon Medical

School Musashikosugi Hospital, Japan4 Email: [email protected]

Background and Purpose: Various complications, such as esophagogastric varices, ectopic varices, ascites, and hepatic encephalopathy, can occur in portal hypertension. Bleeding from esophagogastric or ectopic varices is the most critical complication of portal hypertension. Portal hypertension can arise from any condition interfering with blood flow at any level within the portal system. Material and Methods: Many years ago, surgery was the only treatment available for esophagogastric varices in Japan. A number of surgical procedures have been developed to manage esophagogastric varices. Results: Broadly, these can be classified as shunting and nonshunting procedures. There are two types of shunting procedure, namely nonselective and selective. While nonselective shunt, such as portacaval or mesocaval shunt, effectively reduces the incidence of variceal bleeding, it is associated with a high risk of hepatic encephalopathy. A selective shunt, such as distal splenorenal shunt (DSRS) or left gastric venous caval shunt, were developed to preserve portal blood flow through the liver while lowering variceal pressure. The hope was that both bleeding and hyperammonemia would be prevented. DSRS effectively prevents rebleeding, but still carries a risk of hyperammonemia. We improved the DSRS procedure by additionally performing splenopancreatic disconnection and gastric transection. Historically, nonshunting procedures, such as the Hassab operation, esophageal transection (ET), splenectomy, or terminal esophago-proximal gastrectomy, were developed in an attempt to decrease the high rates of encephalopathy associated with portosystemic anastomoses. ET divides and reanastomoses the distal esophagus and devascularizes the distal esophagus and proximal stomach; splenectomy, selective vagotomy, and pyloroplasty are performed concomitantly. Recently, laparoscopic

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Hassab operation is performed as minimally invasive surgery. Conclusion(s): We review surgical treatment for portal hypertension. Keyword(s): Portal hypertension, Surgery, Spleen, Hassab operation, Laparoscopic surgery

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A Third Trimester Pregnancy with a Presentation of Sigmoid Volvulus: A Case Report and Literature Review

Malek Abdallah Muflih Alomari

King Hussein medical center, Jordan

Email: [email protected] Background and Purpose: Introduction Sigmoid volvulus in pregnancy is a quite uncommon entity presenting as acute abdomen. There is no specific presentation in pregnancy to differentiate it as a cause of Intestinal obstruction. High index of suspicion is needed and early diagnosis considerably decreases mortality and morbidity for both mother and fetus. We report a rare case of 32- gestational week lady who presented as large bowel obstruction as a consequence of sigmoid volvulus. Material and Methods: Presentation of case We report A 23-year old Jordanian women gravida 2, para 2, in her 32nd week of gestation who was admitted from emergency department as case of intestinal obstruction. Hemodynamically, she was stable and her CTG showed normal heart beats and uterine contractions. Radiological assessment revealed sigmoid volvulus. Failed sigmoidoscopy mandated exploration laparatomy to resect hugely distended sigmoid colon and to create temporary stoma. Results: Discussion Sigmoid volvulus carries substantial risks in pregnant women especially in the case of delayed recognition. Most volvulus cases take place in late pregnancy. In the absence of peritoneal signs and hemodynamic instability flexible sigmoidoscopy is considered the first choice. Otherwise, laparatomy for complicated volvulus after unsuccessful sigmoidoscopy should be decided to resolve this issue, being-in this occasion- a life-saving procedure.

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Conclusion(s): Conclusion Although literature includes less than 100 cases, clinicians should keep volvulus in mind as a differential diagnosis for intestinal obstruction in pregnancy. Delay in diagnosis put both mother and infant in jeopardy. The principles of surgery to treat pregnant and non-pregnant women are the same, but it is more favorable to do stoma in pregnant patients. Reconstitution of GI continuity can be done, once the patient recovers from stress of surgery and delivery. Keyword(s): Sigmoid Volvulus, Third-trimester pregnancy, intestinal obstruction, stoma.

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IL-6 as an Early Marker of Anastomotic Leakage after Elective Colorectal Surgery

Maxim Chernykh, Rostislav Pavlov, Mikhail Alekseev, Lyubov Kornoukhova,

Anastasia Novikova, Valery Danilin

SPSU Clinic, Russia Email: [email protected]

Background and Purpose: Anastomotic leakage (AL) after elective colorectal surgery remains a serious problem, despite the development of surgical techniques. It has been shown, that more than 50% of AL had the highest severity at moment of diagnosis, which required relaparotomy. So the early stages of AL are not diagnosed, until they progress to a severe condition. The clinic of LA in the early postoperative period is similar to the systemic inflammatory response syndrome (SIRS), which develops in response to surgical trauma. Before systemic symptoms such as fever, leukocytosis, and other septic symptoms develop, the infection is first localized at the site of the anastomosis, which includes various immune cells and cytokines. It has been shown that combination of Dutch leakage score (DLS) and C-reactive protein (CRP) may be useful for detection of AL. At the same time, there is data that the level of interleukin-6 (IL-6) during SIRS begins to respond 12-24 hours earlier than CRP. We present retrospective data about the IL-6 level in the postoperative period in patients undergoing colorectal resection, depending on the presence or absence of AL. Material and Methods: IL-6 level was measured in 44 patients undergoing elective colorectal resection with anastomosis. IL-6 level was evaluated the day before surgery (baseline) and at POD1-5. After discharge, the patients were divided into two groups; depending on the presence of AL. Results: Among 44 patients enrolled, the AL rate was 6,8%. The baseline IL-6 level in both groups did not differ and amounted to 6 pg/mL. IL levels on POD1 and POD2 in both groups did not differ statistically significantly (37 in the non-AL group and 59 in the AL group, 27 vs 42, respectively, p > 0,1). A statistically significant difference in the levels of IL was obtained at POD3 and POD4 (13 vs 163, 17 vs 135, p < 0,05 respectively).

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Conclusion(s): We consider that the use of IL-6 as a predictor of AL after elective colorectal surgery is more promising. These retrospective findings will form the basis of a prospective study, which will be launched in our clinic soon. Keyword(s): anastomotic leakage, colorectal surgery, interleukin-6, colorectal cancer, postoperative complications

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Short-term Multimodal Prehabilitation Program in ERAS protocol in Colorectal Surgery: Pilot Study

Anastasia Novikova, Rostislav Pavlov, Maxim Chernykh, Valery Danilin, Svetlana

Nepamnyaschaya

SPSU Clinic, Russia Email: [email protected]

Background and Purpose: Colorectal cancer is third in prevalence and second in mortality cancer worldwide. Surgery is indicated for most patients with colorectal cancer. Research on the effectiveness of prehabilitation in the ERAS program is growing popularity around the world. The generally accepted terms of prehabilitation are 3-4 weeks. However, the optimal length of the prehabilitation program has not been determined. According to Russian law, a patient with a malignant disease must start receiving treatment within 10 days from the date of diagnosis. In this connection, it seems important to study the effect of 10-day-long prehabilitation program developed in collaboration with nutritionists and physiotherapy specialists on postoperative recovery. The purpose of this study was to conduct a pilot study to assess the impact of the developed pre-rehabilitation program on the postoperative course of the disease, the incidence of complications and the treatment period in a hospital setting. Material and Methods: The study included 20 patients with diagnosed colon cancer, staged as T1-T3, N0-1, M0. 10 patients were included in the experimental group and 10 in the control group. In all cases surgery was performed in a planned laparoscopic approach. The patients of the main group underwent preoperative preparation in accordance with the established pre-rehabilitation plan. Treatment of the comparison group was carried out in full accordance with existing standards. Results: The frequency of complications I-II (Clavien-Dindo) was 30% (n = 3) in the control group and 10% (n = 1) in experimental group. The length of stay in the intensive care unit of patients in both groups did not differ and was no more than 10 hours. The average time of postoperative inpatient treatment of patients in experimental group was 4.20 days, versus 5.40 days in control group. Patients of the experimental group rated their quality of life much better at the end of the 28-day postoperative follow-up (EORTC QLQ-C30, QLQ-R29).

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Conclusion(s): This pilot study demonstrates the feasibility of conducting a prospective randomized clinical trial in order to assess the positive impact of short-term prehabilitation program on the frequency of complications, quality of life and the period of postoperative hospital stay. Keyword(s): ERAS, Colorectal Surgery, Colorectal Cancer, Prehabilitation, Fast-track

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Dynamics of Blood Cells Count after Splenic Artery Embolization in Patients with Portal Hypertension

Viktoria Petrushenko, Dmytro Grebeniuk, Mykola Melnychuk, Serhii Cheshenchuk,

Andrii Cheshenchuk

National Pirogov Memorial Medical University, Vinnytsya, Ukraine Email: [email protected]

Background and Purpose: Bleeding from esophageal varices is a life threatening complication of portal hypertension. Prevention of bleeding in patients at risk for a first bleeding or re-bleeding episode is therefore a major goal. Splenic artery embolization decreases pressure in the portal vein system and reduces the frequency of episodes of variceal vein bleeding. The purpose of the study was to evaluate dynamics of blood cells count after splenic artery embolization in patients with portal hypertension. Material and Methods: The total number of patients in the study was 16. All patients had liver cirrhosis (Child Pugh Score 7.2±1.7) and portal hypertension. To all patients’ splenic artery embolization was performed. According to the aim and objectives of the study, count of red, white blood cells and platelets before and 3 months after embolization were analyzed. Results: Splenic artery embolization was technically successful in all patients. Performing of embolization led to increase in the numbers of red blood cells (3.09 ± 1.78 x 106/μl and 10.87 ± 1.88 x 106/μl, p>0.05, before and after respectively), white blood cells (3.89 ± 2.05 x 103/μl and 5.21 ± 1.99 x 103/μl, p<0.05, before and after respectively), platelets (135.32±21.36 x 103/μl and 187.57 ± 39.31 x 103/μl, p<0.01, before and after respectively). Conclusion(s): Changes in white blood cells and platelets count were statistically significant while red blood cell counts showed some increasing trend 3 months after splenic artery embolization in patients with liver cirrhosis and portal hypertension. Keyword(s): portal hypertension, splenic artery embolization, blood cells count

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TNF-α and IL-8 Levels in Patients with Acute and Chronic Pancreatitis

Viktoria Petrushenko, Dmytro Grebeniuk, Nataliia Liakhovchenko

National Pirogov Memorial Medical University, Vinnytsya, Ukraine

Email: [email protected] Background and Purpose: One of the most actual problems of surgery for a long time remains the problem of pancreatitis. Despite the constant development of ideas about the pathogenesis of the inflammatory process in the pancreas, the development and introduction into clinical practice of new methods of diagnosis and treatment, the problem of acute and chronic pancreatitis does not lose its relevance. In our opinion, the study of the levels of the inflammatory markers in patients with acute and chronic pancreatitis is of scientific interest. The aim of the study was to research TNF-α and IL-8 levels in patients with acute and chronic pancreatitis. Material and Methods: The total number of patients in the study was 192. The study contingent included 86 patients with a confirmed diagnosis of acute edematous pancreatitis (group 1), 36 patients with a confirmed diagnosis of chronic pancreatitis (group 2) and 70 conditionally healthy people (control group). According to the aim and objectives of the study, levels of TNF-α and IL-8 were analyzed. Results: Level of TNF-α was significantly higher in group 1 (65.2±7.8 pg/mL) than in group 2 (52.5±6.2 pg/mL) and the control group (48.9±5.6 pg/mL). But there was no significant difference between group 2 and control group. Level of IL-8 was significantly higher in group 1 (224.1±10.3 pg/mL) than in group 2 (161.5±7.1 pg/mL) and the control group (19.1±1.1 pg/mL). Also there was significant difference between group 2 and control group. Conclusion(s): TNF-α and IL-8 levels could be used as the criteria of acute and chronic pancreatitis. Keyword(s): TNF-α, IL-8, acute pancreatitis, chronic pancreatitis

Content - IASGO 2021

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