Predictors and preventers of postoperative bedridden status in the elderly ages over 75 after emergency general surgery: a retrospective cohort study.

Aim: We investigated the proportion of bedridden patients after emergency surgery among the elderly ages over 75; defined as the latter-stage elderly in Japan, the associated factors, and interventions used to prevent it. Methods: Eighty-two latter-stage elderly patients who underwent emergency surgery for non-traumatic illness between January 2020 and June 2021 in our hospital were included in the study. Backgrounds and various perioperative factors were compared retrospectively between the groups including patients who became bedridden from Performance Status Scale 0 to 3 before admission (Bedridden group) and those who did not (Keep group). Results: Three cases of death and seven patients who were bedridden before admission were excluded. The 72 remaining patients were divided into the Bedridden group (n = 10, 13.9%) and the Keep group (n = 62, 86.1%). There were significant differences in the prevalence of dementia, pre- and postoperative circulatory dynamics, renal dysfunction, coagulation abnormality, length of stay in the high care unit/intensive care unit, and number of hospital days, with a relative risk of 13 (1.74-96.71), a sensitivity of 1.00, and a specificity of 0.67 for a preoperative shock index of 0.7 or higher being associated with the Bedridden group. Among patients with a preoperative shock index of 0.7 or higher, there was a significant difference in SI at 24 h postoperatively between the two groups. Conclusion: Preoperative shock index may be the most sensitive predictor. Early circulatory stabilization seems to be protective against patients becoming bedridden.

Factors associated with prolonged duration of viral clearance in non-severe SARS-CoV-2 patients in Osaka, Japan.

BACKGROUND: We investigated factors associated with prolonged viral clearance of SARS-CoV-2 among non-severe adult patients in Osaka, Japan. A total of 706 laboratory-confirmed COVID-19 patients were enrolled in this longitudinal observational study between 29 January 2020 and 31 May 2020, across 62 hospitals and three non-hospital recuperation facilities. METHODS: Logistic regression analysis was performed to investigate the factors associated with prolonged (29 days: upper 25% in duration) viral clearance of SARS-CoV-2. Linear regression analysis was conducted to assess these factors 14 days after symptom onset. RESULTS: The median duration of viral clearance was 22 days from symptom onset. After adjustment for sex, age, symptoms, comorbidity, and location of recuperation, comorbidities were associated with prolonged duration: (OR, 1.77 [95% CI, 1.11-2.82]) for one, (OR, 2.47 [95% CI, 1.32-4.61]) for two or more comorbidities. Viral clearance 14 days after symptom onset was 3 days longer for one comorbidity and 4 days longer for two or more comorbidities compared to clearance when there was no comorbidity. CONCLUSION: The presence of comorbidity was a robust factor associated with a longer duration of viral clearance, extending by 3 to 4 days compared to patients with no comorbidity.

Evaluation of Preoperative Magnetic Resonance Cholangiopancreatography in Acute Cholecystitis to Predict Technical Difficulties in Laparoscopic Cholecystectomy.

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging technique that provides high-quality visualization of the biliary tree, including the gallbladder. This study aimed to evaluate the useful-ness of preoperative MRCP for acute cholecystitis in predicting technical difficulties during laparoscopic chole-cystectomy (LC). A total of 168 patients who underwent LC with preoperative MRCP were enrolled in this study. Patients were divided into two groups according to preoperative MRCP findings: the visualized group (n = 126), in which the entire gallbladder could be visualized; and the non-visualized group (n = 42), in which the entire gallbladder could not be visualized. The perioperative characteristics and postoperative complica-tions of the two groups were retrospectively analyzed. Operation time was longer in the non-visualized group (median 101.5 vs. 143.5 min; p < 0.001). The non-visualized group had significantly more intraoperative blood loss than the visualized group (median 5 vs. 10 g; p = 0.05). The rate of conversion to open cholecystectomy was significantly higher in the non-visualized group (1.6 vs. 9.5%; p = 0.03). In conclusion, patients in the non- visualized group showed higher difficulty in performance of LC. Our MRCP-based classification is a simple and effective means of predicting difficulties in performing LC for acute cholecystitis.

Synchronous Total Occlusion of the Celiac Axis and Superior Mesenteric Artery: An Autopsy Case.

Acute mesenteric ischemia (AMI) is often caused by superior mesenteric artery (SMA) embolization. We report a rare case of synchronous celiac axis and SMA embolization in an elderly woman with initially mild abdominal pain. Ultimately, a second contrast-enhanced computed tomography revealed extensive necrosis from the stomach to the transverse colon together with liver ischemia due to hours of occlusion. Multiorgan failure made palliation the only option, and she died the following evening. Autopsy revealed a fragile atherosclerosis-asso-ciated thrombus. Careful examination and repeat diagnostic tests should be performed in patients with mild abdominal symptoms at risk for AMI.

Pretreatment Absolute Lymphocyte Count and Neutrophil-to-lymphocyte Ratio Are Prognostic Factors for Stage III Breast Cancer.

BACKGROUND/AIM: Stage III breast cancer comprises a broad spectrum of disease, including the extent of supraclavicular/internal mammary lymph node metastasis. In this study, we evaluated the usefulness of the absolute lymphocyte count (ALC) and neutrophil-to-lymphocyte ratio (NLR) in predicting the prognosis of patients with stage III breast cancer. PATIENTS AND METHODS: Seventy-five patients with stage III breast cancer who underwent surgery were included. We compared their clinicopathological factors according to the presence or not of supraclavicular/internal mammary lymph node metastasis, and pretreatment ALC or NLR. RESULTS: Patients with metastasis of the studied lymph nodes had a poorer prognosis in comparison to those without metastasis. In patients without these types of lymph node metastasis, both the ALC and NLR were predictive factors for relapse-free and overall survival. Among these patients, those with a low ALC or high NLR had recurrence-free and overall survival comparable to those of patients with supraclavicular/internal mammary lymph node metastasis. CONCLUSION: Pretreatment ALC and NLR were prognostic factors for patients with stage III breast cancer.

Prevalence of Diabetes in Tuberculosis Patients in Kathmandu Valley, Nepal.

In this descriptive cross-sectional study, the data on the prevalence of diabetes mellitus (DM) among tuberculosis (TB) patients at the Urban Directly Observed Treatment Centers in the Kathmandu, Bhaktapur, and Lalitpur districts of Nepal were collected. The prevalence of DM was assessed in 67 previously treated TB (PTTB) and 214 new TB patients. DM was diagnosed in 8 PTTB and 20 new TB patients. Clinical interviews identified 14 patients with DM, rapid blood glucose test was used to diagnose DM in 4 patients, and oral glucose tolerance test was used to diagnose DM in another 4 patients. Impaired glucose tolerance and impaired fasting glycemia were observed in 8 and 5 patients, respectively. The 18-24-year age group had the largest number of new TB patients (82, 38.3%). However, the incidence of DM among TB patients was higher in the >35-year age group. Moreover, DM was diagnosed in 24.2% of PTTB patients and in 23.1% of new TB patients. To determine the impact of DM screening in TB patients, a larger number of samples should be analyzed. DM screening for patients with TB is expected to start in developing countries. This should be initiated by conducting clinical interviews about DM and glucose tests using rapid kits.

Aberrant common hepatic artery from the left gastric artery and with no connection to the gastroduodenal artery: Risky vascular anomaly in gastrectomy.

Knowledge of anatomical variations of the celiac axis is important in upper abdominal surgery. Aberrant common hepatic artery originating from the left gastric artery without connecting the gastroduodenal artery is extremely rare. Preoperative vascular anatomy assessment using reconstructions of CT images may be useful for safe surgical procedure.

The characteristics and clinical course of patients with COVID-19 who received invasive mechanical ventilation in Osaka, Japan.

OBJECTIVE: To describe the detailed clinical course of patients with coronavirus disease 2019 (COVID-19) who received invasive mechanical ventilation. METHODS: We conducted a case series of patients with COVID-19 who received invasive mechanical ventilation in Osaka, Japan, between January 29 and May 28, 2020. We describe the patient characteristics and clinical course from onset. Additionally, we fitted logistic regression models to investigate the associations between patient characteristics and the 30-day mortality rate. RESULTS: A total of 125 patients who received invasive mechanical ventilation (median age [interquartile range], 68 [57-73] years; male, 77.6%) were enrolled. Overall, the 30-day mortality was 24.0%, and the median (interquartile range) length of ICU stay and length of invasive mechanical ventilation use were 16 (12-29) days and 13 (9-26) days, respectively. From clinical onset, 121 patients (96.8%) were intubated within 14 days. In multivariable logistic regression analysis, age of 65 years or older (odds ratio, 3.56; 95% confidence interval, 1.21-10.49; P = 0.02) and male sex (odds ratio, 3.75; 95% confidence interval, 1.00-11.24, P = 0.04) were significantly associated with a higher 30-day mortality rate. CONCLUSIONS: In this case series of patients with COVID-19 who received invasive mechanical ventilation in Japan, the 30-day mortality rate was 24.0%, and age 65 years or older and male sex were associated with higher 30-day mortality rate.

Cricopharyngeal myotomy for cricopharyngeus muscle dysfunction after esophagectomy.

BACKGROUND: Pharyngoesophageal dysphagia sometimes develops after esophagectomy. However, severe dysphagia after esophagectomy due to cricopharyngeus muscle dysfunction is a rare complication. There are no recommended clinical treatments for cricopharyngeus muscle dysfunction after esophagectomy. We report a case of myotomy for cricopharyngeus muscle dysfunction after esophagectomy. CASE PRESENTATION: A 75-year-old man with mild dysphagia diagnosed with advanced esophageal cancer by esophagogastroduodenoscopy at a clinic was admitted to our hospital. He had occasional mild dysphagia when he swallowed solid foods. After chemotherapy, the patient underwent minimally invasive esophagectomy with regional lymph node dissection and was reconstructed with a gastric conduit and cervical anastomosis by the retrosternal route. Aspiration pneumonia developed after esophagectomy without paralysis of the vocal cords. In esophagoscopy, there was no stricture around the anastomosis. However, severe pharyngoesophageal dysphagia with cricopharyngeus muscle dysfunction was revealed by videofluoroscopic examination. Bilateral cricopharyngeal myotomy was performed because balloon dilations had failed. The histological findings revealed atrophy and fibrosis of the cricopharyngeus muscle fibers. Pharyngoesophageal dysphagia improved immediately after myotomy. The patient swallowed solid food easily without dysphagia 12 months after myotomy. CONCLUSION: Dysphagia after esophagectomy was worsened by cricopharyngeus muscle dysfunction. Cricopharyngeus myotomy may lead to long improvement of pharyngo-oesophageal dysphagia after esophagetomy.

Nondegenerated cystic neuroendocrine tumor of the pancreas: a case report.

BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) are typically solid neoplasms but, in very rare cases, present as cystic lesions. We describe a case of a cystic neuroendocrine tumor that developed as a small cystic lesion. CASE PRESENTATION: In 2011, a 66-year-old Japanese woman underwent computed tomography (CT) that revealed a cystic lesion in the tail of the pancreas measuring 9 mm. She did not have any symptoms. She underwent a CT scan every year thereafter. The cystic lesion gradually increased and was 40 mm in 2019; endoscopic retrograde pancreatography (ERP) was then performed. Cytological examination demonstrated class IIIb adenocarcinoma, and we conducted laparoscopic distal pancreatectomy. Pathological examination showed PNET. CONCLUSION: Although cystic change of PNET is generally caused by ischemia or necrosis inside the tumor, in our case, PNET occurred as a small cyst that increased without changing form.

Case of inflammatory granuloma in inguinal hernia sac after hysterosalpingography with oily contrast medium.

INTRODUCTION: The foreign body reaction caused by oil contrast medium, Lipiodol, is rare. We present a rare case of inflammatory granuloma in the inguinal hernia sac after hysterosalpingography with lipiodol. PRESENTATION OF CASE: A 30-year-old woman who had left inguinal growing mass for 7 months after hysterosalpingography with Lipiodol for examination of infertile. About 3 cm soft mass was palpable on the left inguinal region, and plane CT scan showed a multifocal cystic mass with metal concentration. Thus, laparoscopic herniorrhaphy was performed to repair the inguinal hernia and to confirm the contents of cystic lesion. The hernia sac filled with mucinous contents. Pathological examination revealed that inflammatory granuloma due to numerous lipid droplets and phagocytic images of leukocytes in the hernia capsule. DISCUSSION AND CONCLUSION: Although oil contrast medium is safety agent, there is rear complication which need the surgical treatment. Complete resection of granuloma, including hernia sac, is important to prevent recurrence.

Metformin Prevents Peritoneal Dissemination via Immune-suppressive Cells in the Tumor Microenvironment.

BACKGROUND/AIM: Metformin, a drug for type 2 diabetes, also exerts anticancer effects. This study addressed the immunological effects of metformin on peritoneal dissemination. MATERIALS AND METHODS: We developed a mouse model of peritoneal dissemination via intraperitoneal injection of RLmale1, an X-ray-induced leukemia cell line, into BALB/c mice. Cell-surface markers, cytokine production, and myeloid-derived suppressor cells (MDSCs) were examined in cells from spleen and peritoneal lavage fluid. RESULTS: Metformin-treated mice exhibited suppressed intraperitoneal tumor growth and extended survival, and these effects were lost in mice with severe combined immunodeficiency. MDSCs induction was inhibited in metformin-treated mice. Although MDSC mobilization into the peritoneal cavity was correlated with suppression of interferon-γ production by tumor-infiltrating lymphocytes, the T-helper 1 ability of these lymphocytes was preserved in metformin-treated mice. CONCLUSION: Our findings demonstrate the action of metformin on both intraperitoneal tumors and immune-suppressive cells and might contribute to the development of immunotherapy against peritoneal dissemination.

A Novel Prognostic Scoring System Using Inflammatory Response Biomarkers for Esophageal Squamous Cell Carcinoma.

BACKGROUND: We describe a novel scoring system, namely the inflammatory response biomarker (IRB) score. The aim of this study is to evaluate the clinical value of IRB score in patients undergoing curative resection for esophageal squamous cell carcinoma (SCC). METHODS: We retrospectively reviewed patients who underwent curative esophagectomy. We evaluated IRB score in both non-elderly (<70 years) and elderly (≥70 years) SCC patients. The IRB score was determined as follows: a high lymphocyte-to-monocyte ratio (LMR) (>4), a high neutrophil-to-lymphocyte ratio (NLR) (>1.6), and a low platelet-to-lymphocyte ratio (PLR) (<147) were each scored as 1, and the remaining values were scored as 0; the individual scores were then summed to produce the IRB score (range 0-3). RESULTS: Univariate analyses demonstrated that the TNM pStage (p < 0.0001), tumor size (p = 0.002), LMR (p = 0.0057), PLR (p = 0.0328) and IRB score (p = 0.0003) were significant risk factors for a worse prognosis. On multivariate analysis, the TNM pStage (p < 0.0001) and IRB score (p = 0.0227) were independently associated with worse prognosis in overall patients. Among non-elderly patients, multivariate analyses demonstrated that the pStage (p = 0.0015) and IRB score (p = 0.0356) were independent risk factors for a worse prognosis. Among elderly patients, multivariate analysis demonstrated that the pStage (p = 0.0016), and IRB score (p = 0.0102) were independent risk factors for a worse prognosis. CONCLUSION: The present study provides evidence that the preoperative IRB score can be considered a promising independent prognostic factor of cancer-specific survival in patients undergoing curative resection for SCC, and that its predictive ability is useful in both non-elderly and elderly patients.

Case of colonic intussusception secondary to mobile cecum syndrome repaired by laparoscopic cecopexy using a barbed wound suture device.

A 27-year-old man with recurrent right lower quadrant pain was admitted to our hospital. Ultrasonography and computed tomography examination of the abdomen revealed a target sign in the ascending colon, which was compatible with the diagnosis of cecal intussusception. The intussusception was spontaneously resolved at that time, but it relapsed 6 mo later. The patient underwent a successful colonoscopic disinvagination; there was no evidence of neoplastic or inflammatory lesions in the colon and terminal ileum. The patient underwent laparoscopic surgery for recurring cecal intussusception. During laparoscopy, we observed an unfixed cecum on the posterior peritoneum (i.e. a mobile cecum). Thus, we performed laparoscopic appendectomy and cecopexy with a lateral peritoneal flap using a barbed wound suture device. The patient's post-operative course was uneventful, and he continued to do well without recurrence at 10 mo after surgery. Laparoscopic cecopexy using a barbed wound suture device is a simple and reliable procedure that can be the treatment of choice for recurrent cecal intussusception associated with a mobile cecum.

Validation of a novel prognostic scoring system using inflammatory response biomarkers in patients undergoing curative thoracoscopic esophagectomy for esophageal squamous cell carcinoma.

BACKGROUND: Systemic inflammatory markers, including the lymphocyte-to-monocyte ratio, neutrophil-to-lymphocyte ratio, and platelet-to-lymphocyte ratio have been shown to predict postoperative recurrence and survival in various types of cancer. However, their role in esophageal cancer has yet to be determined. This study aimed to evaluate the prognostic significance of an inflammatory response biomarker (IRB) score, independent of conventional clinicopathological criteria, in patients with esophageal cancer undergoing curative resection. PATIENTS AND METHODS: We retrospectively reviewed a database containing the medical records of 147 consecutive patients who underwent curative esophagectomy for esophageal squamous cell carcinoma. The IRB score was determined as follows: a low lymphocyte-to-monocyte ratio (<4), a low neutrophil-to-lymphocyte ratio (<1.6), and a high platelet-to-lymphocyte ratio (>147), which were each scored as 1, with all remaining values scored as 0. The scores were added together to produce the IRB score (range: 0-3). RESULTS: An IRB score of 2-3 (hazard ratio: 6.023, 95% confidence interval: 1.675-13.078; P<0.01) was identified as an independent poor prognostic factor of cancer-specific survival (CSS) in a multivariate logic regression analysis. The 5-year CSS rates in patients with the IRB scores of 0-1, 2, and 3 were 37.8%, 67.8%, and 72.5%, respectively. As determined by Kaplan-Meier analysis and the log-rank test, these differences were significant (P<0.001). CONCLUSION: The IRB score can predict the systemic inflammatory response as accurately as conventional tumor markers and is useful for determining CSS in patients with esophageal cancer undergoing curative thoracoscopic esophagectomy.

[ESTIMATION OF POSITIVE RATES OF INTERFERON-GAMMA RELEASE ASSAY BY AGE GROUP IN JAPAN].

[Background] Interferon-gamma release assay (IGRA) is necessary for evaluating Mycobacteriun tuber- culosis infection in Japan. Application of IGRA for contact surveys has been extended for the aged population; how- ever, there is little information on positive rates with Quanti- FERON® in Tube (QFT-3G) and T-SPOT.®TB (T-SPOT), which sometimes makes it difficult to interpret the results of IGRA performed in contact investigation including the aged population. [Objective] To estimate the positive rate of IGRAs by age group in the general population as well as among healthcare workers. [Methods] We requested all public health centers in Japan to provide contact investigation data for which the risk of infection is limited. Collected data included results of IGRAs in the target group, sputum bacteriological examinations and chest-image findings, and symptoms of the index cases as well as closeness and duration of contact between the index case and the target group. We scrutinized all the cases and exclude data that were not eligible for this study. Positive rates by age group were calculated by summing the number of contacts who were "positive" and dividing by the number of examinees. [Results] In spite of our effort to exclude newly infected persons from the index case, a small portion (probably 3%) may be due to those newly infected by a source case, as it is difficult to exclude those who get infected by casual contact. It is sometimes difficult to collect information on the close- ness and overall duration of contact with the index case, which is a limitation in the questionnaire. Positive rates of IGRA by age group in the general popula- tion were one third to one fifth of the predicted prevalence of infection, which is consistent with findings in the study using QFT Gold (QFT-2G) that IGRA wanes after infection. There were no differences of IGRA positive rate between the general population and health care workers. It may be because the risk of infection for health care workers is similar, as the number of infectious TB patients has been decreasing and infection control in hospitals has generally improved. It may be also because targets for IGRA in contact examina- tion among health care workers tend to be broad including a certain number of low risk staff. [Conclusion] With reference to past studies, we estimated that IGRA positive rates were 5% in the 60's and 15% in the 70's. It will be useful in assessing the possibility or spread of infection for aged groups in contact investigation.

Triple-drug therapy to prevent pancreatic fistula after pancreatectomy in a rat model.

BACKGROUND: Pancreatic fistula (PF) is one of post-operative complications in pancreatic surgery, but there is no consensus about the optimal treatment for PF. Our group has established a rat model of PF, and we conducted the present investigation to determine the efficacy of the triple-drug therapy (somatostatin analogue, gabexate mesilate, and imipenem/cilastatin) against PF using our rat model. METHODS: In the PF rat model, the triple-drug therapy was administered to the treated (T) group (n = 4), and we compared the results with those of a control (C) group (n = 4). The rats were sacrificed on postoperative day 3 (POD 3) and the levels of amylase and lipase in serum and ascites were measured. The intra-abdominal adhesion was scored. Each pancreas was evaluated pathologically, and inflammation was scored. RESULTS: The ascitic amylase levels on POD 3 were 1982 (1738-2249) IU/L in the C group and significantly lower at 136 (101-198) IU/L in the T group (p = 0.02). The ascitic lipase levels on POD 3 were 406 (265-478) U/L in the C group and significantly lower at 13 (7-17) U/L in the T group (p = 0.02). The intra-abdominal adhesion score on POD 3 was 2 (1-2) in the C group and significantly lower at 0 (0-1) in the T group (p = 0.02). The histological evaluation showed that the average of pancreatic inflammatory score was 8.5 (8-9) in the C group and significantly milder at 5 (5-7) in the T group (p = 0.01). CONCLUSION: Our findings suggest that the triple-drug therapy could be useful as a treatment for PF in clinical settings.

Human Fibroblast Sheet Promotes Human Pancreatic Islet Survival and Function In Vitro.

In previous work, we engineered functional cell sheets using bone marrow-derived mesenchymal stem cells (BM-MSCs) to promote islet graft survival. In the present study, we hypothesized that a cell sheet using dermal fibroblasts could be an alternative to MSCs, and then we aimed to evaluate the effects of this cell sheet on the functional viability of human islets. Fibroblast sheets were fabricated using temperature-responsive culture dishes. Human islets were seeded onto fibroblast sheets. The efficacy of the fibroblast sheets was evaluated by dividing islets into three groups: the islets-alone group, the coculture with fibroblasts group, and the islet culture on fibroblast sheet group. The ultrastructure of the islets cultured on each fibroblast sheet was examined by electron microscopy. The fibroblast sheet expression of fibronectin (as a component of the extracellular matrix) was quantified by Western blotting. After 3 days of culture, islet viabilities were 70.2 ± 9.8%, 87.4 ± 5.8%, and 88.6 ± 4.5%, and survival rates were 60.3 ± 6.8%, 65.3 ± 3.0%, and 75.8 ± 5.6%, respectively. Insulin secretions in response to high-glucose stimulation were 5.1 ± 1.6, 9.4 ± 3.8, and 23.5 ± 12.4 µIU/islet, and interleukin-6 (IL-6) secretions were 3.0 ± 0.7, 5.1 ± 1.2, and 7.3 ± 1.0 ng/day, respectively. Islets were found to incorporate into the fibroblast sheets while maintaining a three-dimensional structure and well-preserved extracellular matrix. The fibroblast sheets exhibited a higher expression of fibronectin compared to fibroblasts alone. In conclusion, human dermal fibroblast sheets fabricated by tissue-engineering techniques could provide an optimal substrate for human islets, as a source of cytokines and extracellular matrix.

Sox9 expression in carcinogenesis and its clinical significance in intrahepatic cholangiocarcinoma.

BACKGROUND: Intrahepatic cholangiocarcinomas develop through a multi-step carcinogenesis. Precancerous lesions are defined as biliary intraepithelial neoplasia. Sex determining region Y-box9 (Sox9) is required for the normal differentiation of the biliary tract. AIMS: To evaluate the Sox9 expression in carcinogenesis and its correlation with clinicopathological features in intrahepatic cholangiocarcinoma. METHODS: Sox9 expression in normal epithelium, biliary intraepithelial neoplasia, and intrahepatic cholangiocarcinoma were investigated immunohistochemically using 43 specimens of intrahepatic cholangiocarcinoma. Sox9 expression in intrahepatic cholangiocarcinoma was compared with the clinicopathological features. The molecular effects of Sox9 were investigated by gene transfection to intrahepatic cholangiocarcinoma cell lines. RESULTS: Sox9 expression was decreased from the normal epithelium to the biliary intraepithelial neoplasia in a stepwise fashion. In 51.2% (22/43) of the patients with intrahepatic cholangiocarcinoma, Sox9 expression was positive, and Sox9 expression was significantly associated with the biliary infiltration (P=0.034) and poor overall survival (P=0.039). Upregulation of Sox9 promoted the cell migration and invasion, and decreased the E-cadherin expression and increased the vimentin and α-SMA expression in cell lines. CONCLUSIONS: Decreased Sox9 expression may be related to the early stage of the carcinogenesis of intrahepatic cholangiocarcinoma. Sox9 overexpression in intrahepatic cholangiocarcinoma is related to biliary infiltration and poorer prognosis, and it promotes cell migration and invasion, via the epithelial-to-mesenchymal transition.