Anastomotic tension "Bridging": a risk factor for anastomotic leakage following low anterior resection.

BACKGROUND: Excessive tension at the anastomosis contributes to anastomotic leakage (AL) in low anterior resection (LAR). However, the specific tension has not been measured. We assessed whether "Bridging," characterized by the proximal colon resembling a suspension bridge above the pelvic floor, is a significant risk factor for AL following LAR for rectal cancer. METHODS: This retrospective study reviewed the medical records and laparoscopic videos of 102 patients who underwent laparoscopic LAR using the double stapling technique at Yachiyo Hospital between January 2014 and December 2023. Patients were classified based on whether they had Bridging (tight or sagging) or were in a Resting state of the proximal colon, and the association between Bridging and AL was examined. RESULTS: AL occurred in 31.3% of the Tight Bridging group, 20% of the Sagging Bridging group, and 2.2% of the Resting group (P = 0.002). The incidence of AL was significantly higher in patients with Bridging than in those without (23.2% vs. 2.2%, P = 0.003). Multivariate analysis revealed that Bridging is an independent risk factor for AL (odds ratio = 6.97; 95% confidence interval: 1.45-33.6; P = 0.016). CONCLUSIONS: The presence of Bridging is a significant risk factor for AL following LAR for rectal cancer, suggesting the need for implementing preventive measures in patients with this condition.

Risk Factors for Stoma Outlet Obstruction: Preventing This Complication after Construction of Diverting Ileostomy during Laparoscopic Colorectal Surgery.

Introduction: Bowel obstruction at the outlet of the stoma, also referred to as "stoma outlet obstruction" (SOO), has been noted to be more common after laparoscopic colorectal surgery with diverting ileostomy than after laparotomy. Thus, the aim of this study is to identify the risk factors for SOO and to evaluate the effectiveness of a modified ileostomy procedure for reducing its incidence. Methods: The medical records of 63 patients who underwent laparoscopic colorectal surgery with diverting ileostomy between January 2014 and July 2021 were retrospectively reviewed. We analyzed the risk factors for SOO using computed tomography findings. Results: In total, 34 patients underwent surgery before modification of the ileostomy procedure (LSa group), and 29 patients underwent surgery after modification (LSb group). In the LSa group, 6 patients have reportedly developed SOO (SOO group), whereas 28 patients did not (non-SOO group). No patients in the LSb group developed SOO. The thickness of the abdominal rectus muscle (ThM) in the SOO group and the non-SOO group was 13.4 mm and 9.6 mm, respectively (p = 0.005). The angle between the ileostomy and the abdominal wall (AIW) was 95.8° in the non-SOO group and 82.2° in the SOO group (p = 0.033). The AIW was 93.4° in the LSa group and 99.7° in the LSb group (p = 0.043). Conclusions: As per our findings, a thick abdominal rectus muscle is predictive of SOO. Correction of the AIW (eliminating medial inclination) by modifying the operative technique has eliminated the occurrence of SOO in our patient population.

The impact of standardized methods of hepatic vein reconstruction with an external iliac vein graft.

BACKGROUND: Liver tumors that invade the hepatic vein are surgically challenging, especially in patients with liver dysfunction. Preservation of as much of the parenchyma as possible is important; thus, when feasible, we perform hepatectomy with hepatic vein reconstruction (HVR) using an external iliac vein (EIV) graft. We conducted a retrospective study to investigate the benefit of HVR and to evaluate our procedure. METHODS: The study included patients treated by hepatectomy with HVR using EIV grafts and vascular clips. We reviewed the surgical outcomes, including total operation and HVR times, postoperative complications, and postoperative liver function. RESULTS: The surgeries included right HVR (n=13), left HVR (n=3), and middle HVR (n=1). The total operation time was 277±72 minutes (155-400 minutes), and the HVR time was 27±5 minutes (19-40 minutes). Graft patency was confirmed in 14 (82%) of the patients. One patient who underwent HVR with running sutures required emergency surgery due to graft thrombosis. Clavien-Dindo > grade IIIa postoperative complications occurred in 4 (23.5%) patients, but there were no treatment-related deaths. CONCLUSIONS: In conclusion, our hepatic resections with HVR using the same techniques and graft materials showed acceptable surgical outcomes. From our experience, we believe that preparatory hepatic resection with HVR is an effective treatment, especially for patients with decreased liver function or with a small residual liver parenchyma.

Laparoscopic transabdominal preperitoneal repair versus open mesh plug repair for bilateral primary inguinal hernia.

AIM: A few studies comparing laparoscopic and open techniques have reported that open repair with mesh is the optimal operation for unilateral primary hernia. The aim of this study is to compare the outcomes of laparoscopic transabdominal preperitoneal repair (TAPP) versus open mesh plug repair (MP) for bilateral primary inguinal hernia. METHODS: This was a retrospective study of 107 patients with bilateral primary inguinal hernia between January 2008 and December 2016. Of these patients, 49 underwent TAPP and 58 underwent MP. The surgical outcomes and the long-term outcomes using a questionnaire were compared between TAPP and MP. RESULTS: In the TAPP group, the operation time was significantly longer (103 vs 91 minutes; P = .019). The postoperative complication rate was not significantly different between the two groups. One patient (1.0%) in the TAPP group and five patients (4.3%) in the MP group suffered recurrence (P = .30). Postoperative groin pain was not significantly different (14% in the TAPP group vs 31% in the MP group; P = .065), but more patients required analgesics in the MP group (4.1% vs 17%; P = .036). The long-term outcomes, according to a questionnaire, were not significantly different between the two groups. The median follow-up period was 22 (range, 0.4-52) months in the TAPP group and 40 (range, 0.5-108) months in the MP group (P < .001). CONCLUSION: TAPP for bilateral primary inguinal hernia achieved better results than MP relative to postoperative pain and the use of medication for pain relief without increasing the complication and recurrence rates.

The preoperative prognostic nutrition index is a prognostic indicator for survival in elderly gastric cancer patients after gastrectomy: a propensity score-matched analysis.

The incidence of gastric cancer (GC) in elderly patients has increased, and it is important for predicting prognosis for those patients. The prognostic nutrition index (PNI), which is a indicator of nutrition status, is useful for the assessment of prognosis for various cancers. The aim of this propensity score-matched study was to investigate the significance of the PNI for predicting the long-term outcome of GC patients who were 80 years old or older. This study included 127 elderly GC patients who underwent gastrectomy. The optimal cutoff value for the PNI score was defined using a receiver operating curve analysis. For the analysis of long-term outcomes, 86 patients were selected by propensity score matching. The long-term outcomes and prognostic factors after gastrectomy were analyzed by univariate and multivariate Cox regression analyses. The cutoff value for the PNI score was set at 46.5. Among the 86 patients, 30 patients died due to noncancer-related disease. The 5-year cancer-specific survival rates of patients with a PNI score < 46.5 and PNI score ≥ 46.5 were 73.5% and 84.6%, respectively (P = 0.832). The 5-year overall survival rates of patients with a PNI score < 46.5 and PNI score ≥ 46.5 were 38.2% and 49.3%, respectively (P = 0.004). According to the multivariate analysis, the PNI score (HR 2.15; 95% CI 1.37-3.94; P = 0.013) and pathological stage (HR 2.16; 95% CI 1.02-4.61; P = 0.045) were independent prognostic factors. The PNI is a promising assessment tool for predicting OS in elderly GC patients.

Laparoscopic pancreaticoduodenectomy for remnant pancreatic recurrence after laparoscopic distal pancreatectomy and hepatectomy for greater omentum leiomyosarcoma.

Laparoscopic pancreatic surgery is one of the most difficult procedures, and the adoption of laparoscopic pancreaticoduodenectomy has been limited. The application of laparoscopic surgery has extended to advance cancer, but there have been no reports of laparoscopic pancreaticoduodenectomy after laparoscopic liver resection and distal pancreatectomy. In the present case, a 67-year-old woman was diagnosed with remnant pancreatic recurrence of metastatic greater omentum leiomyosarcoma. She had previously undergone laparoscopic distal pancreatectomy and left lateral liver sectionectomy in 2016. We performed laparoscopic subtotal stomach-preserving pancreaticoduodenectomy in June 2017. The operation time was 274 minutes, and the estimated blood loss was 50 mL. There were no postoperative complications. In summary, laparoscopic pancreaticoduodenectomy is a safe and feasible procedure for a patient who had previously undergone pancreas and liver surgery.

Feasibility study of open inguinal hernia repair using mesh plug by residents.

BACKGRAUND/OBJECTIVE: Inguinal hernia repair by mesh-plug (MP) is one of the most common general surgeries, and even residents can perform it. The aim of this study was to investigate the postoperative outcome of MP repair by residents and risk factors related to the recurrence. METHODS: This study included 658 patients underwent MP repair for inguinal hernia. We compared short- and long-term outcomes of the MP repair by residents who were postgraduate year two with those by non-residents. Late complications were investigated via questionnaire. RESULTS: Among the patients, 206 patients (31%) underwent MP repair by residents, and the other 452 patients (69%) by non-residents. Operative time was significantly longer in the resident group (63 vs. 58 min, P = 0.004). Incidence of short- and long-term complications was not significantly different. The 3-year recurrence rate was significantly higher in the resident group (4.1 vs. 0.9%, P = 0.003). By multivariate analysis, independent perioperative risk factors related to recurrence were surgery by residents (Odds ratio 3.42, 95% CI 1.34-8.76, p = 0.010) and direct hernia (Odds ratio 7.69, 95% CI 2.83-20.83, p < 0.001). CONCLUSION: The MP repair by residents and direct hernia were risk factors related to recurrence. Surgeons should provide very careful guidance to residents especially for direct hernia.

Etiologies and outcomes of emergency surgery for acute abdominal pain: an audit of 1456 cases in a single center.

PURPOSE: There are few studies that have reported the details of emergency surgery for acute abdominal pain. This study aimed to clarify the etiologies and outcomes of emergency abdominal surgery among patients in different age categories. METHODS: Between January 2014 and December 2016, 1456 patients aged 7 years or older who underwent emergency surgery for acute abdominal pain at our institution were enrolled in this study. The patients were divided into three age groups: 7-17 years (n = 146), 18-64 years (n = 628), and 65 years or older (n = 682). The clinical characteristics, etiology of abdominal emergency surgery, and surgical outcomes were compared among the three groups. RESULTS: The proportion of patients with comorbid conditions significantly increased with increasing ages. In patients in between 7 and 17 and in those between 18 and 64 years, acute appendicitis was the most frequent etiology, followed by bowel obstruction. Conversely, the most frequent etiology was bowel obstruction, followed by biliary disease in patients 65 years or older. The morbidity and mortality rate were 12% and 0.2% in patients 18-64 years, and 25% and 1.8% in patients 65 years or older (P < 0.001 and P = 0.004, respectively). In the group of patients 65 years or older, more patients were transferred to different hospitals for rehabilitation or recovery. CONCLUSIONS: This study demonstrated significant differences among patients in different age categories in terms of the etiologies and outcomes of emergency abdominal surgery.

A Novel Technique of Hand-Sewn Purse-String Suturing by Double Ligation Method (DLM) for Intracorporeal Circular Esophagojejunostomy.

PURPOSE: The optimal method for intracorporeal esophagojejunostomy remains unclear because a purse-string suture for fixing the anvil into the esophagus is difficult to perform with a laparoscopic approach. Therefore, this study aimed to evaluate our novel technique to fix the anvil into the esophagus. MATERIALS AND METHODS: This retrospective study included 202 patients who were treated at our institution with an intracorporeal circular esophagojejunostomy in a laparoscopy-assisted total gastrectomy with a Roux-en-Y reconstruction (166 cases) or a laparoscopy-assisted proximal gastrectomy with jejunal interposition (36 cases). After incising 3/4 of the esophageal wall, a hand-sewn purse-string suture was placed on the esophagus. Next, the anvil head of a circular stapler was introduced into the esophagus. Finally, the circular esophagojejunostomy was performed laparoscopically. The clinical characteristics and surgical outcomes were evaluated and compared with those of other methods. RESULTS: The average operation time was 200.3 minutes. The average hand-sewn purse-string suturing time was 6.4 minutes. The overall incidence of postoperative complications (Clavien-Dindo classification grade ≥II) was 26%. The number of patients with an anastomotic leakage and stenosis at the esophagojejunostomy site were 4 (2.0%) and 12 (6.0%), respectively. All patients with stenosis were successfully treated by endoscopic balloon dilatation. There was no mortality. Regarding the materials and devices for anvil fixation, only 1 absorbable thread was needed. CONCLUSIONS: Our procedure for hand-sewn purse-string suturing with the double ligation method is simple and safe.

The Prognostic Impact of the Lymphocyte-to-Monocyte Ratio in Resected Pancreatic Head Adenocarcinoma.

OBJECTIVE: Although the prognostic significance of systematic inflammation-based scores, such as the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), and the prognostic nutritional index (PNI), has been explored in pancreatic cancers, few reports have investigated the lymphocyte-to-monocyte ratio (LMR). We aimed to retrospectively investigate the prognostic value of the preoperative LMR in patients with resectable pancreatic head cancer (PHC). METHODS: From 2005 to 2016, 165 patients underwent pancreatoduodenectomy for PHC. All samples of peripheral blood were collected within 2 weeks prior to surgery. The best cutoff values of the LMR for predicting survival were determined by using a minimum p value approach (cut-off value: 2.8). The clinicopathological features of LMR <2.8 (n = 25) and ≥2.8 (n = 140) were compared. RESULTS: Patients with LMR ≥2.8 showed significantly lower NLR and PLR, and significantly higher PNI. Levels of CEA and CA19-9 were similar, and the pathological findings were comparable between the groups. The overall survival of patients with LMR ≥2.8 (66.2% at 1 year) was superior to that of patients with LMR <2.8 (36.1% at 1 year, p = 0.015). Multivariate analysis identified LMR <2.8 (hazard ratio 1.72, 95% CI 1.02-2.89, p = 0.042), lymphatic and venous invasion and positive surgical margin as independent prognostic factors. CONCLUSIONS: LMR may carry important prognostic information for patients with resectable PHC. Preoperative LMR may be considered for use in risk stratification for individual patients with PHC.

Comparison of end-to-end anastomosis and interposition graft during pancreatoduodenectomy with portal vein reconstruction for pancreatic ductal adenocarcinoma.

PURPOSE: Many studies report that pancreatoduodenectomy (PD) with portal-superior mesenteric vein resection and reconstruction (PVR) is not a contraindication to extended tumor resection for pancreatic ductal adenocarcinoma. However, the clinical benefit of an interposition graft for PVR still remains controversial. METHODS: Between January 2001 and December 2017, 199 patients with pancreatic cancer underwent PD either with or without PVR, and their medical records were reviewed retrospectively, paying specific attention to the PVR methods and the long-term outcome. RESULTS: Among the 122 patients with PVR, 97 (79.5%) underwent end-to-end anastomosis and 25 (20.5%) had an interposition graft using the right external iliac vein (REIV). The 2-year and 5-year survival rates of the no-PVR group (54.2% and 30.8%, respectively) were longer than both the end-to-end anastomosis group (24.5% and 13.7%) and the interposition graft group (32% and 10.0%) (p < 0.001). However, there was no significant difference in the survival between the end-to-end anastomosis group and the interposition graft group (p = 0.963). A multivariate analysis indicated that the level of preoperative serum albumin < 3.5 g/dL (risk ratio (RR) 2.08, 95% confidence interval (CI) 1.26 to 3.43; p = 0.004), and postoperative adjuvant chemotherapy (RR 1.82, 95% CI 1.19 to 2.79; p = 0.006) were independently associated with overall survival after PVR. CONCLUSIONS: An interposition graft using the REIV for PVR following PD is safe and effective. There was no significant prognostic difference between PD with end-to-end anastomosis and with an interposition graft in patients with pancreatic ductal adenocarcinoma.

Adverse oncological outcome of surgical site infection after liver resection for colorectal liver metastases.

PURPOSES: Postoperative complications are associated with poor overall and cancer-specific survival after resection of various types of cancer, including primary colorectal cancer. However, the oncological impact of surgical site infection (SSI) after liver resection for colorectal liver metastases (CLM) is unclear. The aim of this study was to investigate the oncological impact of SSI after liver resection for CLM. METHODS: We reviewed data from 367 consecutive patients treated by curative liver resection for CLM between 1994 and 2015. Patients who underwent simultaneous resection of colorectal cancer and synchronous liver metastases (n = 86) were excluded from the analysis. Short- and long-term outcomes were analyzed. RESULTS: SSI developed in 18 (6.4%) of the 281 patients in the analytic cohort (SSI group). The remaining 93.6% (n = 263) did not suffer this complication (no-SSI group). The operative duration was significantly longer in the SSI group than in the No-SSI group (p = 0.002). The overall survival rates 5 years after liver resection for CLM were 33.3% in the SSI group vs. 50.7% in the No-SSI group (p = 0.043). Multivariate analysis indicated that a liver tumor size ≥ 5 cm, R1 resection, and SSI were independently associated with overall survival after liver resection. CONCLUSIONS: SSI after liver resection for CLM is associated with adverse oncological outcomes.

Does the intestinal microenvironment have an impact on the choleretic effect of inchinkoto, a hepatoprotective herbal medicine?

AIM: The choleretic effects of inchinkoto (ICKT), a hepatoprotective herbal medicine, are variable among patients. This study sought to investigate the correlation between the choleretic effects of ICKT and the intestinal microenvironment in patients with biliary obstruction. METHODS: Patients with biliary obstruction who underwent external biliary drainage were enrolled. The concentrations of total bilirubin and bile acid in the bile, and genipin, a major active ingredient of ICKT, in the bloodstream before and after ICKT treatment were measured. Feces were collected from the patients to determine bacterial count and organic acid concentrations. RESULTS: Samples from 37 patients were collected and analyzed. The serum concentration of genipin increased 3 h after ICKT treatment and showed a positive correlation with the percent changes of biliary concentrations of bile acid, total bilirubin, and direct bilirubin. Serum genipin concentration also showed a positive correlation with the fecal concentrations of representative obligate anaerobes such as the Clostridium leptum subgroup, Bacteroides fragilis group, Bifidobacterium, and the Atopobium cluster. In sharp contrast, so-called harmful bacteria such as Clostridium difficile, Enterobacteriaceae, and Enterococcus showed a negative correlation with the concentration of genipin. Genipin concentration after ICKT administration showed a positive correlation with the fecal concentration of short chain fatty acids such as propionic acid and butyric acid, and a negative correlation with the fecal concentration of lactic acid. CONCLUSIONS: The absorption of genipin was variable among patients. This variability may be associated with the fecal microenvironment profile and partly explain the variable choleretic effects of ICKT among patients.

Clinical Effect of Water-Soluble Contrast Agents for Small Bowel Obstruction in the Virgin Abdomen.

BACKGROUND: Several studies have investigated the diagnostic and therapeutic role of water-soluble contrast agents (WSCAs) in adhesive small bowel obstruction (SBO). However, the clinical effect of WSCA for SBO without previous intraabdominal operation (i.e., virgin abdomen, VA) is unclear. The aim of this study was to clarify the clinical effect of WSCA for SBO in the VA. METHODS: Between January 2008 and December 2015, 838 consecutive patients with SBO were initially managed with WSCA and were included in the study. Abdominal X-rays were taken 5 h after administration of 100 ml WSCA and classified into complete/incomplete obstruction groups. The medical records of the patients with SBO were retrospectively analyzed and divided into two groups of patients with VA or non-VA. RESULTS: A total of 44 and 794 VA and non-VA patients were identified, respectively. Six VA patients (13%) and 121 non-VA patients (15%) were classified with complete obstruction (p = 1.000) and subjected to operative exploration on the same day. There were no significant differences in the duration of nasogastric tube decompression (2.2 versus 2.5 days, p = 0.400) and intervals until the initiation of oral intake (2.4 versus 2.6 days, p = 0.553) between the VA and non-VA groups. The overall operative rate was 16% in the VA and 17% in the non-VA groups (p = 1.000). Compared with non-VA, VA was associated with shorter hospital stays (9.6 versus 11.3 days, p = 0.006). CONCLUSIONS: WSCA for SBO in the VA is as effective as in non-VA patients in terms of a therapeutic strategy.

Internal hernia after proximal gastrectomy with jejunal interposition.

Although internal hernia (IH) has been reported after laparoscopic distal or total gastrectomy with Roux-en-Y reconstruction, there are few reports of IH after proximal gastrectomy with jejunal interposition (PG-JI). The aim of this study was to analyze the incidence and clinical features of IH after PG-JI. This study retrospectively reviewed 71 patients who underwent PG-JI for gastric cancer at a single institution between July 2007 and December 2016. The median follow-up period after PG-JI was 50 months. Four patients (5.6%) developed IH. IH occurred in 3 of 38 patients after open PG (7.9%) and 1 of 33 after laparoscopic PG (3.1%; p = 0.38). The site of IH was Petersen in all cases, where the Petersen defect was not closed. All patients had abdominal pain at onset, and the CT revealed a whirl sign. Bowel resection was required in three patients (75%). There was no morbidity. IH after PG-JI occurred regardless of operative approach (open or laparoscopic). A high degree of suspicion for IH should be maintained in patients after gastrectomy with abdominal pain and a whirl sign on CT. Closure of the mesenteric defects should be considered to reduce the incidence of IH after surgery.

Adjuvant hepatic artery infusion chemotherapy after hemihepatectomy for gastric cancer liver metastases.

BACKGROUND: The most frequent pattern of recurrence is remnant liver after hepatectomy for gastric cancer liver metastases (GLM). The evidence of adjuvant hepatic artery infusion chemotherapy (HAIC) after hepatectomy for GLM is lacking. The aim of this study was to evaluate the efficacy of adjuvant HAIC after hemihepatectomy for GLM. METHODS: Between 2001 and 2012, 14 patients who underwent hemihepatectomy for GLM were included in this study. Adjuvant HAIC to the remnant hemiliver was the FEM regimen (333 mg/m2 5-fluorouracil each week, 30 mg/m2 epirubicin once every 4 weeks, and 2.7 mg/m2 mitomycin-C once every 2 weeks) and was administered for 6 months after hemihepatectomy. Clinicopathological prognostic factors for survival were analyzed using a prospectively collected database. RESULTS: Nine patients had solitary GLM, and 5 patients had multiple GLM before surgery. The median period from hemihepatectomy to HAIC was 30 days. The 6-month HAIC completion rate was 79% (n = 11/14). Reasons of HAIC failure included liver dysfunction (n = 1), catheter infection (n = 1), and development of multiple recurrence (n = 1). The median follow-up was 29 (range 8-166) months. Recurrences were detected in 8 patients (57%). The site of recurrences included lung (n = 1), lymph nodes (n = 1), peritoneal dissemination (n = 1), brain (n = 1), pleural (n = 1), and multiple sites (n = 3). The overall 5-year survival rate was 43%. The pathological T4 classification and the preoperative CEA ≥5 ng/mL were significant prognostic factors for overall survival. CONCLUSIONS: Adjuvant HAIC after hemihepatectomy for GLM prevents remnant liver recurrence and may contribute to long-term survival.

Bilobar versus unilobar multiple colorectal liver metastases: a propensity score analysis of surgical outcomes and recurrence patterns.

BACKGROUND: Bilobar multiple colorectal liver metastases (MCLM) are often considered incurable or associated with a poor prognosis even after R0 resection. This study was designed to compare the long-term outcomes and recurrence patterns after one-stage resection in patients with bilobar versus unilobar MCLM. METHODS: The records of patients undergoing parenchymal-sparing intent hepatectomy between 1994 and 2015 were reviewed. Survival and recurrence patterns were analyzed by propensity score matching. RESULTS: The study population included 140 patients: 81 patients with bilobar MCLM versus 59 patients with unilobar MCLM. In the propensity score matching analysis (bilobar, n = 35 vs. unilobar, n = 35), the short-term outcomes did not differ between the two groups. Five-year overall survival (54.8% in bilobar vs. 51.2% in unilobar; P = 0.388) and recurrence-free survival (28.5% in bilobar vs. 36.2% in unilobar; P = 0.261) also did not differ. No significant differences were found in liver-only recurrence (22.9% in bilobar vs. 25.7% in unilobar; P = 1.000) and other recurrence patterns. CONCLUSIONS: The clearance of bilobar MCLM by one-stage resection of parenchymal-sparing intent provided comparable long-term survival to unilobar MCLM.

Exploration of serum biomarkers for predicting the response to Inchinkoto (ICKT), a Japanese traditional herbal medicine.

INTRODUCTION: In patients with obstructive jaundice, biliary drainage sometimes fails to result in improvement. A pharmaceutical-grade choleretic herbal medicine, Inchinkoto (ICKT), has been proposed to exert auxiliary effects on biliary drainage; however, its effects are variable among patients. OBJECTIVES: The aim of this study is to explore serum biomarkers that are associated with pharmaceutical efficacy of ICKT. METHODS: Obstructive jaundice patients who underwent external biliary decompression were enrolled (n = 37). ICKT was given orally 3 times a day at daily dose of 7.5 g. Serum and bile samples were collected before, 3 h after, and 24 h after ICKT administration. The concentrations of total bilirubin, direct bilirubin, and total bile acid in bile specimens were measured. Metabolites in serum samples were comprehensively profiled using LC-MS/MS and GC-MS/MS. Pharmacokinetic analysis of major ICKT components was also performed. RESULTS: ICKT administration significantly decreased serum ALT and increased bile volume after 24 h. The serum concentrations of ICKT components were not well correlated with the efficacy of ICKT. However, the ratio of 2-hydroxyisobutyric acid to arachidonic acid and the ratio of glutaric acid to niacinamide, exhibited good performance as biomarkers for the efficacy of ICKT on bile flow and ALT, respectively. Additionally, comprehensive correlation analysis revealed that serum glucuronic acid was highly correlated with serum total bilirubin, suggesting that this metabolite may be deeply involved in the pathogenesis of jaundice. CONCLUSIONS: The present study indicates that ICKT is efficacious and provides candidates for predicting ICKT efficacy. Further validation studies are warranted.

A case of advanced intrahepatic cholangiocarcinoma accidentally, but successfully, treated with capecitabine plus oxaliplatin (CAPOX) therapy combined with bevacizumab: a case report.

Although surgical resection is the only way to cure biliary tract cancer (BTC), most BTCs are unresectable by the time they are diagnosed. Chemotherapy is usually used to treat unresectable BTC, but its impact on survival is small. Here, we report the case of a 70-year-old woman with a locally advanced intrahepatic cholangiocarcinoma that was initially diagnosed as an unresectable liver metastasis from colon cancer that had invaded all of the major hepatic veins. However, the tumor was noticeably reduced after treatment with CAPOX plus bevacizumab, which is an uncommon therapy for BTC. The tumor was finally resected by inferior right hepatic vein-preserving left hepatic trisectionectomy combined with a resection of the right hepatic vein after a right hepatic vein embolization.