An 11-year-old boy, who underwent a Rastelli operation using a 14mm artificial graft and left pulmonary artery (PA) plasty with an autologous pericardium patch 7 years previously, had severe recurrent left pulmonary stenosis. Reoperation was performed including right ventricular outflow tract reconstruction and left PA plasty. The PA at the most stenotic site was only 2mm in diameter; it was enlarged to 10mm by good exposure and an incision on the pulmonary intima. A bovine pericardium patch with a handmade ePTFE valve was sutured onto the autologous tissue not onto the pulmonary intima to avoid restenosis and in expectation of the growth of the pulmonary orifice. On postoperative 3-D CT, the left pulmonary artery was patent and 9mm in diameter. Pulmonary scintigraphy showed an improvement in the left pulmonary perfusion. This sutureless technique was useful in this case of severe pulmonary stenosis.

Background: Borderline resectable pancreatic adenocarcinoma (BR-PAC) is defined as locally advanced tumor of the pancreas without metastasis that is, although potentially resectable (R), at high risk for positive resection margin following surgery. The therapeutic strategy has remained unestablished because BR-PAC is biologically a heterogeneous subset in which the preoperative prognostic factors are undetermined. Recently, several prognostic factors related to systemic inflammation have been explored in various kinds of cancers: the combination of serum C-reactive protein (CRP) and albumin as the modified Glasgow prognostic factor; a combination of CRP and white blood cell count in the prognostic index; a combination of albumin and lymphocyte counts in Onodera’s prognostic nutritional index; the neutrophil-lymphocyte ratio (NLR); and the platelet-lymphocyte ratio (PLR). Although these prognostic factors have been explored in some small cohort studies of PAC patients, the results still remain controversial especially because PAC patients with diverse clinical stages were included in the cohorts. It has never been reported whether or not the systemic inflammatory response is validated as a predictive risk factor in cohorts of only advanced BR-PAC patients. Method: Between January 2003 and June 2012 at Kobe University Hospital, 136 consecutive pancreatic adenocarcinoma (PAC) patients who underwent surgical curative resection were retrospectively studied. Prior to surgery, the PAC patients were stratified into R- and BR-PAC patients according to the National Comprehensive Cancer Network guidelines. To evaluate the independent prognostic significance of NLR and PLR, univariate and multivariate Cox proportional-hazard models were applied. Results: The median survival in PAC patients with preoperative NLR > 3 (n=45) and NLR < 3 (n=91) was 17.5 months and 31.1 months, respectively (P=0.0037). However, the median survival in PAC patients with PLR > 225 (n=32) and PLR < 225 (n=104) was 21.8 months and 26.2 months, showing no significant difference in overall survival between the two groups (P=0.2526). The median survival in the R-PAC patients with NLR > 3 (n=38) and NLR < 3 (n=70) was 18.1 months and 33.1 months, respectively (P=0.0138). However, the median survival in the R-PAC patients with PLR > 225 (n=27) and PLR < 225 (n=81) was 24.1 months and 25.8 months, showing no significant difference in overall survival between the two groups (P=0.6533). The median survival in BR-PAC patients with preoperative NLR > 3 (n=7) and NLR < 3 (n=21) was 14.8 months and 27.2 months, respectively (P=0.0068). In addition, median survival in BR-PAC patients with preoperative PLR > 225 (n=5) and PLR < 225 (n=23) was 14.8 months and 26.2 months, respectively (P=0.0050). Preoperative NLR > 3 (HR=21.437, 95% CI=4.119-142.980; P=0.0002) and PLR > 225 (HR=30.993, 95% CI=3.844- 384.831; P=0.0009) were the only independent prognostic factors in BR-PAC patients. Conclusion: Preoperative NLR and PLR offer independent prognostic information regarding overall survival in BR-PAC patients following curative resection. The workup is only to obtain a blood sample of 3 mL from PAC patients immediately before treatment. In the near future, these factors associated with the systemic inflammatory response may have the potential to become criteria for BRPAC candidates to undergo neoadjuvant chemotherapy and/or neoadjuvant chemoradiation followed by surgical resection

Background: Borderline resectable pancreatic adenocarcinoma (BR-PAC) isdefined as locally advanced tumor of the pancreas without metastasis that is,although potentially resectable (R), at high risk for positive resection marginfollowing surgery. The therapeutic strategy has remained unestablished becauseBR-PAC is biologically a heterogeneous subset in which the preoperativeprognostic factors are undetermined. Recently, several prognostic factors relatedto systemic inflammation have been explored in various kinds of cancers: thecombination of serum C-reactive protein (CRP) and albumin as the modifiedGlasgow prognostic factor; a combination of CRP and white blood cell countin the prognostic index; a combination of albumin and lymphocyte counts inOnodera’s prognostic nutritional index; the neutrophil-lymphocyte ratio (NLR);and the platelet-lymphocyte ratio (PLR). Although these prognostic factors havebeen explored in some small cohort studies of PAC patients, the results still remaincontroversial especially because PAC patients with diverse clinical stages wereincluded in the cohorts. It has never been reported whether or not the systemicinflammatory response is validated as a predictive risk factor in cohorts of onlyadvanced BR-PAC patients.Method: Between January 2003 and June 2012 at Kobe University Hospital,136 consecutive pancreatic adenocarcinoma (PAC) patients who underwentsurgical curative resection were retrospectively studied. Prior to surgery, the PACpatients were stratified into R- and BR-PAC patients according to the NationalComprehensive Cancer Network guidelines. To evaluate the independentprognostic significance of NLR and PLR, univariate and multivariate Coxproportional-hazard models were applied.Results: The median survival in PAC patients with preoperative NLR > 3 (n=45)and NLR < 3 (n=91) was 17.5 months and 31.1 months, respectively (P=0.0037).However, the median survival in PAC patients with PLR > 225 (n=32) and PLR< 225 (n=104) was 21.8 months and 26.2 months, showing no significantdifference in overall survival between the two groups (P=0.2526). The mediansurvival in the R-PAC patients with NLR > 3 (n=38) and NLR < 3 (n=70) was 18.1months and 33.1 months, respectively (P=0.0138). However, the median survivalin the R-PAC patients with PLR > 225 (n=27) and PLR < 225 (n=81) was 24.1months and 25.8 months, showing no significant difference in overall survivalbetween the two groups (P=0.6533). The median survival in BR-PAC patientswith preoperative NLR > 3 (n=7) and NLR < 3 (n=21) was 14.8 months and 27.2months, respectively (P=0.0068). In addition, median survival in BR-PAC patientswith preoperative PLR > 225 (n=5) and PLR < 225 (n=23) was 14.8 months and26.2 months, respectively (P=0.0050). Preoperative NLR > 3 (HR=21.437, 95%CI=4.119-142.980; P=0.0002) and PLR > 225 (HR=30.993, 95% CI=3.844-384.831; P=0.0009) were the only independent prognostic factors in BR-PACpatients.Conclusion: Preoperative NLR and PLR offer independent prognostic informationregarding overall survival in BR-PAC patients following curative resection. Theworkup is only to obtain a blood sample of 3 mL from PAC patients immediatelybefore treatment. In the near future, these factors associated with the systemicinflammatory response may have the potential to become criteria for BRPACcandidates to undergo neoadjuvant chemotherapy and/or neoadjuvantchemoradiation followed by surgical resection

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.

We present the case of a 76-year-old man who underwent preoperative endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) for obstructive jaundice caused by pancreatic head cancer. The patient had obstructive jaundice and cholangitis during neoadjuvant chemotherapy. Transpapillary biliary drainage using endoscopic retrograde cholangiopancreatography was attempted; however, it was unsuccessful because of duodenal tumor invasion. Therefore, EUS-HGS was performed. Jaundice and cholangitis improved promptly after EUS-HGS, and stent obstruction and migration were not observed before surgery. The stent was safely removed during surgery, and no postoperative complications occurred. Most studies of EUS-HGS for preoperative biliary drainage have been small and retrospective, and few have examined the safety of intraoperative stent removal. The fistula in our patient was promptly identified and the stent was safely removed despite the relatively limited field of view during robot-assisted laparoscopy.The promising findings of our case report can be used to inform EUS-based surgical strategies for biliary drainage with obstructive jaundice.