Neuroendocrine neoplasms can produce multiple hormones that are released into the bloodstream, causing symptoms that vary depending on the type and quantity of hormones involved. We herein report a 63-year-old asymptomatic patient with pancreatic insulinoma who showed marked elevations in circulating calcitonin and procalcitonin levels that returned to normal following surgery. Immunohistochemical analyses confirmed the co-staining of calcitonin and insulin immunoreactivity in the tumor cells, suggesting a calcitonin-producing insulinoma. This insulinoma released calcitonin and a considerable amount of its precursor peptide, procalcitonin, resulting in both hyperprocalcitoninemia and hypercalcitoninemia.

Fluoroscopy-guided gastrointestinal procedures, including gastrointestinal stenting, balloon-assisted endoscopy (BAE), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS), are essential for diagnosis and treatment in gastroenterology. Such procedures involve radiation exposure that necessitates strict safety measures to protect patients, doctors, and medical staff. The April 2020 update to Japan's Ionizing Radiation Injury Prevention Regulations for occupational exposure reduced the lens exposure dose limit to approximately one-seventh of its previous level. This change highlights the need for improved safety protocols. Without adaptation, the sustainability of fluoroscopy-based endoscopic techniques could be at risk due to the potential to exceed these new limits. This review examines the current state of medical radiation exposure in the field of gastroenterology in Japan and discusses the findings of the REX-GI study.

Although single-incision laparoscopic surgery (SILS) has gained some attention as a feasible alternative to conventional multiport laparoscopic surgery (MPLS) in colonic surgery, it became less prevalent than expected. Hence, we conducted this systematic review to evaluate the feasibility, safety, and oncological outcomes of single-incision laparoscopic colectomy (SILC) with meta-analysis and discussion of the future prospect of SILS. The search was conducted from September to October 2023 using PubMed and the Cochrane Central Register of Controlled Trials. Articles on colorectal cancer comparing SILC with multiport laparoscopic colectomy (MPLC) from all randomized controlled trials and comparative studies with 50 patients or more per arm were examined. The primary outcomes were the intra- and postoperative complication rates, and the secondary outcomes were the perioperative and oncological outcomes. The trends of the SILS number in Japan and the trends of the number of articles on SILS in PubMed were also reviewed. There were no significant differences in perioperative complication rates, operative factors, and oncological outcomes between SILC and MPLC, although heterogeneity was observed mainly in operative factors and the total length of the skin incision was significantly shorter in SILC. Therefore, SILC is technically and oncologically feasible and safe when performed by experienced laparoscopic surgeons. The case number of SILS was gradually increasing but the rate of SILS was decreasing in Japan. The number of articles on SILS was also decreasing. SILS has gained foothold to some extent but has plateaued. The emerging new robotic platform may reappraise the concept of SILS.

Abstract Introduction: Surgery is often the treatment of choice for Lumbar disc herniation (LDH) with severe leg pain. This study aimed to investigate the efficacy of Condoliase chemonucleolysis (CC) in patients who were nonambulatory because of severe leg pain. Methods: A total of 58 patients who underwent CC for conservative treatment-resistant LDH were included in this study. Changes in the leg and lower back pain evaluated using the numeric rating scale (NRS) were retrospectively assessed at three time points (1 week, 1 month, and 3 months after treatment). Patients were divided into the ambulatory group (group A) and nonambulatory group (group N) based on their ambulatory status. The clinical and radiological findings including magnetic resonance images were compared between the two groups. Results: Of the 58 patients, 16 (28%) who could not walk independently because of severe leg pain were included in group N. Group N showed significantly higher mean NRS score for leg pain (NRS-LP) before treatment than group A (group N, 7.9; group A, 6.8; p = 0.009). Changes in the mean NRS-LP from pretreatment to 1 week were significantly higher in group N (group N, 5.2; group A, 3.4; p = 0.02). In group N, the mean NRS-LP decreased significantly over time, and 69% of the patients were ambulatory after 1 week, 88% after 1 month, and 94% after 3 months. Conclusions: CC provides early pain relief and can be an immediate treatment option for patients who cannot walk independently because of severe leg pain.

This report describes the case of a 76-year-old man with ulcerative colitis who developed interstitial nephritis after starting 5-Aminosalicylic acid (5-ASA) therapy. The patient experienced an initial improvement in symptoms, but developed fatigue, anorexia, and severe renal dysfunction 2.5 months later. Renal biopsy confirmed drug-induced interstitial nephritis, and conservative treatment with fluid replacement and the discontinuation of 5-ASA improved the patient's condition. Clinicians should monitor patients receiving 5-ASA therapy for potential adverse effects, particularly renal injury, and promptly investigate symptoms of renal dysfunction. Early recognition and discontinuation of the offending agent may prevent further damage and improve patient outcomes.

AbstractPurposePostoperative venous thromboembolism (VTE) risk is pronounced after abdominal cancer surgery. Enoxaparin shows promise in preventing VTE in gastrointestinal, gynecological, and urological cancers, but its application after surgery for hepatobiliary‐pancreatic malignancy has been under‐evaluated due to bleeding concerns. We confirmed the safety of enoxaparin administration in patients undergoing curative hepatobiliary‐pancreatic surgery for malignancies in a prospective, multi‐center, phase I study.MethodsThe study was conducted from April 2015 to May 2021 across eight specialized centers. Patients (n = 262) were randomized to enoxaparin prophylaxis given postoperatively for 8 days (n = 131) or control (n = 131). The primary endpoint was the efficacy in reducing VTE. Secondary endpoints examined safety.ResultsThe full analysis set included 259 patients (131 control, 129 enoxaparin). The per‐protocol population included 233 patients (117 control, 116 enoxaparin). Most cases were hepatic malignancies (111 control, 111 enoxaparin). The median administration duration of enoxaparin was 7 days, with 92% receiving 4000 units/day. Despite a reduction in the relative risk (RR) of VTE due to postoperative enoxaparin administration, the results were not significant (control: four cases, 3.4% vs. treatment: two cases, 1.7%; RR 0.50, 95% CI 0.09–2.70; p = 0.6834). No significant difference was found in the incidence of bleeding events (control: five cases, 4.3% vs. treatment: five cases, 4.3%, RR 1.00, 95% CI 0.53–1.89; p = 1.0000).ConclusionsThe perioperative administration of enoxaparin in hepatobiliary‐pancreatic malignancies is feasible and safe. However, further case accumulation and investigation are necessary to assess its potential in reducing the occurrence of VTE.

BackgroundThe optimal neoadjuvant chemotherapy (NAC) regimen for patients with localized pancreatic ductal adenocarcinoma (PDAC) remains uncertain. This trial aimed to evaluate the efficacy and safety of two neoadjuvant chemotherapy (NAC) regimens, gemcitabine plus nab-paclitaxel (GA) and gemcitabine plus S-1 (GS), in patients with resectable/borderline-resectable (R/BR) PDAC.Patients and MethodsTreatment-naïve patients with R/BR-PDAC were enrolled and randomly allocated. They received two cycles (2 months) of each standard protocol, followed by radical surgery for those without tumor progression in general hospitals belonging to our intergroup. The primary endpoint was to determine the superior regimen on the basis of achieving a 10% increase in the rate of patients with progression-free survival (PFS) at 2 years from allocation.ResultsA total of 100 patients were enrolled, with 94 patients randomly assigned to the GS arm (N = 46) or GA arm (N = 48). The 2-year PFS rates did not show the stipulated difference [GA, 31% (24–38%)/GS, 26% (18–33%)], but the Kaplan–Myer analysis showed significance (median PFS, GA/GS 14 months/9 months, P = 0.048; HR 0.71). Secondary endpoint comparisons yielded the following results (GA/GS arm, P-value): rates of severe adverse events during NAC, 73%/78%, P = 0.55; completion rates of the stipulated NAC, 92%/83%, P = 0.71; resection rates, 85%/72%, P = 0.10; average tumor marker (CA19-9) reduction rates, −50%/−21%, P = 0.01; average numbers of lymph node metastasis, 1.7/3.2, P = 0.04; and median overall survival times, 42/22 months, P = 0.26.ConclusionsThis study found that GA and GS are viable neoadjuvant treatment regimens in R/BR-PDAC. Although the GA group exhibited a favorable PFS outcome, the primary endpoint was not achieved.

This study evaluated the risk of metachronous colorectal cancer (CRC) after resection of index (first) rectal cancer in patients with Lynch syndrome (LS). Clinicopathological data of patients with genetically proven LS were retrospectively analyzed in this multicenter Japanese study. The cumulative incidence of metachronous CRC and the overall survival were compared between patients with index rectal cancer (rectal group) and those with index colon cancer (colon group). The median age at index CRC surgery was lower in the rectal group than in the colon group (37 vs. 46years old, P = 0.01). The cumulative 5-, 10-, and 20-year incidences of metachronous CRC were 3.5%, 13.9%, and 21.1%, respectively, in the rectal cancer group and 14.9%, 22.0%, and 57.9%, respectively, in the colon cancer group (P = 0.02). The overall survival curves were not significantly different between two groups (P = 0.23). This is the first report from an East Asian country to report the risk of metachronous CRC after resection of index rectal cancer in patients with LS. Despite this study having several limitations, we cannot recommend extended resection, such as total proctocolectomy, for index rectal cancer as a standard surgical treatment in patients with LS.

Due to the aggressive nature and poor prognosis of advanced pancreatic cancer, prompt initiation of treatment is critical. We investigated the effect of the interval between cancer diagnosis and initiation of chemotherapy on survival in patients with advanced pancreatic cancer. In this retrospective, single-centre study, consecutive patients with advanced pancreatic cancer between April 2013 and March 2022 were analyzed. Data were extracted from the electronic medical records of patients who received chemotherapy for metastatic, locally advanced or resectable pancreatic cancer or who received chemotherapy due to either being intolerant of or declining surgery. We compared overall survival between two groups: the early waiting time group (waiting time≤30days from diagnosis to chemotherapy initiation) and the elective waiting time group (waiting time≥31days). Prognostic factors, including biliary drainage, were considered. The impact of waiting time on survival was assessed by univariate and multivariate analyses with Cox proportional hazard models. A 1:1 propensity score matching approach was used to balance bias, accounting for significant poor prognosis factors, age and sex. The study involved 137 patients. Overall survival exhibited no statistically significant difference between the early and elective waiting time groups (207 and 261days, P=0.2518). Univariate and multivariate analyses identified poor performance status and metastasis presence as predictors of worse prognosis. This finding persisted post propensity score matching (275 and 222days, P=0.8223). Our study revealed that initiating chemotherapy ˃30days later does not significantly affect treatment efficacy compared to within 30days of diagnosis.

The prognostic factors associated with severe-to-fatal post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remain unclear despite the extensive number of studies on PEP. In total, 3739 ERCP patients with biliary disease with an intact papilla and indicated for ERCP were prospectively enrolled at 36 centers from April 2017 to March 2018. Those with acute pancreatitis diagnosed before ERCP, altered gastrointestinal anatomy, and an American Society of Anesthesiologists (ASA) physical status > 4 were excluded. Univariate and multivariate logistic regression analyses were performed on patient-related factors, operator-related factors, procedure-related factors, and preventive measures to identify potential prognostic factors for severe-to-fatal PEP. Multivariate analyses revealed pancreatic guidewire-assisted biliary cannulation (OR 13.59, 95% CI 4.21-43.83, p < 0.001), post-ERCP non-steroidal anti-inflammatory drug (NSAID) administration (OR 11.54, 95% CI 3.83-34.81, p < 0.001), and previous pancreatitis (OR 6.94, 95% CI 1.45-33.33, p = 0.015) as significant risk factors for severe-to-fatal PEP. Preventive measures included endoscopic biliary sphincterotomy (EST; OR 0.29, 95% CI, 0.11-0.79, p = 0.015) and prophylactic pancreatic stents (PPSs; OR 0.11, 95% CI, 0.01-0.87, p = 0.036). In biliary ERCP, pancreatic guidewire-assisted biliary cannulation, NSAID administration after ERCP, and previous pancreatitis were risk factors for severe-to-fatal PEP, whereas EST and PPS were significant preventive measures for severe-to-fatal PEP.