Impact of adjuvant therapy in patients with invasive intraductal papillary mucinous neoplasms of the pancreas: an international multicenter cohort study.

BACKGROUND: Adjuvant therapy prolongs survival in patients with pancreatic ductal adenocarcinoma. However, no clear guidelines are available regarding the oncologic effects of adjuvant therapy (AT) in resected invasive intraductal papillary mucinous neoplasms (IPMN). The aim was to investigate the potential role of AT in patients with resected invasive IPMN. MATERIALS AND METHODS: From 2001 to 2020, 332 patients with invasive pancreatic IPMN were retrospectively reviewed in 15 centres in eight countries. Propensity score-matched and stage-matched survival analyses were conducted. RESULTS: A total of 289 patients were enroled in the study after exclusion (neoadjuvant therapy, unresectable disease, uncertain AT status, and stage IV). A total of 170 patients were enroled in a 1:1 propensity score-matched analysis according to the covariates. In the overall cohort, disease-free survival was significantly better in the surgery alone group than in the AT group ( P =0.003), but overall survival (OS) was not ( P =0.579). There were no significant differences in OS in the stage-matched analysis between the surgery alone and AT groups (stage I, P =0.402; stage II, P =0.179). AT did not show a survival benefit in the subgroup analysis according to nodal metastasis (N0, P =0.481; N+, P =0.705). In multivariate analysis, node metastasis (hazard ratio, 4.083; 95% CI, 2.408-6.772, P <0.001), and cancer antigen 19-9 greater than or equal to 100 (hazard ratio, 2.058; 95% CI, 1.247-3.395, P =0.005) were identified as adverse prognostic factors in resected invasive IPMN. CONCLUSION: The current AT strategy may not be recommended to be performed with resected invasive IPMN in stage I and II groups, unlike pancreatic ductal adenocarcinoma. Further investigations of the potential role of AT in invasive IPMN are recommended.

Application of a novel surgical difficulty grading system during laparoscopic cholecystectomy.

BACKGROUND: Prevention of bile duct injury and vasculo-biliary injury while performing laparoscopic cholecystectomy (LC) is an unsolved problem. Clarifying the surgical difficulty using intraoperative findings can greatly contribute to the pursuit of best practices for acute cholecystitis. In this study, multiple evaluators assessed surgical difficulty items in unedited videos and then constructed a proposed surgical difficulty grading. METHODS: We previously assembled a library of typical video clips of the intraoperative findings for all LC surgical difficulty items in acute cholecystitis. Fifty-one experts on LC assessed unedited surgical videos. Inter-rater agreement was assessed by Fleiss's κ and Gwet's agreement coefficient (AC). RESULTS: Except for one item ("edematous change"), κ or AC exceeded 0.5, so the typical videos were judged to be applicable. The conceivable surgical difficulty gradings were analyzed. According to the assessment of difficulty factors, we created a surgical difficulty grading system (agreement probability = 0.923, κ = 0.712, 90% CI: 0.587-0.837; AC2  = 0.870, 90% CI: 0.768-0.972). CONCLUSION: The previously published video clip library and our novel surgical difficulty grading system should serve as a universal objective tool to assess surgical difficulty in LC.

EUS-guided pancreatic duct drainage with rendezvous technique for post-Whipple pancreatic duct stone.

Video 1EUS-guided pancreatic drainage using the rendezvous technique in a patient with pancreaticojejunal anastomosis stenosis and pancreatic duct stone.

Assembling a library of typical surgery video clips to construct a system for assessing the surgical difficulty of laparoscopic cholecystectomy.

BACKGROUND: To explore best practices for acute cholecystitis, it is necessary to construct a system to assess the difficulty of laparoscopic cholecystectomy (LC) based on intraoperative findings. In this study, multiple evaluators assessed videos of LC to assemble a library of typical video clips for 25 intraoperative findings. METHODS: We have previously identified 25 items that contribute to surgical difficulty in LC. For each item, roughly 30-second video clips were submitted from videos of LC performed at member institutions. We then selected one typical video from the collected clips based on simple tabulation of the instances of agreement. Inter-rater agreement was assessed with Fleiss's κ and Gwet's agreement coefficient (AC). RESULTS: Except in the case of two assessment items ("edematous change" and "easy bleeding"), κ or AC significantly exceeded 0.5 and the typical videos were judged to be applicable. For the two remaining items, the evaluation was repeated after clarifying the definitions of positive and negative findings. Eventually, they were recognized as typical. The completed video clip library contains 31 clips and is divided into five categories (http://www.jshbps.jp/modules/project/index.php?content_id=13). CONCLUSIONS: This clip library may be highly useful in clinical settings as a more objective standard for assessing surgical difficulty in LC.

Fruitful first experience with an 8K ultra-high-definition endoscope for laparoscopic colorectal surgery.

We performed laparoscopic surgery for three cases of colorectal cancer using an 8K ultra-high-definition endoscopic system, which offers 16-fold higher resolution than the current 2K high-definition endoscope. The weight of the camera has been successfully reduced to 370 g. To maximize the advantages of the 8K ultra-high-definition endoscope, surgery was performed by darkening the room and placing a large 85-in. display as close to the surgeon as possible. As a result, the autonomic nerve was preserved, and the membrane structure could be clearly observed. Moreover, we were able to feel the stereoscopic effect near the 3-D image. This suggests the possibility of improved curability and function preservation with the 8K endoscope. Although there are some disadvantages that need to be overcome, the 8K ultra-high-definition endoscope will surely contribute to further progress in laparoscopic surgery.

An opportunity in difficulty: Japan-Korea-Taiwan expert Delphi consensus on surgical difficulty during laparoscopic cholecystectomy.

BACKGROUND: We previously identified 25 intraoperative findings during laparoscopic cholecystectomy (LC) as potential indicators of surgical difficulty per nominal group technique. This study aimed to build a consensus among expert LC surgeons on the impact of each item on surgical difficulty. METHODS: Surgeons from Japan, Korea, and Taiwan (n = 554) participated in a Delphi process and graded the 25 items on a seven-stage scale (range, 0-6). Consensus was defined as (1) the interquartile range (IQR) of overall responses ≤2 and (2) ≥66% of the responses concentrated within a median ± 1 after stratification by workplace and LC experience level. RESULTS: Response rates for the first and the second-round Delphi were 92.6% and 90.3%, respectively. Final consensus was reached for all the 25 items. 'Diffuse scarring in the Calot's triangle area' in the 'Factors related to inflammation of the gallbladder' category had the strongest impact on surgical difficulty (median, 5; IQR, 1). Surgeons agreed that the surgical difficulty increases as more fibrotic change and scarring develop. The median point for each item was set as the difficulty score. CONCLUSIONS: A Delphi consensus was reached among expert LC surgeons on the impact of intraoperative findings on surgical difficulty.

The "right" way is not always popular: comparison of surgeons' perceptions during laparoscopic cholecystectomy for acute cholecystitis among experts from Japan, Korea and Taiwan.

BACKGROUND: Generally, surgeons' perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces. METHODS: A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200-499, 500-999, and ≥1,000). RESULTS: The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the "critical view of safety" technique, identification of Rouvière's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC. CONCLUSIONS: Even among experts, surgeons' perceptions during LC are workplace-dependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence.

Questionnaire survey on work motivations of gastrointestinal and hepatobiliary pancreatic surgeons enrolled in a Japanese national interdisciplinary program.

BACKGROUND: Among young residents, there seems to be a decreasing desire to become surgeons, resulting in a decrease in the number of surgeons. There is concern regarding a shortage of hepatobiliary pancreatic (HBP) surgery residents in Japan. A questionnaire survey was designed to assess the work motivations of Japanese gastrointestinal (GI) and HBP surgeons. METHODS: Questionnaires assessing seven domains related to motivation (aptitude, satisfaction/dissatisfaction, knowledge/skill, evaluation/approval, self-management, community/expectation from other parties, and emotion) were sent to GI and HBP surgeons throughout Japan. Differences between HBP and GI surgeons were analyzed. RESULTS: Responses were received from 27 institutions in Japan between May and August 2014. Mid-career and senior HBP surgeons (11-20 years after graduation) working in university hospitals were significantly less satisfied with their work than GI surgeons (P = 0.036). Evaluation/approval factors were significantly lower in senior HBP surgeons than in GI surgeons 16-20 years after graduation (P = 0.048). CONCLUSIONS: The future satisfaction of young residents seeking to become HBP surgeons should be enhanced, providing an appealing workplace for young residents and preventing discontinuation by mid-career and senior surgeons.

What are the appropriate indicators of surgical difficulty during laparoscopic cholecystectomy? Results from a Japan-Korea-Taiwan multinational survey.

BACKGROUND: Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC. METHODS: A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT. RESULTS: The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons. CONCLUSIONS: Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.

Ligament of Treitz approach in laparoscopic modified radical antegrade modular pancreatosplenectomy: report of three cases.

Laparoscopic distal pancreatectomy for pancreatic cancer is being applied increasingly in selected cases. Open radical antegrade modular pancreatosplenectomy (RAMPS) was introduced to obtain a higher rate of tumor-free margins and a higher lymph node (LN) count. However, there is no standard laparoscopic technique for pancreatic cancer. We treated three patients with RAMPS using a ligament of Treitz approach. We started each procedure by dissecting the ligament of Treitz. We entered and spread the anterior space of the aorta and inferior vena cava. We then dissected the LN of the root of the supra-mesenteric artery and performed RAMPS. The mean number LN retrieved from the patients was 43 ± 22. All three patients underwent pancreatectomy to obtain tumor-free margins, and two patients began adjuvant chemotherapy by postoperative day 14. The ligament of Treitz approach in laparoscopic modified RAMPS offered tumor-free margins and the resection of sufficient regional LN. The procedure also allowed adjuvant chemotherapy to be started early.

Laparoscopic total remnant pancreatectomy after laparoscopic pancreaticoduodenectomy.

Total remnant pancreatectomy after pancreaticoduodenectomy (PD) is a difficult procedure. Recently, distal pancreatectomy and PD have been performed laparoscopically. Herein, we present the first case report of a laparoscopic total remnant pancreatectomy. A 72-year-old woman underwent a totally laparoscopic pylorus-preserving PD for inferior bile duct cancer. The tumor was composed of moderately differentiated tubular adenocarcinoma and was diagnosed as pStage III according to the UICC-TNM classification. Eighteen months later, CT showed a low-density mass in the remnant pancreas. We conducted a total resection of the remnant pancreas laparoscopically. Histologically, it was diagnosed as a primary pancreatic cancer. The patient's postoperative course was uneventful. She was discharged on postoperative day 14. When an initial PD is performed laparoscopically, laparoscopic total remnant pancreatectomy is technically feasible and safe in selected patients.

Partial breast reconstruction for an inferomedial breast carcinoma using an omental flap.

BACKGROUND: Various oncoplastic techniques are used for partial reconstruction after breast-conserving surgery (BCS), but treatment of an inferomedial breast carcinoma (IMBC) can be difficult, especially in a small breast. We review our experience with immediate partial breast reconstruction after BCS for an IMBC using a laparoscopically harvested omental flap (OF). METHODS: The subjects were 24 patients with an IMBC who underwent immediate partial breast reconstruction with the OF between April 2002 and June 2009. A wide excision (>20% of the breast tissue) was performed through a skin incision along the medial inframammary fold. The pedicled OF was harvested laparoscopically and used to fill the dead space in the inferomedial quadrant. RESULTS: The mean follow-up period was 35 months. The mean tumor size was 3.2 cm. The mean volume of resected breast tissue was 180 g and the mean extent of resection was 40%. The complication rate was 12.5% and all were minor and treated conservatively. Laparoscopy-associated complications did not occur, except for one minor injury of the gastroepiploic artery. The surgical margin was positive in only 1 patient (4.2%) and neither local nor systemic recurrence has occurred to date in any patients. Cosmetic outcomes were mostly satisfactory, with minimal donor-site scars in the abdominal wall. Cosmetic failure occurred in 1 patient (4.2%) due to an inadequate OF volume. CONCLUSIONS: Laparoscopic harvesting of the OF is a safe procedure with minimal donor-site morbidities and deformities. This approach is an option for immediate partial reconstruction after BCS for an IMBC.

Carcinosarcoma of the duodenum: Report of a case.

This report describes a case of carcinosarcoma of the duodenum. Carcinosarcoma of the duodenum is a very rare tumor. A 72-year-old man was referred to the hospital because of appetite loss. Endoscopy demonstrated an irregularly depressed lesion (type 3) in the descending portion of the duodenum opposite to the ampulla of Vater. Computed tomography showed a thickened duodenal wall and swelling of the abdominal para-aortic lymph nodes. A biopsy specimen revealed a well-differentiated adenocarcinoma. A diagnosis of duodenal carcinoma was made (cT3, cN1, cM1, cStage IV according to the TNM classification). A subtotal stomach-preserving pancreatoduodenectomy and a lymph node resection were performed. On microscopic examination, adenocarcinoma cells and spindle type sarcoma cells were observed separately in the descending portion of the duodenum opposite to the ampulla of Vater. The adenocarcinoma cells were stained with antibodies against epithelial markers keratin and carcinoembryonic antigen for immunohistochemical analyses. In contrast, the sarcoma cells were stained with antibodies to vimentin and smooth muscle actin. The pathological diagnosis of a true duodenal carcinosarcoma was thus made.

Advanced gastric carcinoma combined with extra-adrenal pheochromocytoma resected after three courses of S-1 and cisplatin as neoadjuvant chemotherapy: report of a case.

We herein describe the case of a patient with advanced gastric carcinoma combined with extra-adrenal pheochromocytoma who received a radical operation after undergoing neoadjuvant chemotherapy. A 48-year-old woman was referred to our hospital for gastric carcinoma. Computed tomography revealed an enlargement of the regional lymph nodes and a para-aortic lymph node. A diagnosis of advanced gastric carcinoma was made (cT3, cN3, cM0, cStage IV according to the Japanese Classification of Gastric Carcinoma, 2nd English edition). A reduction in size was observed in both the gastric tumor and the lymph nodes around the stomach after neoadjuvant chemotherapy. However, the paraaortic lymph node showed no remarkable change. We thus suspected this para-aortic tumor not to be a lymph node, but instead to be an extra-adrenal pheochromocytoma, because of the different response from the other regional lymph nodes. An endocrinological examination confirmed the diagnosis of extra-adrenal pheochromocytoma. A gastrectomy and a resection of the pheochromocytoma were thus performed.

Enteritis cystica profunda presenting as ileoileal intussusception in a child: report of a case.

We report the case of a 3-month-old male infant with small bowel intussusception caused by enteritis cystica profunda (ECP). The baby was admitted because he was refusing to feed, and was passing "red-currant jelly"-like stools. A palpable mass was identified, and abdominal ultrasonography showed a mass with a lumen and lumen appearance. We performed laparotomy and resected the segment of bowel containing the mass. The resected segment had enteritis cystica profunda, which was considered to have precipitated the intussusception. A review of the English medical literature revealed only three other cases of children with similar symptoms in the last 30 years.

Recent changes and the future roles of esophageal cancer surgery.

An esophagectomy remains the mainstay treatment for esophageal cancer, and an R0 resection is the most important type of surgery performed with a curative intent. Although a transthoracic esophagectomy is thought to offer better chance for cure in comparison to a transhiatal esophagectomy, the superiority of the former procedure over the latter has not been demonstrated by randomized clinical trials (RCTs). An extended esophagectomy with a three-field lymphadenectomy is a type of esophagectomy with the highest quality of tumor clearance and the capability of prolonging patient survival, but it is contraindicated for patients with 5 or more positive nodes, with simultaneous metastasis to three anatomic compartments, with cervical metastasis from lower esophageal cancer, and with intramural metastasis, because of the absence of survival benefits in these cases. An esophagectomy performed by thoracoscopy and laparoscopy techniques is feasible, however, such an esophagectomy combined with a systematic lymphadenectomy may not qualify as minimally invasive because of the equivalent morbidity rates to an open radical esophagectomy. Whether adjuvant chemotherapy with or without radiotherapy can effectively improve patient survival remains controversial, because only two of 15 RCTs of such adjuvant therapy so far reported have demonstrated a positive survival impact in comparison to surgery alone. The recent increased use of definitive chemoradiotherapy suggests the potential need to perform a salvage esophagectomy because the presence of local persistent or recurrent disease is common after this treatment. The development of a safe and effective salvage esophagectomy should thus be urgently established.

Hepatocellular carcinoma in a patient with primary biliary cirrhosis and seronegativity for markers of hepatitis B virus and hepatitis C virus: report of a case.

We report a case of hepatocellular carcinoma (HCC) arising in a patient with primary biliary cirrhosis (PBC) in whom both hepatitis B virus (HBV) and hepatitis C virus (HCV) serological tests were negative. A 72-year-old woman was found to have HCC 10 years after a diagnosis of PBC. All serological tests for HBV and HCV were negative. Preoperative liver biopsy findings suggested moderately differentiated HCC. Dynamic computed tomography (CT) showed hypervascular tumors in segments IV and VII. At laparotomy, a 30-mm tumor was palpated in segment VII and a wedge resection was performed. The second tumor, which measured 10 mm in diameter, was detected in segment IV by abdominal ultrasound, and microwave coagulation therapy was done. HCC arising in hepatitis virus marker-negative PBC is rare and past reports do not clarify whether HBV or HCV infections are associated with HCC.