Early Identification of Patients with Potential Failure of Nonoperative Management for Gastroduodenal Peptic Ulcer Perforation.

INTRODUCTION: We aimed to identify objective factors associated with failure of nonoperative management (NOM) of gastroduodenal peptic ulcer perforation (GDUP) and establish a scoring model for early identification of patients in whom NOM of GDUP may fail. METHODS: A total of 71 patients with GDUP were divided into NOM (cases of NOM success) and operation groups (cases requiring emergency operation or conversion from NOM to operation). Using logistic regression analysis, a scoring model was established based on the independent factors. The patients were stratified into low-risk and high-risk groups according to the scores. RESULTS: Of the 71 patients, 18 and 53 were in the NOM and operation groups, respectively. Ascites in the pelvic cavity on computed tomography (CT) and sequential organ failure assessment (SOFA) score at admission were identified as independent factors for NOM failure. The scoring model was established based on the presence of ascites in the pelvic cavity on CT and SOFA score ≥2 at admission. The operation rates for GDUP were 28.6% and 86.0% in the low-risk (score, 0) and high-risk groups (scores, 2 and 4), respectively. CONCLUSION: Our scoring model may help determine NOM failure or success in patients with GDUP and make decisions regarding initial treatment.

Development of a scoring model based on objective factors to predict gangrenous/perforated appendicitis.

BACKGROUND: The mortality rate of gangrenous/perforated appendicitis is higher than that of uncomplicated appendicitis. However, non-operative management of such patients is ineffective. This necessitates their careful exam at presentation to identify gangrenous/perforated appendicitis and aid surgical decision-making. Therefore, this study aimed to develop a new scoring model based on objective findings to predict gangrenous/perforated appendicitis in adults. METHODS: We retrospectively analyzed 151 patients with acute appendicitis who underwent emergency surgery between January 2014 and June 2021. We performed univariate and multivariate analyses to identify independent objective predictors of gangrenous/perforated appendicitis, and a new scoring model was developed based on logistic regression coefficients for independent predictors. Receiver operating characteristic (ROC) curve analysis and the Hosmer-Lemeshow test were performed to assess the discrimination and calibration of the model. Finally, the scores were classified into three categories based on the probability of gangrenous/perforated appendicitis. RESULTS: Among the 151 patients, 85 and 66 patients were diagnosed with gangrenous/perforated appendicitis and uncomplicated appendicitis, respectively. Using the multivariate analysis, C-reactive protein level, maximal outer diameter of the appendix, and presence of appendiceal fecalith were identified as independent predictors for developing gangrenous/perforated appendicitis. Our novel scoring model was developed based on three independent predictors and ranged from 0 to 3. The area under the ROC curve was 0.792 (95% confidence interval, 0.721-0.863), and the Hosmer-Lemeshow test showed a good calibration of the novel scoring model (P = 0.716). Three risk categories were classified: low, moderate, and high risk with probabilities of 30.9%, 63.8%, and 94.4%, respectively. CONCLUSIONS: Our scoring model can objectively and reproducibly identify gangrenous/perforated appendicitis with good diagnostic accuracy and help in determining the degree of urgency and in making decisions about appendicitis management.

Risk factors for postoperative disseminated intravascular coagulation in surgical patients with non-occlusive mesenteric ischemia.

PURPOSE: The prognostic impact of disseminated intravascular coagulation (DIC) in surgical patients with non-occlusive mesenteric ischemia (NOMI) is unclear. This study aimed to confirm the association between postoperative DIC and prognosis and to identify preoperative risk factors associated with postoperative DIC. METHODS: This retrospective study included 52 patients who underwent emergency surgery for NOMI between January 2012 and March 2022. Kaplan-Meier curve analysis with the log-rank test was used to compare 30-day survival and hospital survival between patients with and without postoperative DIC. In addition, univariable and multivariable logistic regression analyses were performed to identify the preoperative risk factors for postoperative DIC. RESULTS: The 30-day and hospital mortality rates were 30.8% and 36.5%, respectively, and the incidence rate of DIC was 51.9%. Compared to patients without DIC, patients with DIC showed significantly lower rates of 30-day survival (41.5% vs 96%, log-rank P < 0.001) and hospital survival (30.2% vs 86.4%, log-rank, P < 0.001). Logistic regression analyses showed that the Japanese Association for Acute Medicine (JAAM) DIC score (OR = 2.697; 95% CI, 1.408-5.169; P = 0.003) and Sequential Organ Failure Assessment (SOFA) score (OR = 1.511; 95% CI, 1.111-2.055; P = 0.009) were independent risk factors for postoperative DIC in surgical patients with NOMI. CONCLUSION: The development of postoperative DIC is a significant prognostic factor for 30-day and hospital mortalities in surgical patients with NOMI. In addition, the JAAM DIC score and SOFA score have a high discriminative ability for predicting the development of postoperative DIC.

Exposure of the hepatic vein trunk via tracing of its branches: a useful surgical procedure for laparoscopic anatomical hepatectomy.

BACKGROUND: Although there are various advantages of laparoscopic liver resection (LLR) over open liver resection, some problems have been reported, such as disorientation and lack of control of bleeding during liver parenchymal dissection. In this study, we discuss a strategy to overcome the disorientation experienced during liver parenchymal dissection, especially in anatomical LLR. TECHNICAL PRESENTATION: This procedure involves hepatic parenchymal dissection from the hepatic vein branch along its trunk to reveal an important landmark in anatomical LLR. Knowing which region of the liver is perfused into each hepatic vein in preoperative 3D simulation allows the tracing of the hepatic vein branch that naturally leads to the hepatic vein trunk. After that, hepatic resection can be easily completed by dissecting the line connected to the other landmarks, the Glisson branch, the root of the hepatic vein, and the liver demarcation line. CONCLUSION: In conclusion, this surgical procedure that traces the branch of the hepatic vein exposes the trunk, which makes it a very useful tool for limited laparoscopic anatomical hepatectomy.

Preoperative scoring system for prediction of extended resection during emergency surgery for acute appendicitis.

PURPOSE: Appendicectomy is the primary treatment for acute appendicitis. However, extended resection (ER) may be required in difficult cases. Preoperative prediction of ER may identify challenging cases but remains difficult. We aimed to establish a preoperative scoring system for ER prediction during emergency surgery for acute appendicitis. METHODS: This was a single-center retrospective study. Patients who underwent emergency surgery for acute appendicitis between January 2014 and December 2022 were included and divided into ER and appendicectomy groups. Independent variables associated with ER were identified using multivariate logistic regression analysis. A new scoring system was established based on these independent variables. The discrimination of the new scoring system was assessed using the area under the receiver operating characteristic curve (AUC). The risk categorization of the scoring system was also analyzed. RESULTS: Of the 179 patients in this study, 12 (6.7%) underwent ER. The time interval from symptom onset to surgery ≥ 4 days, a retrocecal or retrocolic appendix, and the presence of an abscess were identified as independent preoperative predictive factors for ER. The new scoring system was established based on these three variables, and the scores ranged from 0 to 6. The AUC of the scoring system was 0.877, and the rates of ER among patients in the low- (score, 0-2), medium- (score, 4), and high- (score, 6) risk groups were estimated to be 2.5%, 28.6%, and 80%, respectively. CONCLUSION: Our scoring system may help surgeons identify patients with acute appendicitis requiring ER and facilitate decision-making regarding treatment options.

Impact of atherosclerosis on the postoperative complications of colorectal surgery in older patients with colorectal cancer.

BACKGROUND: Atherosclerosis is associated with various comorbidities; nonetheless, its effect on the postoperative complications of colorectal surgery in older patients with colorectal cancer (CRC) remains unclear. This study aimed to evaluate the impact of atherosclerosis on the postoperative complications of colorectal surgery in older adults with CRC. METHODS: Patients aged ≥ 65 years who underwent surgery for CRC between April 2017 and October 2020 were enrolled. To evaluate atherosclerosis, we prospectively calculated the cardio-ankle vascular index (CAVI) measured by the blood pressure/pulse wave test and abdominal aortic calcification (AAC) score from computed tomography. Risk factors for Clavien-Dindo grade ≥ III postoperative complications were evaluated by univariate and logistic regression analyses. RESULTS: Overall, 124 patients were included. The mean CAVI value and AAC score were 9.5 ± 1.8 and 7.0 ± 8.0, respectively. Clavien-Dindo grade ≥ III postoperative complications were observed in 14 patients (11.3%). CAVI (odds ratio, 1.522 [95% confidence interval, 1.073-2.160], p = 0.019), AAC score (1.083 [1.009-1.163], p = 0.026); and operative time (1.007 [1.003-1.012], p = 0.001) were identified as risk factors for postoperative complications. Based on the optimal cut-off values of CAVI and AAC score, the probability of postoperative complications was 27.8% in patients with abnormal values for both parameters, which was 17.4 times higher than the 1.6% probability of postoperative complications in patients with normal values. CONCLUSIONS: Atherosclerosis, particularly that assessed using CAVI and AAC score, could be a significant predictor of postoperative complications of colorectal surgery in older adults with CRC.

Handling of Hilar Vasculature in Living Donor Right Hepatectomy Using Extrahepatic Glissonean Approach.

Donor hepatectomy is one of the most important procedures in LDLT because it affects the safety of donors and the outcome of the recipients. We standardized a method of securing the important vessels at the hepatic hilum while advancing the dissection toward the central direction. This research introduces our technique of handling hilar vasculature in living donor hepatectomy, using the extrahepatic Glissonean approach, and discusses its efficacy. At first, after the extrahepatic right Glissonean approach, the resected hepatic artery and portal vein are secured on the same line as with the secured Glisson. The resected hepatic artery and portal vein are followed in the central direction, and the surrounding area is dissected. The dissection is continued up to the main brunch of the hepatic artery and portal vein. The bile duct can be secured by subtracting the hepatic artery and portal vein from the tape that secured the Glissonean pedicle. The bile duct, hepatic artery, and the portal vein are dissected in this order, before dissecting the right hepatic vein, completing the surgery. This method of dissection approaching the extrahepatic Glisson carried out toward the central direction suggests to acquire minimal tissue removal and to shorten operative time. This could result in adequate perfusion to the remaining liver and donor safety, taken together effective results on the recipient.

Prediction model for irreversible intestinal ischemia in strangulated bowel obstruction.

BACKGROUND: Preoperatively diagnosing irreversible intestinal ischemia in patients with strangulated bowel obstruction is difficult. Therefore, this study aimed to establish a prediction model for irreversible intestinal ischemia in strangulated bowel obstruction. METHODS: We included 83 patients who underwent emergency surgery for strangulated bowel obstruction between January 2014 and March 2022. The predictors of irreversible intestinal ischemia in strangulated bowel obstruction were identified using logistic regression analysis, and a prediction model for irreversible intestinal ischemia in strangulated bowel obstruction was established using the regression coefficients. Receiver operating characteristic analysis and fivefold cross-validation was used to assess the model. RESULTS: The prediction model (range, 0-4) was established using a white blood cell count of ≥ 12,000/µL and the computed tomography value of peritoneal fluid that was ≥ 20 Hounsfield units. The areas of the receiver operating characteristic curve of the new prediction model were 0.814 and 0.807 after fivefold cross-validation. A score of ≥ 2 was strongly suggestive of irreversible intestinal ischemia in strangulated bowel obstruction and necessitated bowel resection (odds ratio = 15.938). The bowel resection rates for the prediction scores of 0, 2, and 4 were 15.2%, 66.7%, and 85.0%, respectively. CONCLUSION: Our model may help predict irreversible intestinal ischemia that necessitates bowel resection for strangulated bowel obstruction cases and thus enable surgeons to recognize the severity of the situation, prepare for deterioration of patients with progression of intestinal ischemia, and select the appropriate surgical procedure for treatment.

Metabolomic Profiling of Plasma, Urine, and Saliva of Kidney Transplantation Recipients.

Kidney biopsy is commonly used to diagnose kidney transplant dysfunction after transplantation. Therefore, the development of minimally invasive and quantitative methods to evaluate kidney function in transplant recipients is necessary. Here, we used capillary electrophoresis-mass spectrometry to analyze the biofluids collected from transplant recipients with impaired (Group I, n = 31) and stable (Group S, n = 19) kidney function and from donors (Group D, n = 9). Metabolomics analyses identified and quantified 97 metabolites in plasma, 133 metabolites in urine, and 108 metabolites in saliva. Multivariate analyses revealed apparent differences in the metabolomic profiles of the three groups. In plasma samples, arginine biosynthesis and purine metabolism between the I and S Groups differed. In addition, considerable differences in metabolomic profiles were observed between samples collected from participants with T cell-mediated rejection (TCR), antibody-mediated rejection, and other kidney disorders (KD). The metabolomic profiles in the three types of biofluids showed different patterns between TCR and KD, wherein 3-indoxyl sulfate showed a significant increase in TCR consistently in both plasma and urine samples. These results suggest that each biofluid has different metabolite features to evaluate kidney function after transplantation and that 3-indoxyl sulfate could predict acute rejection.

A New Preoperative Risk Score for Predicting Postoperative Complications in Elderly Patients Undergoing Hepatectomy.

BACKGROUND: Postoperative complications are not rare in the elderly population after hepatectomy. However, predicting postoperative risk in elderly patients undergoing hepatectomy is not easy. We aimed to develop a new preoperative evaluation method to predict postoperative complications in patients above 65 years of age using biological impedance analysis (BIA). METHODS: Clinical data of 59 consecutive patients (aged 65 years or older) who underwent hepatectomy at our institution between 2017 and 2020 were retrospectively analyzed. Risk factors for postoperative complications (Clavien-Dindo ≥ III) were evaluated using multivariate regression analysis. Additionally, a new preoperative risk score was developed for predicting postoperative complications. RESULTS: Fifteen patients (25.4%) had postoperative complications, with biliary fistula being the most common complication. Abnormal skeletal muscle mass index from BIA and type of surgical procedure were found to be independent risk factors in the multivariate analysis. These two variables and preoperative serum albumin levels were used for developing the risk score. The postoperative complication rate was 0.0% with a risk score of ≤ 1 and 57.1% with a risk score of ≥ 4. The area under the receiver operating characteristic curve of the risk score was 0.810 (p = 0.001), which was better than that of other known surgical risk indexes. CONCLUSION: Decreased skeletal muscle and the type of surgical procedure for hepatectomy were independent risk factors for postoperative complications after elective hepatectomy in elderly patients. The new preoperative risk score is simple, easy to perform, and will help in the detection of high-risk elderly patients undergoing elective hepatectomy.

Efficacy of the Milan criteria as a prognostic factor in patients with colorectal liver metastases.

PURPOSE: This study aimed to apply the principles of the "Milan criteria" to patients undergoing hepatic resection for CRLM and to evaluate the efficacy of prognostic factors. METHODS: The medical records of consecutive patients who underwent curative resection for CRLM from April 2007 to April 2019 were retrospectively reviewed. Time to aggressive treatment failure (TATF) was defined as the time interval from the initial surgery until the first unresectable recurrence or recurrence that could only be treated with doublet or lower dose chemotherapy, or death. The risk factors associated with recurrence-free survival (RFS), TSF, TATF, and overall survival (OS) were evaluated. RESULTS: On univariate analysis, the Milan criteria significantly predicted long-term OS, TATF, TSF, and RFS. Moreover, the Milan criteria were able to stratify patients with CRLM into distinct prognostic groups with regard to long-term OS, TATF, TSF, and RFS. CONCLUSIONS: Milan criteria, a simple index, are a factor contributing to all the survival time and are a very important factor in discussing the prognosis of CRLM.

Long-term outcomes of living donor liver transplantation after locoregional treatment for hepatocellular carcinoma: an experience from a single institute.

PURPOSE: The precise role of downstaging or bridge therapy for cirrhotic patients with hepatocellular carcinoma (HCC) beyond or within the Milan criteria (MC) before living donor liver transplantation (LDLT) remains undefined. METHODS: We conducted a single-center, retrospective cohort study of 40 cirrhotic patients with HCC who underwent LDLT from 2000 to 2018. Dynamic computed tomography images at the initial presentation and immediately before LDLT as well as the final histopathological findings were reviewed to determine whether they met or exceeded MC. RESULTS: Overall, 29 patients underwent various pre-transplant HCC treatments, including ablation and embolization (bridge therapy, n = 20; downstaging, n = 9). Of the 9 patients who were initially beyond the MC, 4 (44.4%) were successfully downstaged to within the MC. Five patients beyond the MC immediately before LDLT demonstrated a significantly worse 5-year overall survival rate than patients within the MC (16.7% vs. 82.2%, P = 0.004), regardless of the radiological HCC stage at presentation or the final pathological tumor status. All 3 recurrent patients had HCC beyond the MC immediately before transplant and died of their disease at 13, 24, and 50 months after transplantation. CONCLUSIONS: Successful downstaging for HCC cases beyond the MC provides similar outcomes to those within the MC at presentation, regardless of the histopathological findings.

New risk factors of postoperative complications in elective gastrointestinal surgery of elderly patients: a prospective cohort study.

BACKGROUND: Gastrointestinal surgery in elderly individuals presents unexpected postoperative complications. However, predicting postoperative complications in elderly patients undergoing gastrointestinal surgeries is challenging because of the lack of a reliable preoperative evaluation system. We aimed to prospectively evaluate three new preoperative assessment methods to predict the postoperative complications in elderly patients undergoing elective gastrointestinal surgery. Moreover, we aimed to identify new risk factors of postoperative complications in this patient group. METHODS: This prospective cohort study enrolled 189 patients (age ≥ 65 years) who underwent elective gastrointestinal surgery at Tokyo Medical University Hachioji Medical Center between April 2017 and March 2019. Assessments performed preoperatively included the biological impedance analysis for evaluating the skeletal muscle mass, the SF-8 questionnaire for evaluating the subjective health-related quality of life, and the blood pressure/pulse wave test for assessing arteriosclerosis. The risk factors for Clavien-Dindo Grade ≥ III postoperative complications were assessed using these new evaluation methods. RESULTS: Clavien-Dindo Grade ≥ III postoperative complications were observed in 28 patients (14.8%). Univariate and multivariate analyses identified male sex, low skeletal muscle mass, and cardio-ankle vascular index ≥ 10 (arteriosclerosis) as significant independent risk factors of developing Grade ≥ III complications. CONCLUSIONS: Male sex, low skeletal muscle mass, and arteriosclerosis were significant risk factors of postoperative complications in elderly patients undergoing elective gastrointestinal surgery. The obtained knowledge could be useful in identifying high-risk patients who require careful perioperative management.

Efficacy of Peak Hounsfield Units of the Visceral Fat Area in Predicting Postoperative Complications after Pancreaticoduodenectomy.

BACKGROUND: Morbidity following pancreaticoduodenectomy (PD) has been reported to remain high. This study sought to measure the peak Hounsfield units (HUs) of visceral attenuation in patients undergoing PD and to assess the quality of adipocytes by comparing these measurements with perioperative factors. METHODS: Patients undergoing PD were retrospectively identified (n = 108). Abdominal perimeter, subcutaneous fat area (SFA), visceral fat area (VFA), and peak HU of the VFA were measured. Logistic regression analysis was used to identify independent predictors of postoperative pancreatic fistula (POPF) or complications. Histopathological examination was performed for qualitative diagnosis of the stromal tissue. RESULTS: The overall rate of POPF was 16%, and severe complications occurred in 23% of the cases. A criterion for peak HU of the VFA only independently predicted POPF (p = 0.007) in the multivariate analysis. A criterion for peak HU of the VFA (p = 0.015) was associated with an increased rate of postoperative severe complications in the univariate analysis. The peak HU of the VFA was significantly correlated with abdominal perimeter (p < 0.001) and VFA (p < 0.001). The peak HU of the VFA was significantly correlated with adipocyte diameter (p < 0.001) and the ratio of stromal connective tissue area around the adipocytes (p < 0.001). CONCLUSION: The peak HU of the VFA was an independent factor contributing to severe complications, including POPF after PD. It reflects the amount of stromal connective tissue around the adipocytes.

Resection of recurrent hepatocellular carcinoma with thrombi in the inferior vena cava, right atrium, and phrenic vein: a report of three cases.

BACKGROUND: Prognosis for patients with advanced hepatocellular carcinoma with a tumor thrombus in the inferior vena cava or right atrium is extremely poor due to cancer progression, pulmonary embolism, and congestion of the circulatory system caused by right heart failure. Surgical resection of the tumor thrombi may potentially yield better results than non-surgical treatments through prevention of sudden death. However, the benefits of surgical resection in patients with hepatocellular carcinoma and a tumor thrombus extending to the inferior vena cava, right atrium, and potentially in the phrenic vein are unclear. Here, we report three such cases. CASE PRESENTATION: Of the total 136 patients who underwent hepatectomies for hepatocellular carcinoma in our institution, three patients with prior hepatectomies and recurrent hepatocellular carcinoma had tumor thrombi in the inferior vena cava, right atrium, and phrenic vein. Surgical resections were performed, as there was a possibility of sudden death, despite the risk of leaving residual tumor. For all patients, we performed resection of the tumor thrombi in the inferior vena cava and right atrium and combined diaphragm resection. Surgical resection was performed using the total hepatic vascular exclusion technique in all cases. Additional passive veno-venous bypass was also performed in two cases, in which complete tumor resections could not be achieved. The microscopic surgical margins of the combined resected diaphragms were positive in all cases. Progression-free survival was 20.2, 3.8, and 9.5 months for case 1, 2, and 3, respectively. The respective overall postoperative survival was 98.0, 38.9, and 30.9 months. The patients died due to liver cirrhosis, acute heart failure, and hepatocellular carcinoma, respectively. Sudden death did not occur for any of the patients. CONCLUSION: Surgical resections may extend prognosis for patients with recurrent hepatocellular carcinoma with tumor thrombi in the inferior vena cava, right atrium, and phrenic vein, although the indications should be considered carefully.

Living donor liver transplantation for idiopathic portal hypertension with extrahepatic portal vein stenosis and splenic artery aneurysms: a case report and review of the literature.

BACKGROUND: Idiopathic portal hypertension (IPH) generally has a good prognosis and rarely results in liver transplantation. Furthermore, there are few reports of living donor liver transplantation (LDLT) for IPH with extrahepatic portal vein stenosis. CASE PRESENTATION: We report the case of a 51-year-old female patient diagnosed with IPH more than 20 years ago. She suffered severe jaundice, massive ascites, and encephalopathy at the time of her visit to our hospital. The patient's extrahepatic portal vein showed a scar-like stenosis, and the portal flow was completely hepatofugal. Collateral circulation such as the splenorenal shunt was well developed, and multiple splenic artery aneurysms up to 2 cm were observed in the splenic hilum. Her Model for End-Stage Liver Disease score increased to over 40 because of renal dysfunction, requiring temporary dialysis. We performed LDLT using her husband's right lobe graft and splenectomy. The extrahepatic stenotic portal vein was completely resected, and the superficial femoral vein (SFV) graft collected from the recipient's right leg was used for portal reconstruction as an interposition graft. Although the clinical course after LDLT had many complications, the patient was discharged on postoperative day 113 and has been fine for 2 years after LDLT. Histopathologically, the explanted liver had obliterative portal venopathy, nodular regenerative hyperplasia, and incomplete septal cirrhosis. CONCLUSION: This case showed that severe IPH is occasionally associated with extrahepatic portal vein stenosis and can be treated with LDLT with portal vein reconstruction using an interposition graft. It was also suggested that the SFV is a useful choice for the interposition graft.

[Esophagogastric Junctional Adenocarcinoma Responding Completely to Chemotherapy in an Elderly Patient with Long-Term Survival and No Recurrences-A Case Report].

An 85-year-old man was diagnosed with esophagogastric junctional adenocarcinoma, E=G, Type 2, por, 6 cm in size, cT4aN1M0, cStage ⅢA. He had a history of atherosclerosis obliterans and thoracoabdominal aortic aneurysm. Considering the comorbidities and life expectancy, we decided to perform chemotherapy without tumor resection. Although the renal function was poor, we chose SP therapy(S-1 80mg/kg/day for 14 days, followed by 7-day rest, CDDP 30mg/kg/day on day 1)because the current status of the patient was satisfactory. The primary tumor remarkably shrank after 2 courses of SP therapy and completely disappeared after 5 courses of SP therapy. There were no adverse events during the entire course of treatment. We detected clinical CR and provided the S-1 monotherapy for another 2 years. The patient has survived with no recurrences for 7 years since the initial chemotherapy. Although intensive chemotherapy regimens are avoided in elderly patients, the patient, in this case, showed a favorable prognosis from powerful chemotherapy.

[A Case of Left Transverse Colon Cancer Safely Resected Using Three-Dimensional CT Angiography and Indocyanine Green Fluorography].

A 77-year-old man was admitted to our hospital because of a positive occult blood test result and diagnosed as having left transverse colon cancer(cT2N0M0)on detailed examination. The patient underwent a sigmoidectomy for colon cancer 24 years previously. Three-dimensional(3D)-CT angiography was performed before the present operation. The left branch of the middle colic artery, which was independently branched, and the marginal artery of the colon were found to be supplying blood from the left side of the transverse colon to the anastomosis of the sigmoid colon. In addition, the root of the left branch of the middle colic artery arose from the caudal side of the first jejunal vein. Therefore, a left hemicolectomy was performed. In accordance with the preoperative simulation, we safely resected the left branch of the middle colic artery at the root. Intraoperative blood flow evaluation using indocyanine green(ICG)fluorography clearly displayed the demarcation of the oral blood flow and the point of anastomosis. No notable complications occurred after the surgery. The results of the pathological analyses indicated a pT1bN0M0 tumor stage. Therefore, we conclude that 3D-CT angiography and ICG fluorography are useful for performing safer operations for left transverse colon cancers.

Clinical Impact of Neoadjuvant Chemotherapy and Chemoradiotherapy in Borderline Resectable Pancreatic Cancer: Analysis of 884 Patients at Facilities Specializing in Pancreatic Surgery.

BACKGROUND: The efficacy of neoadjuvant therapy (NAT), including neoadjuvant chemotherapy (NAC) and neoadjuvant chemo-radiotherapy (NACRT), for patients with borderline resectable pancreatic cancer (BRPC) has not been elucidated. This study aimed to clarify the efficacy of NAC and NACRT for patients with BRPC. METHODS: The study analyzed the treatment outcomes of 884 patients treated for BRPC from 2011 to 2013. Treatment results were compared between upfront surgery and NAT and between NAC and NACRT using propensity score-matching analysis. Overall survival (OS) was calculated via intention-to-treat analyses. RESULTS: The overall resection rates for the patients who underwent NAT were significantly lower than for the patients who underwent upfront surgery (75.1% vs 93.3%; p < 0.001). However, the R0 resection rate was significantly higher for NAT than for upfront surgery (p < 0.001). Additionally, the OS for the patients who received NAT was significantly longer than for those who underwent upfront surgery (median survival time [MST], 25.7 vs 19.0 months; p = 0.015). The lymph node rate for the patients with NACRT was significantly lower than for those who underwent NAC (p < 0.001). However, the resection rate for the NACRT cases was significantly lower than for the NAC cases (p = 0.041). The local recurrence rate for the NACRT cases was significantly lower than for the NAC cases (p = 0.002). However, OS did not differ significantly between NAC and NACRT (MST, 29.2 vs 22.5 months; p = 0.130). CONCLUSIONS: The study showed that NAT has potential benefit for patients with BRPC. Compared with NAC, NACRT decreased the rates for lymph node metastasis and local recurrence but did not improve the prognosis.

Resection of Hepatic Lesions Perfused by the Cholecystic Vein Using Indocyanine Green Navigation in Patients with cT2 Gallbladder Cancer.

BACKGROUND: Various approaches to hepatectomy have been proposed for cT2 gallbladder cancers (GBC), but the optimal management strategy remains unclear. The aim of this study is to assess the effectiveness of using an indocyanine green (ICG)-based intraoperative navigation system during hepatic resection for cT2 GBC. METHODS: From September 2007 to December 2017, 24 consecutive patients diagnosed with cT2 GBC underwent hepatic resection using ICG navigation. After cannulation of the cholecystic artery, ICG diluted with dissolution liquid was injected and ICG fluorescence illumination was visualized with the HyperEye Medical System. And additional histopathological examination was performed on the most recent 15 of the 24 patients for detection of microscopic liver metastasis. RESULTS: For all patients, the disease-free survival rate was 59.1% at 5 years and overall survival rate was 86.2% at 5 years. Microscopic liver metastasis was detected in the resected liver in 3 (20%) of 15 patients, whose site of liver was S6, S5, and S5, respectively. The weight of the liver resected using ICG navigation was significantly smaller than that of S4a/S5 segmentectomy (P < 0.0001). CONCLUSION: Resected hepatic lesion using ICG imaging was possible to perform hepatectomy including liver micro-metastasis without excess or deficiency. This procedure might be novel intraoperative imaging method to provide valuable information on the optimal surgical approach to cT2 GBC.