Successful treatment for pseudoaneurysm following distal pancreatectomy with celiac axis resection without postoperative pancreatic fistula: a case report.

BACKGROUND: Distal pancreatectomy with celiac axis resection (DP-CAR) represents an innovative surgical approach for locally advanced pancreatic body cancer in cases involving celiac axis invasion. However, this procedure carries significant perioperative risks, including arterial aneurysms and organ ischemia. Understanding these risks is crucial for optimizing patient outcomes and guiding treatment decisions. CASE PRESENTATION: This case report describes a unique case of a 74-year-old male patient who was diagnosed with locally advanced pancreatic body cancer with invasion of the celiac and splenic arteries. He underwent DP-CAR after six cycles of chemotherapy. His postoperative course was uneventful without any evidence of postoperative pancreatic fistula. However, at the 10-month postoperative follow-up, pseudoaneurysm was incidentally detected in the anterior superior pancreaticoduodenal artery by follow-up computed tomography. It was successfully treated with coil embolization. He had no signs of tumor recurrence or relapse of pseudoaneurysm formation 2 years postoperatively. This case report discusses the potential risks of pseudoaneurysm formation in patients undergoing DP-CAR due to hemodynamic changes. We emphasize the significance of close monitoring in such cases. CONCLUSIONS: The case highlights the importance of recognizing and managing potential complications associated with DP-CAR in patients with pancreatic cancer. Despite its effectiveness in achieving complete resection, DP-CAR carries inherent risks, including the development of pseudoaneurysms. Vigilant surveillance and prompt intervention are crucial for optimizing patient outcomes and minimizing postoperative complications.

Proposal of nomograms to predict clinical outcomes in patients with ampulla of Vater cancer based on the Korea-Japan collaborative study.

BACKGROUND: In this study, we aimed to develop and validate a nomogram to predict overall survival (OS) and recurrence-free survival (RFS) in patients who underwent curative resection of ampulla of Vater (AOV) cancer. This is the first study for nomograms in AOV cancer patients using retrospective data based on an international multicenter study. METHODS: A total of 2007 patients with AOV adenocarcinoma who received operative therapy between 2002 January and 2015 December in Korea and Japan were retrospectively assessed to develop a prediction model. Nomograms for 5-year OS and 3-year RFS were constructed by dividing the patients who received and who did not receive adjuvant therapy after surgery, respectively. Significant risk factors were identified by univariate and multivariate Cox analyses. Performance assessment of the four prediction models was conducted by the Harrell's concordance index (C-index) and calibration curves using bootstrapping. RESULTS: A total of 2007 and 1873 patients were collected for nomogram construction to predict 5-year OS and 3-year RFS. We developed four types of nomograms, including models for 5-year OS and 3-year RFS in patients who did not receive postoperative adjuvant therapy, and 5-year OS and 3-year RFS in patients who received postoperative adjuvant therapy. The C-indices of these nomograms were 0.795 (95% confidence interval [CI]: 0.766-0.823), 0.712 (95% CI: 0.674-0.750), 0.804 (95% CI: 0.7778-0.829), and 0.703 (95% CI: 0.669-0.737), respectively. CONCLUSIONS: This predictive model could help clinicians to choose optimal treatment and precisely predict prognosis in AOV cancer patients.

Enteral versus parental nutrition after pancreaticoduodenectomy under enhanced recovery after surgery protocol: study protocol for a multicenter, open-label randomized controlled trial (ENE-PAN trial).

BACKGROUND: Infectious complications are the main causes of morbidity after pancreaticoduodenectomy (PD). Early enteral nutrition (EN) is a reasonable form of nutritional support that aims to mitigate the occurrence and severity of infectious complications by maintaining gut immunity. However, it remains unclear whether EN is beneficial for patients who underwent PD and are under enhanced recovery after surgery (ERAS) protocol. METHODS: A multicenter (six hospitals), open-label, randomized controlled trial will be started in July 2022. A total of 320 patients undergoing open PD will be randomly assigned to an EN group or a peripheral parental nutrition (PPN) group in a 1:1 ratio. The stratification factors will be the hospital, age (≥ 70 or not), and preoperative diagnosis (pancreatic cancer or not). In the EN group, enteral nutrition will start on postoperative day (POD) 1 at 200-300 ml/day via the percutaneous tube placed operatively. The volume of the diet will be increased to 400-600 ml/day on POD 2 and depend on the surgeon's decision from POD 3. In the PPN group, PPN will be delivered after surgery. In both groups, oral feeding will start on POD 3. Each treatment will be finished when patients' oral food intake reaches 60% of the nutritional requirement (25-30 kcal/day). The primary endpoint will be the occurrence of postoperative infectious complications within 90 days of surgery. The secondary endpoints will be all complications, including major ones such as Clavien-Dindo grade 3 or more and clinically relevant postoperative pancreatic fistula. Data will be analyzed per the intention to treat. DISCUSSION: This will be the first, large, and well-designed RCT that aims to determine whether EN is beneficial for patients who underwent PD under the ERAS protocol. According to the results of this study, either EN or PPN would be adopted as the standard nutritional support for patients undergoing PD. TRIAL REGISTRATION: jRCT1030210691. Registered on March 23, 2022.

A locally advanced pancreatic body cancer presenting common bile duct invasion resected via distal pancreatectomy after gemcitabine plus nab-paclitaxel chemotherapy: A case report.

INTRODUCTION: The locally advanced pancreatic cancer has been steadily recognized as a potentially curable disease by a combination of chemotherapy and surgery. The remarkable effect of advanced chemotherapy would help surgeons do a function-preserving operation for advanced pancreatic cancer. PRESENTATION OF CASE: A 73-year-old woman presenting with obstructive jaundice was diagnosed to have a 3-cm pancreatic body cancer invading the celiac axis (CA), superior mesenteric artery (SMA), portal/splenic vein confluence, and the common bile duct (CBD). A plastic internal stent tube was placed endoscopically. After 11 cycles (231 days) of a weekly doublet chemotherapy with 1000 mg/m2 of gemcitabine and 125 mg/m2 of albumin-bound paclitaxel, the tumor shrunk based on imaging done every four months during chemotherapy, with residual periarterial high-density area around CA and proximal SMA and the patient was referred for surgery. During the operation, the absence of cancer cells was confirmed at (1) the origin of the proper hepatic artery, gastroduodenal artery and the left gastric artery, and (2) pancreatic cut stump along the right border of the portal vein; thus, distal pancreatectomy with coeliac axis resection was done. The patient had postoperative adjuvant chemotherapy with 100 mg/day of tegafur/gimeracil/oteracil for half a year and is currently alive and well, without signs of recurrence and diabetes mellitus a year after surgery. DISCUSSION: Although surgical techniques aimed at local radicality are important, especially for conversion surgery for locally advanced pancreatic cancer, surgeons should consider the balance between radicality, safety, and functional preservation of surgery.

An anatomical review of various superior mesenteric artery-first approaches during pancreatoduodenectomy for pancreatic cancer.

When pancreatic head cancer invades the superior mesenteric artery (SMA), attempts at curative resection are aborted. Preoperative imaging diagnostics to determine the surgical curability have yet to surpass the intraoperative information acquired via inspection, palpation, and trial dissection. Pancreatoduodenectomy (PD) is a standard measure for treating periampullary cancers. In conventional PD, SMA invasion is usually identified by dissecting the retroportal lamina, which connects the uncinate process and SMA nerve plexus after dividing the neck of the pancreas. During PD for pancreatic head cancer, this retroperitoneal margin frequently vitiates surgical curability. SMA-first approaches during PD are methods where the SMA is dissected first by severing the posterior pancreatic capsule to assess the SMA involvement of pancreatic cancer early in the operation. The first report of such an approach prompted subsequent reports of various maneuvers that are now known collectively as "artery-first" approaches. We herein review those approaches by classifying them according to (1) the side of the mesocolon from where the SMA approach occurs (supracolic or infracolic) and (2) the direction of access (right or left and anterior or posterior). The steps of the reported PD procedures are numbered according to a timeline and summarized using anatomical division of the SMA.

Emergency laparoscopic cholecystectomy for intraabdominal hemorrhage in a patient with a left ventricular assist device: a case report.

BACKGROUND: Continuous-flow left ventricular assist devices (LVADs), called "second generation LVADs," have significantly improved the survival and quality of life outcomes. Accordingly, non-cardiac surgery in a patient with LVADs has required for conditions not directly related to their LVADs. And the management of bleeding in non-cardiac site remains one of long-term critical topics. Laparoscopic approach is useful in a patient with LVADs; however, there have been only few clinical reports. This report describes the first case of laparoscopic cholecystectomy (LC) for intraabdominal hemorrhage from the gallbladder serosa in a patient with LVADs. CASE PRESENTATION: A 56-year-old man with an LVAD had undergone LVAD (Jarvik 2000™; Jarvik Heart, Inc., New York, NY, USA) implantation at 53 years of age. He was in shock, and contrast-enhanced computed tomography revealed abdominal hemorrhage from the gallbladder serosa. Emergency laparoscopic cholecystectomy was performed. We could avoid injury of the LVADs driveline, which was located across the upper abdominal midline, near the right hypochondriac region, by laparoscopic approach. LVADs (Jarvik 2000) did not disturb the operating field because of its smaller size. There were no intra- and postoperative complications. CONCLUSIONS: Laparoscopic approach is useful and safe in a patient with LVADs for abdominal surgery. We could perform LC for intraabdominal hemorrhage from gallbladder serosa safety.

A long-surviving case of gastric cancer with main portal vein tumor thrombus after surgical resection and postoperative S-1 therapy.

Gastric cancer patients with main portal vein tumor thrombus usually have a short survival time, owing to its aggressive behavior. Herein, we report a long-surviving case of gastric cancer with main portal vein tumor thrombus. A 78-year-old man presenting with anorexia and body weight loss was diagnosed with gastric cancer. The patient was referred to our hospital for further examination and treatment. Endoscopy revealed a type 3 tumor (8.0 cm in length) in the body of the stomach. Biopsy led to the diagnosis of moderately differentiated adenocarcinoma. Enhanced computed tomography revealed a large tumor thrombus extending from the gastric coronary vein to the portal trunk. A total gastrectomy with lymphadenectomy, splenectomy, and thrombectomy was performed. Postoperative chemotherapy with S-1 was administered for 18 months. The patient died a natural death without recurrence at 49 postoperative months. To the best of our knowledge, the patient was the oldest to be diagnosed with gastric cancer with main portal vein tumor thrombus at diagnosis, who survived >36 months. Although gastric cancer with main portal vein tumor thrombus is a rare occurrence, its prognosis is extremely poor. Intensive surgery and long-term chemotherapy may be effective at improving survival time in these patients.

Video-assisted thoracoscopic esophagectomy in the left lateral decubitus position in an esophageal cancer patient with pectus excavatum.

During thoracic cavity operations, it is difficult to obtain sufficient working space and good operative field visibility in patients with pectus excavatum because the space between the vertebral bodies and sternum is very narrow. Here, we report the successful treatment of esophageal cancer in a patient with pectus excavatum. A 77-year-old man with esophageal cancer was referred to our hospital for further treatment. He was diagnosed with multiple early esophageal squamous cell carcinomas. The patient had pectus excavatum, but because it was asymptomatic, a video-assisted thoracoscopic radical esophagectomy in the left lateral decubitus position without pectus excavatum repair was selected. Despite the patient's unusual anatomy, video-assisted thoracoscopic esophagectomy in the left decubitus position allowed for good operative field visibility, as the videoscope was inserted from the side of the diaphragm. This operative procedure is useful in patients with esophageal cancer who also have pectus excavatum. To the best of our knowledge, this is the second report of video-assisted thoracoscopic esophagectomy in an esophageal cancer patient with pectus excavatum.

Usefulness of multi-detector helical CT with multiplanar reconstruction for depicting the duodenal varices with multiple collateral shunt vessels.

Duodenal varices are a rare complication in patients with portal hypertension. Bleeding from duodenal varices often results in a severe prognosis. Diagnosis of the disease is usually based on findings obtained by endoscopy or angiography. However, it occasionally fails to detect the lesion and demonstrate its porto-systemic shunt vessels which are necessary information to decide an appropriate treatment. Recent advances in CT may make it possible for us to reveal duodenal varices with complicated porto-systemic shunt vessels. We report the case of a 58-year-old man with liver cirrhosis with repeated bleeding from duodenal varices. Esophagogastroduodenoscopy (EGD) revealed multinodular varices in the third portion of the duodenum. Then we conducted a capsule endoscopy (CE) and found fresh blood in the duodenum, suggesting duodenal variceal hemorrhage. Angiography depicted the varices with one afferent and two efferent vessels. Abdominal CT examination was conducted using a four-channel multi-detector row CT scanner. The multiplanar reconstructed images revealed not only the varices, but also three afferent and two efferent vessels. The patient was treated by surgical ligation and sclerotherapy, because of its complicated porto-systemic shunt and reserved liver function. No gastrointestinal bleeding has been seen after the surgery. Our case suggests the usefulness of multi-detector CT with multiplanar reconstruction (MPR) for the diagnosis and therapeutic decision of duodenal varices.

Incidence and management of biliary complications after adult-to-adult living donor liver transplantation.

BACKGROUND: There are few detailed reports of biliary complications in a large adult living donor liver transplantation (LDLT) series. PATIENT AND METHODS: Biliary complications, treatment modalities, and outcomes in these patients were retrospectively analyzed in 310 adult LDLT. RESULTS: One patient underwent retransplantation. Duct-to-duct anastomosis was primarily performed in 223 patients (72%). During the observation period (median 43 months), biliary complications were observed in 111 patients (36%); 53 patients (17%) had bile leakage, 70 patients (23%) had bile duct stenosis, and 12 patients (4%) had bile leakage followed by stenosis. A biliary anastomotic stent tube was placed in 266 patients (86%) at the time of transplantation. Univariate analysis of various clinical factors revealed duct-to-duct anastomosis as the single significant risk factor (p=0.009) for biliary complications. The three-yr and five-yr overall patient survival rates were 88% and 85% in those with biliary complications, and 85% and 83%, respectively, in those without biliary complications (p=0.59). CONCLUSION: Biliary complications are a major cause of morbidity following LDLT. Duct-to-duct anastomosis carried a higher risk for bile duct stenosis. With appropriate management, however, there was little influence on overall survival.

Value of prophylactic abdominal drainage in 1269 consecutive cases of elective liver resection.

BACKGROUND: The value of prophylactic abdominal drainage in patients undergoing hepatectomy is controversial. We carried out a retrospective study to clarify the value of this procedure. METHODS: The study subjects were 1269 consecutive patients who underwent elective hepatectomy with drain insertion for malignant tumors without associated gastrointestinal procedures or bilio-enteric anastomosis. Symptomatic abdominal fluid collections were treated by the drain salvage method, percutaneous puncture, and/or re-operation, in that order of preference. RESULTS: One patient died (mortality rate, 0.07%) and 7 patients had postoperative bleeding (0.6%). Bile leakage, found in 111 (8.7%) patients, subsided with retention of the drain in 78 (70%) and use of the drain salvage technique in 8 (7.2%), whereas percutaneous puncture and re-operation were required in 11 (9.9%) and 14 (12.6%). Symptomatic fluid collection, observed in 65 (5.1%) patients, was treated by the drain salvage technique in 20 (31%) patients, while puncture and re-operation were required in 25 (38%) and 20 (31%). CONCLUSIONS: Placement of drains was effective in a considerable proportion of patients undergoing hepatectomy, with regard to reducing the frequency of development of subphrenic fluid collections and biliary fistula/biloma formation.

Portal vein complications after adult-to-adult living donor liver transplantation.

Successful management of portal vein (PV) complications after liver transplantation is crucial to long-term success. Little information is available, however, regarding the incidence and treatment of PV complications after adult-to-adult living donor liver transplantation (LDLT). Between January 1996 and October 2006, 310 adult LDLTs were performed at our institution. PV thrombus was present in 54 patients at the time of LDLT. The incidence of PV complications, choice of therapeutic intervention, and outcomes were retrospectively analyzed. Among the 310 recipients, PV complications were identified in 28 (9%). Risk factors included smaller graft size, presence of PV thrombus at the time of LDLT, and use of jump or interposition cryo-preserved vein grafts for PV reconstruction. When divided into early (within 3 months, n = 11) and late (after 3 months, n = 17) complications, the use of vein grafts for PV reconstruction predisposed to the occurrence of late, but not early, PV complications. Portal vein thrombosis occurred more frequently in the early period (eight out of 11, 73%), whereas stenosis occurred more frequently in the later period (14 out of 17, 82%). Surgical interventions were favored in the earlier period, whereas interventional radiologic approaches were selected for later events. Overall 3- and 5-year survival rates were 81% and 77%, respectively, in patients with PV complications and 88% and 84%, respectively, in those without PV complications (P = 0.21, log-rank test). PV complications are a significant problem following LDLT with both early and late manifestations. Acceptable long-term results, however, are achievable with periodic ultrasonographic surveillance and timely conventional therapeutic interventions. The use of cryo-preserved vein grafts for reconstructing portal flow should be discouraged.

Outcome of living donor liver transplantation for post-Kasai biliary atresia in adults.

Previous reports described the effectiveness of living donor liver transplantation (LDLT) for post-Kasai biliary atresia (BA) in the pediatric population. Information on the outcome of LDLT in patients that have reached adulthood after the Kasai procedure, however, is limited. A recent report postulated a poorer long-term outcome of LDLT in these adults. We reviewed our experience to evaluate the validity of this hypothesis. Between January 1996 and October 2006, 385 LDLTs were performed at our institution. There were 80 post-Kasai BA cases in the series; 60 (75%) were pediatric, and 20 (25%) were adults. There were no ABO blood type-incompatible cases. None were complicated with severe hepatopulmonary syndrome, portopulmonary hypertension, or hepatocellular carcinoma. The 5-year overall survival rates were 90% for the adults and 90% for the children (P > 0.99). The median follow-up period was 7 years in the adults and 11 years in the children. There was no donor mortality. The outcome of LDLT in adult post-Kasai BA patients in the present series was satisfactory; that is, adult and pediatric patient survival rates were not different. This finding suggests that for post-Kasai BA patients without serious comorbidity at the time of transplantation, LDLT can be performed safely in all age groups.

Biliary complications in right lateral sector graft live donor liver transplantation.

Biliary complications remain the most challenging issue in adult living donor liver transplantation (LDLT) and to the best of our knowledge, no study has focused on the biliary complications in LDLT with right lateral sector graft (RLSG), a graft consisting of segments VI and VII according to Couinaud's nomenclature for liver segmentation. Between January 1996 and October 2006, 310 LDLTs were performed for adult recipients at our institution. Among them, 20 patients received RLSG. The incidence of biliary complications during follow-up in these patients with RLSG was retrospectively analyzed. Follow-up period after transplantation ranged from 1 to 87 months (median 58 months). The 3-year and 5-year graft survival rates following the use of RLSGs in LDLT were 90% and 90%, respectively. Biliary complications were encountered in altogether nine patients. Two patients (10%) were complicated with bile leakage requiring surgical intervention. Seven patients (35%) were complicated with bile duct stenosis, which occurred with a median interval of 26 months (range: 6-51 months) after LDLT. Four were treated surgically and the other three were treated by endoscopic approach. Outcomes of the interventions were satisfactory in all cases. The incidence and severity of biliary complications after LDLT using RLSG was within an acceptable range with excellent graft survival. Accordingly, it is concluded that RLSG is a technically feasible option that may effectively expand the donor pool. Further application of RLSG is warranted.

Hepatofugal portal flow after living donor liver transplantation.

BACKGROUND/AIMS: Reversed portal flow following liver transplantation is life-threatening complication. There are few reports, however, regarding reversed portal flow after liver transplantation. METHODOLOGY: We performed 180 living donor liver transplantations (LDLTs) over 8 years. Portal vein flow was routinely measured postoperatively two or three times a day during the first 2 weeks after LDLT. Surgical correction of reversed portal flow was attempted as soon as possible. RESULTS: Five patients (2%) were complicated by postoperative hepatofugal portal flow. The reversed portal flow was corrected surgically in all the patients by splenectomy and/or ligation of the residual collateral veins. The revision operation was repeated in two patients. In three patients, the shunts responsible for hepatofugal flow were not detected in preoperative imaging, which must be approached under the guidance of intraoperative ultrasound or radiologic examination. All five patients survived the operation. CONCLUSIONS: Hepatofugal flow causes ischemic damage to the graft, which will not normalize spontaneously. Prompt treatment of the reversed portal flow salvaged the graft.

Measurement of des-gamma-carboxy prothrombin levels in cancer and non-cancer tissue in patients with hepatocellular carcinoma.

In a recent experiment, we discovered that liver tissue adjacent to HCC can also produce des-gamma-carboxy prothrombin (DCP). The goal of this study was to advance measurements of DCP levels in hepatocellular carcinoma (HCC) and non-cancer tissues using an electro-chemiluminescence immunoassay (ECLIA) and immunohistochemistry, and to assess their clinical significance. DCP levels in HCC tissues ranged from 0.7 to 209862.4 mAU/0.1 g tissue weight, with a median of 492.6 mAU/0.1 g. DCP levels in non-cancer tissues ranged from 0 to 2329.9 mAU/0.1 g tissue weight, with a median of 88.8 mAU/0.1 g. DCP levels in cell membranes were significantly higher than in the cytoplasm (p<0.001). DCP levels in HCC tissue were significantly higher than in non-cancer tissue (p<0.001). The logarithm of serum DCP levels correlated not only with that of DCP levels in HCC tissues (p=0.019), but also with that in non-cancer tissues (p=0.020), and the total DCP level of liver tissues (p=0.016). The logarithm of DCP levels in HCC tissues correlated with that of DCP levels in non-cancer tissues (p=0.011). DCP levels in HCC tissue with portal vein invasion were significantly greater than in HCC tissues without portal vein invasion (p=0.028). DCP levels in non-cancer tissues with intrahepatic metastatic lesions were significantly higher than in non-cancer tissues without intrahepatic metastatic lesions (p=0.023). Our results suggest that the origin of elevated serum DCP may lie not only in HCC tissue, but in non-cancer tissue. The existence of HCC may influence production of DCP in non-cancer tissue. Tissue DCP may be a prognostic factor, while increased DCP levels in non-cancer tissues may play an important role in hepatocarcinogenesis.