Liver anatomy for totally laparoscopic segment 7 resection from a caudal magnified view-a 3-dimensional computed tomographic analysis.

BACKGROUND: Laparoscopic resection of hepatic segment 7 is considered particularly difficult. We analyzed anatomic variation of this segment in caudally oriented 3-dimensional (3D) magnified computed tomographic (CT) images obtained prior to liver resection. METHODS: Analysis included 105 patients with preoperative 3D CT evaluation preceding liver resection for hepatobiliary malignancies between April 2021 and April 2024. RESULTS: Five ramification patterns were evident from a caudal magnified view. Some patients who had multiple segment 7 (S7) portal pedicles and an S7 pedicle branching ventrally posed difficulty in performing segmentectomy for the exact extent of S7. Distance from the point where a perpendicular line from the right rim of the inferior vena cava (IVC) intersected the right posterior portal pedicle to the point of bifurcation of the S6 and 7 pedicles was 34.6 mm (range, 3.9-78.8; mean ± standard deviation, 35.2 ± 14.8 mm). The median angle between the perpendicular line from the right rim of the IVC and the line from the root of the S7 pedicle to the right rim of the IVC was 77° (10-140); the mean ± standard deviation was 75.3° ± 28.1. Differences among ramification patterns also were evident. The angle between the right posterior portal pedicle and the S7 pedicle was 143° (79-215) or 143.3 ± 26.7, and that between S7 and S6 pedicles was 71°(15-123) or 75.5 ± 21.7°, representing relatively little variation. CONCLUSIONS: Understanding these details of caudal-view anatomy may resolve difficulties and clarify access required for exposing S7 portal pedicles.

Jejunal vein tributary analysis and intraoperative clamp testing in avoiding congestion after pancreatoduodenectomy.

PURPOSE: Although venous drainage of the jejunal loop may be maintained after sacrifice of jejunal vein tributaries during pancreatoduodenectomy, risk of severe jejunal mesenteric congestion following division of these tributaries can be difficult to predict. This study considered how best to predict safety of jejunal vein tributary dissection. METHODS: Preoperative imaging findings and results of intraoperative clamp tests of jejunal vein tributaries during pancreatoduodenectomy were analyzed in 121 patients with hepatobiliary and pancreatic disease to determine whether this information adequately predicted safety of resecting superior mesenteric vein branches. RESULTS: Jejunal vein tributaries caudal to the inferior border of the pancreatic uncinate process tended to be fewer when tributaries cranial to this landmark were more numerous. Tributaries cranial to the border drained a relatively wide expanse of jejunal artery territory in the jejunal mesentery. The territory of jejunal tributaries cranial to the inferior border of the pancreas did not vary according to course of the first jejunal vein branch relative to the superior mesenteric artery. One patient among 30 (3%) who underwent intraoperative clamp tests of tributaries cranial to the border showed severe congestion in relation to a venous tributary coursing ventrally to the superior mesenteric artery. CONCLUSION: Jejunal venous tributaries drained an extensive portion of jejunal arterial territory, but tributaries located cranially to the inferior border of the pancreas could be sacrificed without congestion in nearly all patients. Intraoperative clamp testing of these tributaries can identify patients whose jejunal veins must be preserved to avoid congestion.

Failure of peritoneal lavage to prevent operative site infection and peritoneal tumor recurrence in pancreatic surgery.

BACKGROUND: Although intraoperative peritoneal lavage often is performed routinely with the aim of reducing peritoneal contamination, evidence of lavage benefit in elective pancreatic surgery is limited. METHODS: We retrospectively classified patients who had undergone pancreatic surgery to groups given or not given peritoneal lavage, then comparing clinical results. This saline lavage was performed at the end of the operation. The primary endpoint was rate of surgical site infection. Frequency of peritoneal recurrence also was evaluated. RESULTS: Among all 104 patients in the study, incidence of infectious complications in the lavage group (n = 65) was significantly higher than in the non-lavage group (n = 39; 35% vs. 15%, P = 0.041), while incidences of postoperative complications overall and surgical site infection did not differ between lavage (80% and 26%) and non-lavage groups (67% and 10%, P = 0.162 and 0.076, respectively). Among 63 patients undergoing pancratoduodenectomy, frequencies of positive bacterial cultures of drainage fluids on postoperative days 1 and 3 were greater in the non-lavage group (P < 0.001 and P = 0.012), but surgical site infection was significantly more frequent in the lavage group (P = 0.043). Among patients with pancreatic and biliary cancers, lavage did not affect frequency of peritoneal recurrence. CONCLUSION: Intraoperative lavage did not prevent surgical site infection or peritoneal recurrence of pancreatobiliary cancer.

[A Case of Solitary Metastasis of Renal Cell Carcinoma to the Thyroid Gland].

A case of solitary metastasis of renal cell carcinoma to the thyroid gland is presented. The patient was a 82-year-old man found to have an abnormal mass in his neck. He had a past history of renal clear cell carcinoma of the left kidney (pT1aN0M0, G1>2, alveolar type, clear cell subtype), which had been resected 12 years previously. Ultrasonography revealed a tumor mass in the right hemithyroid gland. This time fine needle biopsy of the thyroid tumor suggested metastatic thyroid carcinoma. Right hemithyroidectomy was performed last year. The histopathological findings were suggestive of clear cell carcinoma, thus metastatic renal carcinoma was diagnosed. This is the 26th case of thyroid solitary metastasis of clear cell renal cell carcinoma reported in Japan to date.

Zinc supports liver regeneration after partial resection.

Objectives: Safe removal of extensive liver tumor burdens depends on regeneration of the remnant liver, which requires a large amount of zinc over a short period of time. We studied how zinc influences regeneration. Material and Methods: We measured perioperative serum zinc concentrations after liver cancer diagnosis in 77 patients undergoing hepatectomy to determine how serum zinc affected short-term outcomes and remnant liver regeneration. Results: Serum zinc concentration at diagnosis showed no correlation with inflammatory or nutritional parameters except for a weak correlation with the lymphocyte-to-monocyte ratio. When patients were divided into a high pre-hepatectomy zinc group (≥75 µg/dL, n= 39, H group) and a low zinc group (<75 µg/dL, n= 38, L group), short-term results such as mortality (p> 0.999), morbidity (p= 0.490), and hospital stay (p= 0.591) did not differ between groups. However, hypertrophy in the future liver remnant after hepatectomy in the H group (127.7 ± 24.7% of original volume) was greater than in the L group (115.9 ± 16.7%, p= 0.024). In a subgroup of patients with extended hepatectomy, hypertrophy was 130.9 ± 26.8% in the H group vs. 116.4 ± 16.5% in the L group (p= 0.037). Conclusion: Greater serum zinc at diagnosis was associated with greater hypertrophy in the future liver remnant.

CRMP4 Up-regulates M2 Macrophages and Myeloid-derived Suppressor Cells to Promote Pancreatic Cancer in Mice.

BACKGROUND/AIM: We previously observed higher prevalence of high-grade pancreatic intraepithelial neoplasia (PanIN) in LSL-KrasG12D/+; Pdx1Cre/+ (KC-Crmp4wild) mice than LSL-KrasG12D/+; Pdx1Cre/+; Crmp4-/- (KC-Crmp4-/-) mice. This study investigated the relationship between collapsin response mediator protein 4 (CRMP4) and immune cell infiltration in pancreatic cancer. MATERIALS AND METHODS: PanIN was induced by intraperitoneal injection of caerulein into KC-Crmp4wild and KC-Crmp4-/- mice, and immune cells in PanIN lesions were compared. Subcutaneous tumors were created by injecting Pan02 cells, and tumor diameter was compared between Crmp4wild and Crmp4-/- mice every 7 days. Peritumoral immune cells were examined immunohisto chemically. RESULTS: High-grade PanIN in KC mice showed statistically significantly high expression of CD163 (p=0.031) and CD11b (p=0.027). Following subcutaneous injection of Pan02 cells, tumor diameter was greater in Crmp4wild mice than Crmp4-/- mice. Crmp4wild mice exhibited higher CD163 and CD11b expression than Crmp4-/- mice in tumors (p<0.001). CONCLUSION: CRMP4 might promote pancreatic cancer by up-regulating M2 macrophages and myeloid-derived suppressor cells.