Impact of reconstructed portal vein morphology on postoperative nutritional status in pancreatoduodenectomy: a computational fluid dynamics study.

This study evaluated the impact of reconstructed portal vein/superior mesenteric vein (PV/SMV) morphology on the long-term nutritional status following pancreatoduodenectomy (PD) using computational fluid dynamics (CFD). Twenty-four patients who underwent PD with PV/SMV resection and reconstruction without tumor recurrence for over 9 months after the operation were enrolled in the study. Three-dimensional models were constructed from computed tomography images obtained 3-6 months postoperatively. The pressure (p) at the inlet and turbulence dissipation rate (ε) at the outlet were investigated in the models. Patients with values of either p or ε above the upper interquartile range were classified as the poor flow group. The prognostic nutritional index improvement rate was significantly lower at 9 postoperative months in the poor flow group than in the good flow group (P = 0.016). This finding indicates the utility of a CFD analysis for evaluating the reconstructed PV/SMV morphology.

Prolonged warm ischemia time in the recipient is associated with post-transplant biliary stricture following living-donor liver transplantation.

PURPOSE: Post-transplant biliary stricture (PBS) is a common and important complication following orthotopic liver transplantation (LT). This study clarified the incidence of PBS and identified its risk factors. METHODS: We retrospectively reviewed the medical records of 67 patients who underwent living-donor LT (LDLT) at our institute between June 2010 and July 2022 and analyzed their clinical characteristics, prognosis, and risk factors for PBS. RESULTS: Of the 67 patients, 26 (38.8%) developed PBS during the observation period. Multivariate analyses revealed the following independent risk factors for PBS formation: increased red cell transfusion volume per body weight (> 0.2 U/kg; hazard ratio [HR], 3.8; P = 0.002), increased portal vein pressure (PVP) at the end of LT (> 16 mmHg; HR, 2.88; P = 0.032), postoperative biliary leakage (HR, 4.58; P = 0.014), and prolonged warm ischemia time (WIT) (> 48 min; HR, 4.53; P = 0.008). In patients with PBS, the cumulative incidence of becoming stent free was significantly higher in patients with a WIT ≤ 48 min than in those with a WIT > 48 min (P = 0.038). CONCLUSION: Prolonged WIT is associated with intractable PBS following LDLT.

Reduced chemokine C-C motif ligand 1 expression may negatively regulate colorectal cancer progression at liver metastatic sites.

Colorectal cancer (CRC) liver metastasis, albeit a stage-IV disease, is completely curable by surgical resection in selected patients. In addressing the molecular basics of this phenomenon, differentially expressed genes at primary and liver metastatic sites were screened by RNA sequencing with the use of paraffin-embedded surgical specimens. Chemokine C-C motif ligand 1 (CCL1), a chemotactic factor for a ligand of the chemokine C-C motif receptor 8 (CCR8), was isolated as one of the differentially expressed genes. Histological analysis revealed that the number of CCL1-positive cells, mainly tumour associated macrophages (TAMs) located in the stroma of CRC, decreased significantly at liver metastatic sites, while the expression level of CCR8 on CRC remained unchanged. To explore the biological significance of the CCL1-CCR8 axis in CRC, CCR8-positive CRC cell line Colo320DM was used to assess the effect of the CCL1-CCR8 axis on major signalling pathways, epithelial mesenchymal transition induction and cell motility. Upon stimulation of recombinant CCL1 (rCCL1), phosphorylation of AKT was observed in Colo320DM cells; on the other hand, the corresponding significant increase in MMP-2 levels demonstrated by RT-qPCR was nullified by siRNA (siCCR8). In the scratch test, rCCL1 treatment significantly increased the motility of Colo320DM cells, which was similarly nullified by siCCR8. Thus, the activation of the CCL1-CCR8 axis is a positive regulator of CRC tumour progression. Reduced CCL1 expression of TAMs at liver metastatic sites may partly explain the unique slow tumour progression of CRC, thus providing for a grace period for radical resection of metastatic lesions.

Dorsal approach in laparoscopic extended left hemi-hepatectomy: A case series.

RATIONALE: The utility of the dorsal approach has been reported for laparoscopic left hemi-hepatectomy. PATIENT CONCERNS: The aim of the present study is to show the usefulness of the dorsal approach for laparoscopic extended left-hemi-hepatectomy while ensuring safe identification of hepatic veins and dissection of the dorsal tumor margin. DIAGNOSES: Tumors requiring extended left hemi-hepatectomy. INTERVENTIONS: After mobilization of the lateral sector and division of the Arantius plate, parenchyma above the Arantius plate is removed to expose the root of the middle hepatic vein and left hepatic vein. Each of these veins can be isolated separately either intra- or extra-hepatically. After removing the parenchyma on the cranial side of the left Glissonean pedicle continuous with the exposed hepatic veins, the left Glissonean pedicle is isolated using the Glissonean pedicle transection method. After division of the left hepatic vein and Glissonean pedicle, segment 4 (in which the main part of the tumor is commonly located) is dissected from the anterior plane of the paracaval portion of the caudate lobe by the dorsal approach, along with the hepatic hilum. Following dissection of the dorsal side of the tumor, and division of parenchyma from the anterior edge of the liver, the anterior Glissonean branches and middle hepatic vein are divided safely and the specimen is resected. OUTCOMES: Three patients underwent laparoscopic extended left hemi-hepatectomy, with no open conversions. Operative time and blood loss were 331 (concomitant with another partial hepatectomy), 277, and 315 minutes; and 200, 100, and 100 g, respectively. The postoperative courses were uneventful. LESSONS: The dorsal approach maximizes the advantages of laparoscopic extended left hemi-hepatectomy and can be performed safely.

Impact of the inferior vena cava morphology on fluid dynamics of the hepatic veins.

We reported previously that a large vertical interval between the hepatic segment of the inferior vena cava (IVC) and right atrium (RA), referred to as the IVC-RA gap, was associated with more intraoperative bleeding during hemi-hepatectomy. We conducted a computational fluid dynamics (CFD) study to clarify the impact of fluid dynamics resulting from morphologic variations around the liver. The subjects were 10 patients/donors with a large IVC-RA gap and 10 patients/donors with a small IVC-RA gap. Three-dimensional reconstructions of the IVC and hepatic vessels were created from CT images for the CFD study. Median pressure in the middle hepatic vein was significantly higher in the large-gap group than in the small-gap group (P = 0.008). Differences in hepatic vein pressure caused by morphologic variation in the IVC might be one of the mechanisms of intraoperative bleeding from the hepatic veins.

Clamp-crushing Pancreatic Transection in Minimally Invasive Distal Pancreatectomy.

BACKGROUND: Minimally invasive distal pancreatectomy has become a widely accepted procedure for tumors located in the pancreatic body or tail. However, pancreatic transection by linear stapler is generally avoided for pancreatic body tumors located above the portal vein because the surgical margin width is narrowed after taking into account the cutting allowance for insertion of the stapling device. Herein, we report a parenchymal clamp-crushing procedure that provides a sufficient surgical margin in pancreatic transection. METHODS: Two patients with suspected early pancreatic cancer underwent pancreatic transection using the clamp-crushing procedure. The planned pancreatic transection line was set just to the left of the gastroduodenal artery in both cases. Robotic and laparoscopic distal pancreatectomy were performed in 1 patient each. Patients were positioned supine with split legs. Parenchymal transection was performed with crushing by VIO 3 (ERBE Elektromedizin) operated in softCOAG Bipolar mode with Effect 2/modulation 50. After crushing, remnant tissue was cut in autoCUT Bipolar mode operated by VIO 3 with Effect 2/modulation 50, or cut after secured by clipping. RESULTS: The surgical duration was 253 and 212 minutes, and estimated blood loss was 0 and 50 mL in the 2 patients, and both were discharged with uneventful courses. Pathologic examination confirmed a negative surgical margin in both patients. CONCLUSION: Clamp-crushing pancreatic transection for distal pancreatectomy might be a suitable treatment option for achieving sufficient surgical margin in pancreatic body tumors located close to the portal vein.

Diagnostic value of quantification of cell-free DNA for suspected gallbladder cancer.

Background and Aim: An accurate preoperative diagnosis as the basis for deciding the most appropriate surgical procedure is essential for patients with suspected gallbladder cancer (GBC). The aim of this study was to investigate the usefulness of cell-free DNA (cfDNA) for the preoperative detection of ≥T2 invasion in patients with suspected GBC. Methods: Twenty-four patients who underwent resection for suspected GBC were enrolled. The concentration of cfDNA obtained from blood samples preoperatively was measured and evaluated in two distributions. The first peak (less than 200 base pairs) of cfDNA distribution was defined as the shorter fragment cfDNA, considered to originate mainly from apoptosis; and the second peak (200 base pairs or more) was defined as the longer fragment cfDNA, originating mainly from necrosis. Results: Pathological analysis identified benign disease in 12 patients and GBC in 12 patients, of whom 6 patients had ≥pT2 GBC. Carcinoembryonic antigen (CEA) and carbohydrate antigen (CA)19-9 were significantly higher in the ≥pT2 GBC group than in the benign/

Epstein-Barr Virus-Associated Latent Malignant Lymphoma With Acute Exacerbation After Living Donor Liver Transplantation: Case Report.

Concomitant malignant lymphoma at the time of transplantation is usually considered a contraindication to liver transplantation (LT). We report a case of Epstein-Barr virus (EBV)-associated malignant lymphoma that was latent preoperatively and rapidly became aggravated after LT. A 69-year-old man was referred to our hospital with an exacerbation of abdominal distension due to polycystic liver. As cystic infection, ascites, and deteriorated liver reserve function occurred after hepatic artery embolization, he underwent living-donor LT with his daughter as the donor. His respiratory condition worsened, and he was moved to the intensive care unit on postoperative day 34. Histopathologic examination of the excised liver returned around the same time revealed findings suggestive of EBV-associated malignant lymphoma in lymph nodes near the gallbladder. Subsequent computed tomography scans showed apparent neoplastic lesions in the abdominal cavity and worsening pleural effusion and ascites. Numerous atypical lymphocytes were observed in the pleural effusion and ascites, and the patient was diagnosed with exacerbation of EBV-associated malignant lymphoma. He was treated unsuccessfully with rituximab and died 66 days after LT. Caution should be exercised in elderly immunocompromised transplant candidates who may have comorbid EBV-associated lymphoproliferative disease.

The impact of cystic duct tube on the onset time of postoperative bile leakage after hepatectomy: A propensity score-matched analysis.

BACKGROUND: The cystic duct tube (C-tube) was used to reduce bile leakage (BL) incidence after hepatectomy. Nevertheless, delayed BL is sometimes experienced even using C-tube. This study investigates the impact of C-tube use on the onset time of post-hepatectomy BL. METHODS: Data from 455 consecutive patients who underwent hepatectomy without biliary reconstruction between November 2007 and July 2020 were analyzed retrospectively. A C-tube was used for intraoperative biliary injury or in consideration of BL risk. BL was divided into two groups according to the postoperative onset time: early onset and late onset. To assess the association between C-tube use and BL, propensity score matching in a 1:1 ratio was performed to match BL risk factors between the C-tube and no-C-tube groups. RESULTS: BL occurred in 30 (6.6%) of the 455 included patients. C-tubes were used in 51 patients (11.2%) with open hepatectomy, high-risk hepatectomy, massive blood loss, long operation time, or prophylactic drain placement. After propensity score matching, BL occurred in 17 of 102 patients (16.7%). Early-onset BL occurred significantly less frequently in the C-tube group than in the no-C-tube group (3.9% vs. 15.7%, p = 0.046); however, late-onset BL was more common in the C-tube group (9.8% vs. 3.9%, p = 0.24). Six of seven patients (85.7%) with BL with C-tube use developed BL after C-tube removal. CONCLUSION: C-tube drainage may reduce early-onset BL in cases having risk factors for BL. Conversely, since late-onset BL often occurs after C-tube removal, attention should be paid to those cases.

Intramuscular Adipose Tissue Content as a Predictor of Incisional Hernia after Hepatic Resection.

BACKGROUND: Incisional hernia (IH) is a common surgical complication, with an incidence of 6-31% following major abdominal surgery. This study aimed to investigate the impact of intramuscular adipose tissue content (IMAC) on the incidence of IH in patients who underwent hepatic resection. METHODS: Data of 205 patients who underwent open hepatic resection between 2007 and 2019 at Ehime University Hospital were retrospectively analyzed. Patient characteristics, perioperative findings, and body composition were compared between patients with IH and those without IH. The quantity and quality of skeletal muscle, calculated as skeletal muscle index and IMAC, were evaluated using preoperative computerized tomography images. RESULTS: Forty (19.5%) patients were diagnosed with IH. The cumulative incidence rates were 15.6% at 1 year and 19.6% at 3 years. On univariate analysis, body mass index, areas of subcutaneous and visceral fat, and IMAC were significantly higher in the IH group than in the non-IH group (p = 0.0023, 0.0070, 0.0047, and 0.0080, respectively). No significant difference in skeletal muscle index was found between the groups (p = 0.3548). The incidence of diabetes mellitus, intraoperative transfusion, and postoperative wound infection was significantly higher in the IH group than in the non-IH group (p = 0.0361, 0.0078, and 0.0299, respectively). On multivariate analysis, a high IMAC and wound infection were independent risk factors for IH (adjusted odds ratio, 2.83 and 4.52, respectively; p = 0.0152 and 0.0164, respectively). CONCLUSION: IMAC can predict the incidence of IH in patients undergoing hepatic resection.

[A Case of Unresectable Hepatocellular Carcinoma Treated using Lenvatinib and Conversion Surgery].

A 57-year-old man was treated with lenvatinib for unresectable hepatocellular carcinoma(HCC). Thereafter, the tumor marker levels decreased, and the tumor became resectable. The patient underwent portal vein embolization followed by laparoscopic extended left lobectomy. The patient's postoperative course was uneventful, and the tumor marker levels remained within the normal range. No recurrence was observed 3 months after surgery. In recent years, the use of systemic chemotherapy with drugs, such as lenvatinib, followed by conversion surgery has been reported in some cases of unresectable HCC. The present case reports successful conversion surgery following lenvatinib treatment.

Association between the Preoperative C-Reactive Protein-to-Albumin Ratio and the Risk for Postoperative Pancreatic Fistula following Distal Pancreatectomy for Pancreatic Cancer.

Postoperative pancreatic fistula (POPF) are major postoperative complications (POCs) following distal pancreatectomy (DP). Notably, POPF may worsen the prognosis of patients with pancreatic cancer. Previously reported risks for POCs include body mass index, pancreatic texture, and albumin levels. Moreover, the C-reactive protein-to-albumin ratio (CAR) is a valuable parameter for prognostication. On the other hand, POCs sometimes lead to a worse prognosis in several cancer types. Thus, we assumed that CAR could be a risk factor for POPFs. This study investigated whether CAR can predict POPF risk in patients with pancreatic cancer following DP. This retrospective study included 72 patients who underwent DP for pancreatic cancer at Ehime University between January 2009 and August 2022. All patients underwent preoperative CAR screening. Risk factors for POPF were analyzed. POPF were observed in 17 of 72 (23.6%) patients. POPF were significantly associated with a higher CAR (p = 0.001). The receiver operating characteristic curve analysis determined the cutoff value for CAR to be 0.05 (sensitivity: 76.5%, specificity: 88.9%, likelihood ratio: 6.88), indicating an increased POPF risk. Univariate and multivariate analysis revealed that CAR ≥ 0.05 was a statistically independent factor for POPF (p < 0.001, p = 0.013). Therefore, CAR has the potential to predict POPF following DP.

Intraoperative selective arterial calcium injection test to confirm complete resection of a proinsulinoma.

Proinsulinoma is a subtype of insulinoma that is surgically curable, but localization can be difficult as these tumors are typically too small to be visualized by imaging. We report the case of a 53-year-old woman referred to our hospital with dizziness and headache. Her blood glucose level was 46 mg/dl and Whipple's triad was present. Although her immunoreactive insulin level during hypoglycemia was in the normal range (5.0 µU/ml), the proinsulin level was elevated (408 pmol/l). Imaging examinations showed no evidence of pancreatic tumor. A preoperative selective arterial calcium injection (SACI) test showed excessive insulin secretion in the splenic artery region, which localized the proinsulinoma to the body or tail of the pancreas, and laparoscopic spleen-preserving distal pancreatectomy was performed. Intraoperative SACI test performed after tumor removal did not show excessive insulin secretion. The intraoperative SACI test appears to be useful for localization and for confirming complete resection of proinsulinoma.

Geriatric nutritional risk index as a potential prognostic marker for patients with resectable pancreatic cancer: a single-center, retrospective cohort study.

In pancreatic cancer, postoperative complications (POCs) are associated with disease outcomes. The geriatric nutritional risk index (GNRI) is known to predict POCs after pancreatoduodenectomy (PD) or distal pancreatectomy (DP) in patients with hepatobiliary pancreatic tumors, including pancreatic cancer. Through POC occurrence risk, we aimed to determine whether GNRI could predict prognosis in patients who underwent PD or DP for resectable pancreatic cancer. This retrospective study examined 139 patients who underwent radical pancreatectomy for resectable pancreatic cancer at Ehime University. All patients were subjected to nutritional screening using GNRI and were followed up for POC diagnosis and patient outcomes such as overall survival (OS). Patients were divided based on the GNRI value of 99 (Low group: N = 74, GNRI < 99; High group: N = 65, GNRI ≥ 99), which was determined by receiver operating characteristic curve analysis. Multivariate analysis showed that GNRI < 99 was statistically correlated with POCs after curative pancreatic resection (p = 0.02). Univariate and multivariate analyses confirmed that GNRI < 99 was significantly associated with long OS (p = 0.04). GNRI could be a potential prognostic marker for resectable pancreatic cancer after curative pancreatic resection despite being a simple and noninvasive approach.

Importance of reconstruction of middle hepatic vein tributaries of right-lobe grafts in living donor liver transplantation: demonstration of the reconstruction technique.

PURPOSE: The aim of the present study on living donor liver transplantation (LDLT) using a right-lobe graft without the middle hepatic vein (MHV) was to investigate the clinical impact of MHV tributary reconstruction using our criteria and techniques. METHODS: The medical records of 40 patients who underwent adult LDLT using a right-lobe graft without the MHV between April 2008 and December 2020 were retrospectively reviewed. In this cohort, the criterion for MHV tributary reconstruction was estimated drainage volume of each MHV tributary greater than 100 mL. The drainage vein of segment 8 (V8) was reconstructed as the common orifice of the right hepatic vein and V8 using a venous patch graft, and that of segment 5 was reconstructed using artificial vascular grafts. The outcomes were compared between the groups with and without MHV tributary reconstruction. Factors associated with postoperative massive ascites were also investigated. RESULTS: Twenty patients underwent MHV tributary reconstruction. There were no significant differences in the amount of postoperative ascites, Clavien-Dindo classification ≥ III postoperative complications, and 90-day in-hospital mortality between the groups (P = 0.678, P = 1.000, and P = 0.244, respectively). On multivariate analyses, a low-estimated functional graft-to-recipient weight ratio, which was calculated using estimated graft volume minus the territory of MHV tributaries that was not reconstructed, was identified as an independent predictor of postoperative massive ascites (odds ratio, 40.479; 95% confidence interval, 3.823-428.622). CONCLUSION: The present study suggests that selective MHV tributary reconstruction might be useful for achieving successful graft function.

Laparoscopic clamp-crushing enucleation with a pancreatic duct stent for tumors located close to the main pancreatic duct.

The perioperative management and technical details of laparoscopic clamp-crushing enucleation for low-malignant-potential pancreatic neuroendocrine neoplasms (PNENs) located close to the main pancreatic duct (MPD) in the body/tail of the pancreas using a perioperative MPD stent are reported. The procedure was performed in two patients with PNEN (13 and 10 mm in diameter) in the body/tail of the pancreas. A naso-pancreatic stent (NPS) was placed preoperatively in both patients. Resection was performed using Maryland-type bipolar forceps. The surgical duration was 139 and 55 min, and the estimated blood loss was 5 and 0 mL, respectively. One patient was discharged uneventfully on postoperative day (POD) 12. The other patient developed a grade B pancreatic fistula, but was discharged on POD 22. Laparoscopic clamp-crushing enucleation with an NPS might be a viable treatment option for tumors located close to the MPD.

Survey of chemotherapy-induced nausea and vomiting in patients with urothelial carcinoma.

Chemotherapy-induced nausea and vomiting (CINV) can cause anorexia, weight loss and deterioration of patient quality of life. It is one of the most unpleasant adverse effects of chemotherapy treatment regimens. For the optimal treatment of gastrointestinal symptoms during urothelial carcinoma chemotherapy, the present study investigated the association between gastrointestinal symptoms and therapeutic effects of gemcitabine plus platinum [cisplatin (GC) or carboplatin (GCa)] therapies. The incidence and frequency of nausea/vomiting with GC split therapy (gemcitabine, 1,000 mg/m2 on days 1 and 8; split-dose cisplatin, 35 mg/m2 on days 1 and 8; 21-day schedule) and GCa therapy [gemcitabine, 750-1,000 mg/m2 on days 1, 8 and 15; carboplatin, area under the blood concentration-time curve=5 mg min/ml (Calvert formula) on day 2; 28-day schedule] were lower compared with those of GC therapy (gemcitabine, 1,000 mg/m2 on days 1, 8 and 15; single-dose cisplatin 70 mg/m2 on day 2; 28-day schedule). However, no differences in therapeutic outcomes were observed among therapies. GCa therapy, regardless of renal function, and GC split therapy demonstrated significant increases compared with GC therapy in alleviating gastrointestinal symptoms associated with cancer chemotherapy in patients with urothelial carcinoma. Overall, these results suggested that split-dose cisplatin administration or the use of carboplatin instead of cisplatin may be useful in patients who experience CINV without compromising treatment effectiveness.

Laparoscopic partial liver resection for hepatocellular carcinoma arising from Fontan-associated liver disease: a case report.

BACKGROUND: The Fontan procedure (FP) is a palliative surgery for functional single ventricle. The Fontan circulation maintains pulmonary circulation by a high central venous pressure, leading to chronic congestive liver. The number of patients diagnosed with hepatocellular carcinoma (HCC) arising from liver fibrosis and cirrhosis after FP is increasing. Several reports have described surgical treatment for HCC after FP, but few have described laparoscopic surgery. CASE PRESENTATION: The patient was a 31-year-old man who had undergone the FP for single right ventricle at 3 years. Several liver masses were detected at 30 years. A liver mass in segment 3 showed increasing size concomitant with increasing alpha-fetoprotein concentration, and a solitary HCC 15 mm in diameter was diagnosed. The tumor was located on the liver surface, abutting the origin of the left hepatic vein. Laparoscopic partial liver resection was performed. The postoperative course was uneventful and the patient was discharged on postoperative day 3. The patient remained disease-free on follow-up after 7 months. CONCLUSIONS: Although we had some concerns, such as difficulty managing general anesthesia and easy venous bleeding due to high central venous pressure, laparoscopic partial liver resection was performed with safe exposure of the left hepatic vein.