A clinical assessment of three-dimensional-printed liver model navigation for thrice or more repeated hepatectomy based on a conversation analysis.

PURPOSES: We performed a conversation analysis of the speech conducted among the surgical team during three-dimensional (3D)-printed liver model navigation for thrice or more repeated hepatectomy (TMRH). METHODS: Seventeen patients underwent 3D-printed liver navigation surgery for TMRH. After transcription of the utterances recorded during surgery, the transcribed utterances were coded by the utterer, utterance object, utterance content, sensor, and surgical process during conversation. We then analyzed the utterances and clarified the association between the surgical process and conversation through the intraoperative reference of the 3D-printed liver. RESULTS: In total, 130 conversations including 1648 segments were recorded. Utterance coding showed that the operator/assistant, 3D-printed liver/real liver, fact check (F)/plan check (Pc), visual check/tactile check, and confirmation of planned resection or preservation target (T)/confirmation of planned or ongoing resection line (L) accounted for 791/857, 885/763, 1148/500, 1208/440, and 1304/344 segments, respectively. The utterance's proportions of assistants, F, F of T on 3D-printed liver, F of T on real liver, and Pc of L on 3D-printed liver were significantly higher during non-expert surgeries than during expert surgeries. Confirming the surgical process with both 3D-printed liver and real liver and performing planning using a 3D-printed liver facilitates the safe implementation of TMRH, regardless of the surgeon's experience. CONCLUSIONS: The present study, using a unique conversation analysis, provided the first evidence for the clinical value of 3D-printed liver for TMRH for anatomical guidance of non-expert surgeons.

Financial burden of surgical treatment for retroperitoneal sarcoma.

PURPOSES: The purpose of this study was to compare the financial burden of surgery for retroperitoneal sarcoma (RPS) and gastric cancer (GC). METHODS: All patients who underwent surgery for GC or RPS between 2020 and 2021 at Nagoya University Hospital were included. The clinical characteristics, surgical fees per surgeon, and surgical fees per hour were compared between the two groups. RESULTS: The GC and RPS groups included 35 and 63 patients, respectively. In the latter group, 37 patients (59%) underwent tumor resection combined with organ resection; the most common organ was the intestine (n = 23, 37%), followed by the kidney (n = 16, 25%). The mean operative time (248 vs. 417 min, p < 0.001) and intraoperative blood loss (423 vs. 1123 ml, p < 0.001) were significantly greater in the RPS group than in the GC group. The mean surgical fee per surgeon was USD 1667 in the GC group and USD 1022 in the RPS group (p < 0.001) and USD 1388 and USD 777 per hour, respectively (p < 0.001). CONCLUSIONS: The financial burden of surgical treatment for RPS is unexpectedly higher than that for GC.

Four-dimensional Flow MRI Assessment of Portal Hemodynamics and Hepatic Regeneration after Portal Vein Embolization.

Background Percutaneous transhepatic portal vein (PV) embolization (PVE) is a standard preoperative procedure for advanced biliary cancer when the future liver remnant (FLR) is insufficient, yet the effect of this procedure on portal hemodynamics is still unclear. Purpose To assess whether four-dimensional (4D) MRI flowmetry can be used to estimate FLR volume and to identify the optimal time for this measurement. Materials and Methods This prospective single-center study enrolled consecutive adult patients with biliary cancer who underwent percutaneous transhepatic PVE for the right liver between June 2020 and November 2022. Portal hemodynamics were assessed using 4D flow MRI before PVE and within 1 day (0-day group) or 3-4 days (3-day group) after PVE. FLR volume was measured using CT before PVE and after PVE but before surgery. Blood flow changes were analyzed with the Wilcoxon signed rank test, and correlations with Spearman rank correlation. Results The 0-day group included 24 participants (median age, 72 years [IQR, 69-77 years]; 17 male participants), and the 3-day group included 13 participants (median age, 71 years [IQR, 68-78 years]; eight male participants). Both groups showed increased left PV (LPV) flow rate after PVE (0-day group: from median 3.72 mL/sec [IQR, 2.83-4.55 mL/sec] to 9.48 mL/sec [IQR, 8.12-10.7 mL/sec], P < .001; 3-day group: from median 3.65 mL/sec [IQR, 2.14-3.79 mL/sec] to 8.16 mL/sec [IQR, 6.82-8.98 mL/sec], P < .001). LPV flow change correlated with FLR volume change relative to the number of days from PVE to presurgery CT only in the 3-day group (ρ = 0.62, P = .02; 0-day group, P = .11). The output of the regression equation for estimating presurgery FLR volume correlated with CT-measured volume (ρ = 0.78; P = .002). Conclusion Four-dimensional flow MRI demonstrated increased blood flow in residual portal branches 3-4 days after PVE, offering insights for estimating presurgery FLR volume. Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Roldán-Alzate and Oechtering in this issue.

A presurgical prognostic stratification based on nutritional assessment and carbohydrate antigen 19-9 in pancreatic carcinoma: An approach with nonanatomic biomarkers.

BACKGROUND: Nutritional status and tumor markers are important prognostic indicators for surgical decisions in pancreatic carcinoma. This study aimed to stratify the probability of surviving pancreatic carcinoma based on systematically chosen nonanatomic biomarkers. METHODS: We included 187 consecutive patients that underwent surgical resections for pancreatic carcinoma. We performed multivariable analyses to evaluate prognostic indicators, including 4 blood-test indexes: the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, prognostic nutritional index, and the modified Glasgow prognostic score; and 4 body-composition indexes: the normalized total psoas muscle area, the normalized total elector spine muscle area, the psoas muscle computed tomography value, and the elector spine muscle computed tomography value. RESULTS: Poor survival was associated with 2 independent risk factors: neutrophil-to-lymphocyte ratio ≥3.0 (hazard ratio, 1.54) and prognostic nutritional index <36 (hazard ratio, 1.60), and with high carbohydrate antigen 19-9 levels (≥37 IU/mL). The 2 indexes were not significantly associated with clinicopathological factors, including carbohydrate antigen 19-9. Patients with no risk factors had significantly better survival than those with 1 (P = .007) or 2 risk factors (P = .001), and survival was similar in the latter 2 groups (P = .253). A presurgical nonanatomic scoring system (range, 0-2) was constructed: 0 points for no risk factors, 1 point for 1 or 2 nutritional risk factors, and 1 point for carbohydrate antigen 19-9 ≥37 IU/mL. Survival rate at 3 years decreased with increasing scores (76% for score 0, 42% for score 1, and 21% for score 2; all P < .05). CONCLUSION: Neutrophil-to-lymphocyte ratio and prognostic nutritional index were independent prognostic risk factors in pancreatic carcinoma and integrating these indexes with carbohydrate antigen 19-9 levels could successfully stratify survival.

New method for the assessment of perineural invasion from perihilar cholangiocarcinoma.

PURPOSE: Perineural invasion (PN) is often found in perihilar cholangiocarcinoma. New procedure was developed to assess PN around the right hepatic artery (RHA) using dual-energy computed tomography (DECT). METHODS: Thirty patients with perihilar cholangiocarcinoma who underwent DECT before biliary drainage were retrospectively reviewed. Mask images, i.e., the periarterial layer (PAL) around the RHA and superior mesenteric artery (SMA), were made from late arterial phase DECT. The mean CT number of the PAL was measured. RESULTS: Twenty patients with PN around the RHA were classified into the PN (+) group. The remaining 10 patients without PN and other 26 patients with other diseases that are never accompanied with PN were classified into the PN (-) group. The PAL ratio (the CT number of the PAL around the RHA relative to that around the SMA) was calculated. Both the mean CT number of the PAL around the RHA and the PAL ratio were significantly higher in the PN (+) group than in the PN (-) group. According to an ROC analysis, the predictive ability of the PAL ratio was superior. Using the cutoff value of the PAL ratio 1.009, a diagnosis of PN around the RHA was made with approximately 75% accuracy. CONCLUSIONS: Assessment with CT number of the PAL reconstructed from DECT images is an easy and objective method to diagnose PN.

Assessment of percutaneous transhepatic portal vein embolization with portal vein stenting for perihilar cholangiocarcinoma with severe portal vein stenosis.

BACKGROUND: The aim of the present study was to assess the clinical efficiency of portal vein (PV) stenting when performed with preoperative percutaneous transhepatic portal vein embolization (PTPVE) in patients with severe PV stenosis due to tumor invasion. METHODS: Between 2007 and 2013, four consecutive patients (one male, three females; mean age, 52 years; age range, 25-73 years) with perihilar cholangiocarcinoma and PV stenosis underwent PTPVE and PV stenting. Patients were analyzed with regard to the procedure, hypertrophy of the future remnant liver (FRL), and plasma clearance rate of indocyanine green by the FRL (ICGK-F). Further, the %FRL volume increase in PTPVE was compared between the stenting group and the usual PTPVE group who have perihilar cholangiocarcinomas without PV stenosis. RESULTS: Preoperative PTPVE with PV stenting was successfully performed and portal flow to the FRL improved after stenting in all four patients. The %FRL volume increase was 18-60% (mean, 34%) in the stenting group and was 12-51% (mean, 21%) in the usual PTPVE group. The ICGK-F value after PTPVE exceeded 0.05 in all four patients. All patients achieved R0 resection. CONCLUSIONS: Preoperative PTPVE with PV stenting appears to be feasible in cases of severe PV tumor invasion and stenosis. This procedure may allow a broader indication for surgery.

Assessment of nodal status for perihilar cholangiocarcinoma: location, number, or ratio of involved nodes.

OBJECTIVE: To analyze lymph node status in resected perihilar cholangiocarcinoma, to clarify which index (ie, location, number, or ratio of involved nodes) is better for staging, and to determine the minimum requirements for node examination. BACKGROUND: In the TNM classification for perihilar cholangiocarcinoma, the number or ratio of involved nodes is not considered for nodal staging. The minimum requirement for histologic examination of lymph nodes is arbitrary. METHODS: This study involved 320 patients with perihilar cholangiocarcinoma who underwent resection from January 2000 to December 2009 at Nagoya University Hospital. The relationship between lymph node status and patient survival was retrospectively analyzed. RESULTS: Total lymph node counts (TLNCs), ie, the number of lymph nodes examined histologically, averaged 12.9 ± 8.3 (range: 1-59). Lymph node metastasis was found in 146 (45.6%) patients and was an independent, powerful prognostic factor. The survival rates were not significantly different between patients with regional node metastasis alone and those with distant node metastasis (19.2% vs 11.5% at 5 years, P = 0.058). The survival for patients with multiple node metastases was significantly worse than that for patients with single metastasis (12.1% vs 27.6% at 5 years, P = 0.002), regardless of the presence or absence of distant lymph node metastasis. The survival for patients with lymph node ratios (LNRs) of 0.2 or less was significantly better than that for patients with LNRs greater than 0.2 (21.4% vs 13.5% at 5 years, P = 0.032). Upon multivariate analysis of the 146 patients with lymph node metastasis, the number of involved nodes (single vs multiple) was identified as an independent prognostic factor (RR of 1.61, P = 0.045), whereas the locations (regional alone vs distant) and ratios (LNR ≤ 0.2 vs LNR > 0.2) of involved nodes were not. When the 148 pN0-R0 patients were divided into 3 groups (ie, those with TLNC ≥ 8, with TLNC = 5, 6, or 7, and with TLNC ≤ 4), survivals were identical between the first and second groups, whereas they were largely different between the former two and the third. CONCLUSIONS: Lymph node metastasis is a powerful, independent prognostic factor in perihilar cholangiocarcinoma and is better classified based not on location but on the number of involved nodes. To adequately assess nodal status, histologic examination of 5 or more nodes is recommended.

Value of multidetector row CT in the assessment of longitudinal extension of cholangiocarcinoma: correlation between MDCT and microscopic findings.

BACKGROUND: A few authors have reported the value of multidetector row CT (MDCT) for evaluating the longitudinal extent of cholangiocarcinoma. They have not focused on CT attenuation of a tumor and actual tumor extent along the bile ducts. We designed the present study to analyze attenuation. METHODS: Between January 2003 and July 2005, 113 consecutive patients with cholangiocarcinoma underwent a surgical resection following MDCT. Of these MDCT studies, 73 (perihilar cholangiocarcinoma, n = 62; middle and distal cholangiocarcinoma, n = 11) were suitable for analysis, and the patients were enrolled in the study. Patients were divided according to tumor hypoattenuation and hyperattenuation on MDCT. Histologic differentiation, desmoplastic reaction, and vascular density were microscopically compared with the tumor attenuation to differentiate the characteristics of the attenuation. The extent of cancer along the bile duct diagnosed by MDCT was compared with the actual extent determined by the microscopic findings. RESULTS: Hyperattenuated tumor was observed in 40 patients. There was no difference in histologic differentiation, desmoplastic reaction, or vascular density between the hyperattenuated and hypoattenuated cholangiocarcinomas. Neither the proximal nor the distal borders between the normal and thickened bile duct wall could be determined in the 33 patients with hypoattenuated tumor; in contrast, an accurate assessment of extent of tumor was obtained in 76% of the proximal borders and 82% of the distal borders in the 40 patients with hyperattenuated tumor. CONCLUSIONS: Although the cause of the difference between the hyperattenuated and hypoattenuated cholangiocarcinoma still is unclear, MDCT can be an alternative to direct cholangiography in selected patients with hyperattenuated cholangiocarcinoma.