The Vertical Array Reconstruction Technique in Pylorus-Preserving Pancreatoduodenectomy.

BACKGROUND/AIMS: We describe a new reconstruction method of duodenojejunal anastomosis, the "vertical array reconstruction" (VAR) technique, following pylorus-preserving pancreatoduodenectomy (PPPD). METHODS: The VAR technique aligns the stomach, duodenum, and jejunal loop vertically along the body's longitudinal axis. It was performed in 120 consecutive patients (between June 2008 and October 2015) who underwent PPPD. We evaluated the incidence of delayed gastric emptying (DGE). RESULTS: The incidence of DGE was 1.7% (n = 2). The proposed clinical grading classified these 2 cases of DGE as grade B. There was no DGE related to pancreatic fistula. The median duration to starting a solid diet was 3 days (range 3-5 days). The median operative time was 450 min (range 391-550 min). CONCLUSION: The VAR technique allows the upper digestive tract to be aligned linearly and can minimize the risk of DGE after PPPD.

Predictive model for survival after liver resection for noncolorectal liver metastases in the modern era: a Japanese multicenter analysis.

BACKGROUND: Survival benefit of liver resection for noncolorectal liver metastases (NCRLM) remains to be defined. METHODS: This multicenter, retrospective cohort analysis included consecutive patients with NCRLM whose primary tumor and all metastases were treated with curative intent between 2000 and 2013. The primary endpoint was 5-year overall survival. Clinicopathological factors that affected prognoses were identified using multivariate Cox regression analyses and were included in a predictive model. RESULTS: Data for 205 patients were analyzed. The three most common primary tumor sites were stomach (39%), pancreas (13%), and urinary tract (10%), with adenocarcinomas the main pathology (52%). R0 resection was achieved in 85%, and the overall survival at 5 years was 41%. In the multivariate analysis, synchronous liver metastases, R1/2 resection, and adenocarcinomas and other carcinomas (with gastrointestinal stromal tumors, neuroendocrine tumors G1/G2, and sarcomas set as the reference group) were independent negative indicators of overall survival. A predictive model effectively stratified the NCRLM patients into low-, intermediate-, and high-risk groups with overall 5-year survival rates of 63%, 38%, and 21%, respectively (P < 0.001). CONCLUSIONS: Patients who underwent curative resection for metachronous disease and favorable tumor pathology are expected to have better survival in the NCRLM cohort.

Risk factors for failure of early recovery from pancreatoduodenectomy despite the use of enhanced recovery after surgery protocols and a physical aging score to predict postoperative risks.

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are beneficial for pancreatoduodenectomy (PD). Our aim was to evaluate risk factors associated with ERAS protocol failure after PD. METHODS: Clinical variables of 187 patients managed using ERAS protocols between April 2011 and April 2017, including non-early recovery (non-ER) patients, with complications or requiring a hospital stay ≥15 days, and early recovery (ER) patients, were compared. A physical aging (PA) score was devised to predict postoperative risks. RESULTS: Independent risk factors of complications were a pre-albumin level ≤18 mg/dl (odds ratio (OR) 2.197; 95% confidence interval (CI) 1.052-4.622), and an American Society of Anesthesiologists (ASA) score ≥II (OR 2.195; 95% CI 1.052-4.746). Independent risk factors for hospital stay ≥15 days (P < 0.001) were age ≥70 years (OR 2.438; 95% CI 1.122-5.299) and an ASA score ≥II (OR 2.348; 95% CI 1.109-4.968). The PA score included age, ASA score, and pre-albumin level. The complication rate for each PA score was as follows: score "0", 12.1%; score "1", 18.2%; score "2", 26.9%; score "3", 30.8%; and score "≥4", 47.2%. CONCLUSIONS: Advanced age, poor nutrition, and serious illnesses can cause ERAS protocol failure. The PA score is effective for predicting postoperative progress.

Utility of Glissonean Pedicle Transection for Surgical Treatment of Severe Liver Trauma.

The most common initial strategy for treatment of severe liver trauma is damage control in which hemostasis is achieved by perihepatic gauze packing and/or vascular embolization. However, we encounter patients in whom this strategy alone is not adequate. We have applied the principles of Glissonean pedicle transection, a technique that was originally devised to ensure safe and quick performance of planned hepatectomy for liver cancer, to 3 cases of severe liver trauma. We performed Glissonean pedicle ligation during damage control surgery in 2 patients and Glissonean pedicle transection during the definitive surgery in 1 patient. We describe the approaches and our experience with them, including operation times and outcomes. From our experience thus far, it seems that 8-12 h after the damage control procedure is appropriate for performing the definitive surgery. Although there are some problems posed by this strategy and cases to which it will not be applicable, the method seems to be particularly useful for cases of severe liver trauma in which the damage is extensive and involves the Glissonean pedicles near the hepatic hilus. We describe our 3 cases in detail and review our experience in light of the available literature.