Short- and long-term outcomes of preservation versus ligation of the inferior mesenteric artery in laparoscopic D3 lymph node dissection for descending colon cancer: a propensity score-matched analysis.

PURPOSE: This study aimed to compare the short- and long-term outcomes of laparoscopic D3 lymph node (LN) dissection between ligation of the inferior mesenteric artery (IMA) (LIMA) and preservation of the IMA (PIMA) for descending colon cancer using propensity score-matched analysis. METHODS: This retrospective study included 101 patients with stage I-III descending colon cancer who underwent laparoscopic D3 LN dissection with LIMA (n = 60) or PIMA (n = 41) at a single center between January 2005 and March 2022. After propensity score matching, 64 patients (LIMA, n = 32; PIMA, n = 32) were included in the analysis. The primary endpoint was the long-term outcomes, and the secondary endpoint was the surgical outcomes. RESULTS: In the matched cohort, no significant difference was noted in the surgical outcomes, including the operative time, estimated blood loss, number of harvested LNs, number of harvested LN 253, and complication rate. The long-term outcomes were also not significantly different between the LIMA and PIMA groups (3-year recurrence-free survival, 72.2% vs. 75.6%, P = 0.862; 5-year overall survival, 69.8% vs. 63.4%, P = 0.888; 5-year cancer-specific survival, 84.2% vs. 82.8%, P = 0.607). No recurrence of LN metastasis was observed around the IMA root. CONCLUSION: Laparoscopic D3 dissection in PIMA was comparable to that in LIMA regarding both short- and long-term outcomes. The optimal LN dissection for descending colon cancer should be investigated in future large-scale studies.

Short-term outcomes of extracorporeal colo-colonic triangular anastomosis versus functional end-to-end anastomosis in laparoscopic-assisted surgery for left-sided colon cancer: a propensity score matching analysis.

PURPOSE: To the best of our knowledge, no studies have compared the short-term outcomes between colo-colonic extracorporeal triangular anastomosis (TA) and functional end-to-end anastomosis (FEEA), with a focus on laparoscopic-assisted surgery for left-sided colon cancer. Therefore, this study compared the short-term outcomes of these anastomoses using propensity score matching analysis. METHODS: This retrospective study included 129 patients with stage I-IV left-sided colon cancer who underwent laparoscopic-assisted surgery with colo-colonic extracorporeal TA (n = 75) or FEEA (n = 54) between May 2009 and March 2021. After propensity score matching, 84 patients (TA, n = 42; FEEA, n = 42) were included in the analysis. The primary endpoint was the complication rate for all grades, and the secondary endpoints were the rates of Clavien - Dindo grade ≥ 3 complications and anastomotic leakage. RESULTS: In the matched cohort, there were no significant differences in the complication rates for all grades (35.7% vs. 26.2%, p = 0.479), Clavien - Dindo grade ≥ 3 complications (11.9% vs. 11.9%, p = 1), and anastomotic leakage (0% vs. 4.8%, p = 0.494) between the TA and FEEA groups. In the univariate logistic regression analysis, TA did not increase the frequency of complications for any grades compared with FEEA (odds ratio: 1.570, 95% confidence interval: 0.616-3.980, p = 0.347). CONCLUSION: Extracorporeal TA demonstrated equivalent short-term outcomes compared with FEEA in cases of laparoscopic-assisted surgery for left-sided colon cancer. TA can be an alternative anastomosis technique in cases wherein FEEA is difficult to perform.

Short- and long-term outcomes of a self-expandable metallic stent versus a transanal decompression tube for pathological stage II and III left-sided obstructive colorectal cancer: a retrospective observational study.

PURPOSE: Few studies have investigated the long-term oncological outcomes of the self-expandable metallic stent (SEMS) as a bridge to surgery (BTS) for obstructive colorectal cancer (OCRC). We conducted this study to compare the short- and long-term outcomes of the SEMS with those of the traditional transanal decompression tube (TDT) in patients with stage II and III left-sided OCRC. METHODS: The subjects of this retrospective study were 78 patients with pathological stage II and III left-sided OCRC who underwent radical surgery after SEMS or TDT placement, between April, 2005 and September, 2019. We compared perioperative data, including decompression success rates and 3-year relapse-free survival (RFS), between the SEMS and TDT groups. RESULTS: A SEMS was placed in 60 (76.9%) patients and a TDT was placed in 18 (23.1%) patients, achieving a clinical success rate of decompression of 98.3% in the SEMS group and 77.8% in the TDT group (P = 0.009). The 3-year RFS of the overall cohort was better in the SEMS group than in the TDT group (74.9% vs. 40.9%, respectively; P = 0.003). CONCLUSIONS: Decompression using a SEMS as the BTS may improve oncological outcomes over those achieved by a TDT in patients with left-sided stage II and III OCRC.

Comparison of prognostic impact between positive intraoperative peritoneal and lavage cytologies in colorectal cancer.

BACKGROUND: The prognostic value of positive intraoperative peritoneal cytology and lavage cytology, including the differences in their prognostic impact, in colorectal cancer is controversial. We aimed to investigate the prognostic values of positive peritoneal cytology and lavage cytology findings for colorectal cancer and compare their prognostic impact. METHODS: We retrospectively evaluated 592 clinical stage II-IV colorectal cancer patients who underwent peritoneal cytology (n = 225) or lavage cytology (n = 367) between November 1993 and December 2018. The prognostic factors for cancer-specific survival were identified, and the differences in cancer-specific survival were examined between the patients. RESULTS: The cytology-positive rate was 10.8% (64/592), 17.8% (40/225), and 6.5% (24/367) in the overall, peritoneal cytology, and lavage cytology groups, respectively. Both positive peritoneal cytology (hazard ratio: 2.196) and lavage cytology (hazard ratio: 2.319) were independent prognostic factors. The peritoneal cytology-positive group showed significantly poorer cancer-specific survival than the cytology-negative group (5-year: 3.5% vs. 59.5%; 10-year: 3.5% vs. 46.1%, p < 0.001). Similar results were obtained for lavage cytology (5-year: 14.1% vs. 73.9%; 10-year: 4.7% vs. 63.5%, p < 0.001). The cancer-specific survival was not significantly different between the peritoneal cytology-positive and lavage cytology-positive groups (p = 0.058). Both positive peritoneal and lavage cytology were associated with poorer cancer-specific survival across all colorectal cancer stages. CONCLUSIONS: Positive peritoneal and lavage cytology are associated with worse cancer-specific survival in colorectal cancer. The prognostic impact was comparable between positive lavage and peritoneal cytology. Thus, cytology should be a standard assessment modality for colorectal cancer.

Hepatectomy for Hepatocellular Carcinoma with Bile Duct Tumor Thrombus, Including Cases with Obstructive Jaundice.

BACKGROUND: This study aimed to evaluate the short- and long-term outcomes of hepatectomy for hepatocellular carcinoma (HCC) with bile duct tumor thrombus (BDTT), including cases with obstructive jaundice. METHODS: The study reviewed 42 HCC patients with BDTT, including six patients who needed preoperative biliary drainage due to obstructive jaundice, and 732 HCC patients without BDTT. The authors analyzed the impact of BDTT on the surgical outcomes and assessed the outcomes of hepatectomy for patients presenting with obstructive jaundice. RESULTS: The HCC patients with BDTT, almost all with stage 3 or 4 disease, had increased alpha-fetoprotein expression, larger tumors, and more portal vein invasion status. The survival of the HCC patients with BDTT was significantly inferior to that of the patients without BDTT (p = 0.0003). Survival did not differ significantly between the HCC patients with BDTT and those without BDTT when the two groups were matched by stage (p = 0.3366). The HCC patients with BDTT who presented with obstructive jaundice demonstrated outcomes similar to those for the HCC patients with BDTT who did not present with obstructive jaundice in terms of the overall survival rate (p = 0.5469). The perioperative outcomes for the HCC patients with BDTT did not depend on the presence or absence of preoperative jaundice. No patients in either BDTT group demonstrated 90-day mortality in this study. CONCLUSIONS: Hepatectomy should be considered for HCC patients with BDTT, even for patients with obstructive jaundice, because the surgical outcomes equivalent to those for HCC without BDTT can be achieved.

Our technique of preceding diaphragm resection and partial mobilization of the hepatic right lobe using a vessel sealing device (LigaSure™) for huge hepatic tumors with diaphragm invasion.

We describe and assess our technique of preceding diaphragm resection and partial mobilization of the hepatic right lobe to treat a huge hepatic tumor with diaphragm invasion. The right hepatic artery and portal vein were divided at the hepatic hilum, and the mesenteries were then dissected with a vessel sealing device (LigaSure Impact™). The invaded diaphragm was dissected roundly using a vessel sealing device and the right lobe was partially mobilized. A soft catheter was then passed along the anterior aspect of the retrohepatic inferior vena cava and the liver parenchyma was dissected via a liver hanging maneuver. We performed eight hepatectomies using this technique. The median blood loss was 532.5 ml and the mean excised liver weight was 1859 g. Our results demonstrate the safety and efficiency of the preceding diaphragm resection and partial mobilization technique using a vessel sealing device for right hepatectomy to resect a very large tumor with diaphragm invasion.

Multiplication of alpha-fetoprotein and protein induced by vitamin K absence-II is a powerful predictor of prognosis and recurrence in hepatocellular carcinoma patients after a hepatectomy.

AIM: To evaluate the oncological implications of multiplication of α-fetoprotein (AFP) and protein induced by vitamin K absence or antagonists-II (PIVKA-II) in patients with hepatocellular carcinoma (HCC). METHODS: Data were prospectively collected from 516 consecutive patients who underwent a curative primary hepatectomy for HCC between 1998 and 2010. The AP-factor (AFP × PIVKA-II) was evaluated in relation to 2-year survival outcomes by receiver-operator curve analysis to determine the cut-off values. Patient survival, recurrence-free survival and risk factors were analyzed in accordance with the preoperative AP-factor. RESULTS: The AP-factor was categorized into three groups depending on the serum concentrations of AFP and PIVKA-II as follows: AP1 (n = 206; AFP < 200 ng/mL and PIVKA-II < 100 mAU/mL), AP2 (n = 152; AFP × PIVKA-II < 10(5) ) and AP3 (n = 158; AFP × PIVKA-II ≥ 10(5) ). The AP-factor was found to be significantly related to pathological factors such as differentiation, portal vein invasion, hepatic vein invasion and intrahepatic metastasis. Multivariate analysis was performed to identify the risk factors for survival and recurrence. Albumin, AP-factor and pathological factors including portal vein invasion, hepatic vein invasion and intrahepatic metastasis are independent risk factors for survival. Tumor number, AP-factor, and a non-cancerous liver were determinants of recurrence. CONCLUSION: The AP-factor is closely related to differentiation and microscopic vascular invasion, and was selected by multivariate analysis as an independent factor for survival and recurrence, in HCC. Patients hopeful of obtaining good outcomes after a hepatectomy could be selected by the AP-factor evaluation.

[Efficacy of Sorafenib for Extrahepatic Recurrence of Hepatocellular Carcinoma after Liver Resection].

Sorafenib is the first molecularly targeted drug recommended as a treatment for advanced hepatocellular carcinoma (HCC). Herein, we report the efficacy of sorafenib for extrahepatic recurrence of HCC. From September 2004 to March 2015, 47 patients who were diagnosed with recurrent HCC after liver resection were treated with sorafenib. The overall response rate was 17.5% (complete response: CR 1, partial response: PR 6, stable disease: SD 17, progressive disease: PD 13, SD beyond PD 3), and the disease control rate was 67.5%. The median time to disease progression, including extrahepatic recurrence, was significantly better than in the group with only intrahepatic metastasis (p=0.034). Therefore, sorafenib might be an effective treatment for extrahepatic recurrence of HCC.

[Effect of Preoperative Bowel Preparation on Surgical Site Infection in Liver Surgery].

BACKGROUND: In our institute, the protocol for preoperative bowel preparation before liver surgery has been changed from polyethylene glycol lavage (NiflecR: N group) to magnesium citrate (MagcorolR: M group). METHODS: Ninety patients who underwent hepatectomy without reconstruction of the bile duct, gastorectomy, or colorectal resection from 2012 to 2013 were enrolled in this study. The impacts of preoperative bowel preparation were compared between the 2 groups. RESULTS: There were no significant differences between the 2 groups in terms of surgical procedure, operative time, bleeding amount, and duration of postoperative hospital stay. Surgical-site infection did not occur in both groups. There were no significant differences in the white blood cell count and platelet count of the patients in both groups. The C-reactive protein level in the M group was significantly lower than that in the N group on days 1, 3, and 5 after the operation, whereas the ammonia level in the M group was significantly lower than that in the N group on day 5 after the operation. CONCLUSION: It is possible to simplify preoperative bowel preparation associated with liver surgery while ensuring appropriate safety.

Identification of novel serum biomarkers of hepatocellular carcinoma using glycomic analysis.

UNLABELLED: The altered N-glycosylation of glycoproteins has been suggested to play an important role in the behavior of malignant cells. Using glycomics technology, we attempted to determine the specific and detailed N-glycan profile for hepatocellular carcinoma (HCC) and investigate the prognostic capabilities. From 1999 to 2011, 369 patients underwent primary curative hepatectomy in our facility and were followed up for a median of 60.7 months. As normal controls, 26 living Japanese related liver transplantation donors were selected not infected by hepatitis B and C virus. Their mean age was 40.0 and 15 (57.7%) were male. We used a glycoblotting method to purify N-glycans from preoperative blood samples from this cohort (10 µL serum) which were then identified and quantified using mass spectrometry (MS). Correlations between the N-glycan levels and the clinicopathologic characteristics and outcomes for these patients were evaluated. Our analysis of the relative areas of all the sugar peaks identified by MS, totaling 67 N-glycans, revealed that a proportion had higher relative areas in the HCC cases compared with the normal controls. Fourteen of these molecules had an area under the curve of greater than 0.80. Analysis of the correlation between these 14 N-glycans and surgical outcomes by univariate and multivariate analysis identified G2890 (m/z value, 2890.052) as a significant recurrence factor and G3560 (m/z value, 3560.295) as a significant prognostic factor. G2890 and G3560 were found to be strongly correlated with tumor number, size, and vascular invasion. CONCLUSION: Quantitative glycoblotting based on whole serum N-glycan profiling is an effective approach to screening for new biomarkers. The G2890 and G3560 N-glycans determined by tumor glycomics appear to be promising biomarkers for malignant behavior in HCCs. (HEPATOLOGY 2013;).

Immunohistochemical analysis of cancer stem cell markers in pancreatic adenocarcinoma patients after neoadjuvant chemoradiotherapy.

BACKGROUND: Cancer stem cells (CSCs) have been reported to play an important role in chemoradiation resistance. Although the association of CSC markers with clinicopathological outcomes after neoadjuvant chemoradiotherapy (NACRT) has been reported in various types of cancers, there have been no such reports for pancreatic cancer. Here we examined the sequential changes in CSC marker expressions after NACRT in patients with pancreatic adenocarcinoma (PA) and the impact of these changes on the prognosis. METHODS: We used immunohistochemistry to evaluate the expressions of the CSC markers epithelial cell adhesion molecule (EpCAM), CD24, CD44, CD133, CXCR4 and Aldehyde dehydrogenase 1 (ALDH1) in resected specimens obtained from 28 PA patients, and we compared these expressions with the patients' clinicopathological parameters and survival data. RESULTS: The expression frequencies of CD44 and ALDH1 were significantly higher in the NACRT group (n = 17) compared to the non-NACRT group (n = 11), but the CD133 expression was significantly lower in the NACRT group. In the NACRT group, the expression of CD133 was inversely correlated with that of ALDH1, and CD133+/ALDH1- expression was associated with an unfavorable patient outcome. CONCLUSION: This is the first report showing that NACRT may influence the expression frequencies of CD44, CD133 and ALDH1 in PA patients. Moreover, CD133 and ALDH1 expressions may be useful predictors of prognosis in PA patients who have received NACRT.

Usefulness of artificial vascular graft for venous reconstruction in liver surgery.

BACKGROUND: The purpose of this study was to evaluate the results of hepatectomy with inferior vena cava or hepatic vein resection, followed by vessel reconstruction with an artificial vascular graft. METHODS: From 2000 to 2011, 1,434 patients underwent several types of hepatectomy at our institution. Of these, we reviewed the cases of eight patients (0.56%) who underwent hepatectomy with inferior vena cava or hepatic vein resection and subsequent reconstruction using an expanded polytetrafluoroethylene (PTFE) graft. RESULTS: We resected the inferior vena cava in six patients and the hepatic vein in two patients. All eight patients underwent subsequent reconstruction using an expanded PTFE graft. The median operative time was 443 minutes and the median blood loss was 2,017 mL. The median postoperative hospital stay period was 18.5 days and the in-hospital mortality rate was 0%. Complications occurred in four patients: two patients experienced bile leakage, one experienced a wound infection, and one experienced pleural effusion. The two patients who experienced bile leakage had undergone reoperation on postoperative day 1. No complication with the artificial vascular graft occurred in these eight cases. Histological invasion to the replaced inferior vena cava or hepatic vein was confirmed in four cases. All artificial vascular grafts remained patent during the observation period. CONCLUSIONS: Hepatectomy combined with inferior vena cava or hepatic vein resection, followed by reconstruction with an expanded PTFE graft can be performed safely in selected patients.

Long-term outcome of laparoscopic hepatectomy in patients with hepatocellular carcinoma.

BACKGROUND/AIMS: The long-term prognosis for patients with hepatocellular carcinoma (HCC) who undergo laparoscopic hepatectomy has not been well compared with that for patients after open hepatectomy. METHODOLOGY: We analyzed patient survival (PS) and disease-free survival (DFS) of 310 consecutive patients who underwent primary hepatectomy between January 2001 and March 2010. The patients were divided into Group LAP (laparoscopic approach) (n = 24) and Group OPN (with open laparotomy) (n = 286). The median follow-up time was 60.9 months (range, 12.0-123.9 months). RESULTS: The 5-, and 7-year PS rates of Group LAP were 87.9%, and 87.9%, and those of Group OPN were 82.2% and 69.3%, respectively (P = 0.5638). The 5-, and 7-year DFS rates of Group LAP were 47.1%, and 31.4%, and those of Group OPN were 29.4%, and 24.3%, respectively (P = 0.4594). Laparoscopic hepatectomy in patients of Group LAP resulted in a better outcome of blood loss (P = 0.0314), operative time (P < 0.0001), and hospital stay (P = 0.0008). CONCLUSIONS: The long-term outcome of laparoscopic hepatectomy for patients with HCC was identified to be comparable to open hepatectomy with regard to PS and DFS. Laparoscopic hepatectomy is a promising therapeutic option for patients with HCC.

[Intra-arterial infusion of IA-call® combined with oral anticancer drugs for recurrent hepatocellular carcinoma after liver resection].

Continuous hepatic artery infusion chemotherapy for hepatocellular carcinoma (HCC) refractory to trans-arterial chemoembolization ( TACE) sometimes adversely affects the quality of life (QOL) of patients. Herein, we report a one-shot intraarterial infusion of cisplatin powder (IA-call®) combined with oral anticancer drugs for recurrent HCC refractory to TACE after liver resection.From July 2013, 4 patients who were diagnosed with recurrent HCC refractory to TACE after liver resection were treated with IA-call® infusions at 1-2 month intervals.Encapsulated tegafur-uracil (UFT-E) or sorafenib were administered sequentially.On average, IA-call® was administered 3.6 times per patient at a mean dosage of 93 mg per treatment. UFT-E was combined with the IA-call® infusion for 3 patients, and a sorafenib combination was used for 1 patient.In terms of the therapeutic effects of these regimens, we observed complete response (CR) in 1 patient, partial response (PR) in 2 patients, and progressive disease (PD) in 1 patient(response rate: 75%). Therefore, one-shot intra-arterial infusion of IAcall ® combined with oral anticancer drugs is an effective therapy for recurrent HCC while maintaining patients' QOL.

Clinicopathological characteristics and prognostic factors in young patients after hepatectomy for hepatocellular carcinoma.

BACKGROUND: The aim of this study was to analyze the clinicopathological characteristics and the prognostic factors for survival and recurrence of young patients who had undergone hepatectomy for hepatocellular carcinoma. METHODS: Between 1990 and 2010, 31 patients aged 40 years or younger (younger patient group) among 811 consecutive patients with hepatocellular carcinoma who had undergone primary hepatectomy were analyzed with regard to patient factors, including liver function, tumor factors and operative factors. The clinicopathological characteristics of the younger patients were compared with those of patients over the age of 40 (older patient group). Then the prognostic factors of the younger patients were analyzed. Continuous variables were expressed as the means ± standard deviation and compared using the χ2 test for categorical variables. Overall survival and recurrence-free survival rates were determined by the Kaplan-Meier method and analyzed by the log-rank test. The Cox proportional hazards model was used for multivariate analysis. RESULTS: In the younger patients, the rates of HBs-antigen-positivity, high alpha-fetoprotein, portal invasion, intrahepatic metastasis, large tumors, low indocyanin green retention rate at 15 minutes, and anatomical resection were significantly higher than the same measures in the older patients. The five-year overall survival rate of the young patients was 49.6%. The prognostic factors of survival were HCV-antibody-positivity and low albumin status. Prognostic factors of recurrence were multiple tumors and the presence of portal invasion. CONCLUSIONS: In younger patients, survival appeared to be primarily affected by liver function, while recurrence was affected by tumor factors. Young patients with hepatocellular carcinoma should be aggressively treated with hepatectomy due to their good pre-surgical liver function.

Surgical management of hepatocellular carcinoma with tumor thrombi in the inferior vena cava or right atrium.

BACKGROUND: The prognosis for advanced hepatocellular carcinoma (HCC) with tumor thrombi in the inferior vena cava (IVC) or right atrium (RA) is poor, and there is no established effective treatment for this condition. Thus study aimed to evaluate the efficacy of surgical resection and prognosis after surgery for such cases. METHODS: Between January 1990 and December 2012, 891 patients underwent hepatectomy for HCC at our institution. Of these, 13 patients (1.5%) diagnosed with advanced HCC with tumor thrombi in the IVC or RA underwent hepatectomy and thrombectomy. Data detailing the surgical outcome were evaluated and recurrence-free and overall survival rates were calculated using the Kaplan-Meier method. RESULTS: Seven patients had an IVC thrombus and six had an RA thrombus. Extra-hepatic metastasis was diagnosed in 8 of 13 patients. Surgical procedures included three extended right lobectomies, three extended left lobectomies, five right lobectomies, and two sectionectomies. Right adrenal gland metastases were excised simultaneously in two patients. All IVC thrombi were removed under hepatic vascular exclusion and all RA thrombi were removed under cardiopulmonary bypass (CPB). Four patients (30.8%) experienced controllable postoperative complications, and there was no surgical mortality. The mean postoperative hospital stay for patients with IVC and RA thrombi was 23.6 ± 12.5 days and 21.2 ± 4.6 days, respectively. Curative resection was performed in 5 of 13 cases. The 1- and 3-year overall survival rates were 50.4%, and 21.0%, respectively, and the median survival duration was 15.3 months. The 1- and 3-year overall survival rates for patients who underwent curative surgical resection were 80.0% and 30.0%, respectively, with a median survival duration of 30.8 months. All patients who underwent curative resection developed postoperative recurrences, with a median recurrence-free survival duration of 3.8 months. The 1-year survival rate for patients who underwent noncurative surgery and had residual tumors was 29.2%, with a median survival duration of 10.5 months. CONCLUSIONS: Aggressive surgical resection for HCC with tumor thrombi in the IVC or RA can be performed safely and may improve the prognoses of these patients. However, early recurrence and treatment for recurrent or metastatic tumors remain unresolved issues.

An intraductal papillary neoplasm of the bile duct mimicking a hemorrhagic hepatic cyst: a case report.

An intraductal papillary neoplasm of the bile duct is a biliary, epithelium-lined, cystic lesion that exhibits papillary proliferation and rarely causes large hemorrhagic cystic lesions. Here, we report a case of an intraductal papillary neoplasm of the bile duct mimicking a hemorrhagic hepatic cyst in a middle-aged man with large hemorrhagic hepatic cysts who experienced abdominal pain and repeated episodes of intracystic bleeding. Following portal vein embolization, extended right hepatic lobectomy was performed, and intraoperative cholangiography revealed communication between the intracystic space and the hepatic duct. Although histological studies revealed that the large hemorrhagic lesion was not lined with epithelium, the surrounding multilocular lesions contained biliary-derived epithelial cells that presented as papillary growths without ovarian-like stroma. A diagnosis of oncocytic-type intraductal papillary neoplasm of the bile duct was made, and we hypothesized that intracystic bleeding with denudation of the lining epithelial cells might occur as the cystically dilated bile duct increased in size. Differential diagnosis between a hemorrhagic cyst and a cyst-forming intraductal papillary neoplasm of the bile duct with bleeding is difficult. However, an intraductal papillary neoplasm of the bile duct could manifest as multilocular hemorrhagic lesions; therefore, complete resection should be performed for a better prognosis.

[Long-term survival of a patient with metachronous lymph node metastasis and bile duct tumor thrombus due to hepatocellular carcinoma successfully treated with repeated surgery].

A 64-year-old man with hepatocellular carcinoma located in the left lateral lobe and segment 5 was referred to our hospital for surgical treatment. We performed left lateral sectionectomy and segmentectomy 5. The pathological diagnosis was moderately to poorly differentiated hepatocellular carcinoma, and the pathological stage was stage III. Eight months later, intrahepatic recurrence in segment 1 and lymph node metastasis in the hepatoduodenal ligament occurred. Partial resection of segment 1 was performed, and the metastatic lymph node was surgically removed. Twenty four months after the first operation, lymph node metastases along the lesser curvature and retropancreatic space were extirpated. Lymph node metastases along the common hepatic artery were removed 76 months after the first operation. The patient developed jaundice 88 months after the initial surgery, and the bile duct tumor thrombus derived from intrahepatic recurrence in segment 1 caused obstructive jaundice. After percutaneous transhepatic biliary drainage, we performed median sectionectomy and bile duct tumor thrombus removal without bile duct resection. At his 8-year follow-up visit after the primary operation, the patient was healthy and did not show any signs of recurrence. Lymph node metastasis and bile duct tumor thrombus are rare patterns of hepatocellular carcinoma recurrence, and aggressive surgery can result in long-term survival when complete resection is anticipated.

Hybrid robot-assisted abdominoperineal resection supported by simultaneous trans-perineal approach for anal gland adenocarcinoma with vaginal invasion: a case report.

Hybrid surgery (abdominal robotic approach with a trans-anal approach) has been reported to improve oncological outcomes in cases involving advanced cancer or technical difficulties. A 74-year-old woman presented with anal pain and stenosis. Examination revealed palpable sclerosis on the anterior wall at the anal verge with possible vaginal invasion. A biopsy revealed an adenocarcinoma. We performed a two-team robot-assisted abdominoperineal resection combined with resection of the vagina supported by a simultaneous trans-perineal approach. After rendezvous at the posterior side, the abdominal team cut the posterior wall of the vaginal vault while the perineal team confirmed the surgical margin. Histopathological findings identified the tumour as an anal gland adenocarcinoma (pT4b [vagina] N0M0 pathological stage IIC) with a negative circumferential resection margin. Hybrid surgery combined with resection of the posterior wall of the vagina may be performed safely and is a valuable surgical option for multimodal treatment of anal adenocarcinomas.

Chemical Bowel Preparation Exerts an Independent Preventive Effect Against Surgical Site Infection Following Elective Laparoscopic Colorectal Surgery.

BACKGROUND: We investigated the independent clinical value of mechanical bowel preparations (MBP) and chemical bowel preparations (CBP) for preventing surgical site infection (SSI) in patients undergoing elective laparoscopic colorectal surgery. MATERIALS AND METHODS: This retrospective cohort study included 475 patients who underwent elective laparoscopic colorectal surgery between January 2018 and March 2022. CBP was introduced in January 2021 and included kanamycin (1 g) and metronidazole (1 g) 2 times a day, the day before surgery. In some cases, MBP was omitted in patients who planned to undergo right-sided colectomy, those with tumor obstruction, and those with poor general conditions, depending on the judgment of the physician. The primary endpoint was the overall SSI incidence, while the secondary endpoints were the incidences of incisional SSI and organ-space SSI, culture from the surgical site, and length of postoperative hospital stay. RESULTS: In total, 136 patients underwent CBP. MBP was omitted in 53 patients. Overall, SSI occurred in 80 patients (16.8%), including 61 cases of incisional SSI (12.8%) and 36 cases of organ-space SSI (7.6%). Multivariate logistic regression revealed that CBP exerted an independent preventive effect on overall and incisional SSI, whereas MBP did not. However, CBP was not associated with a decreased risk of overall SSI in patients who had undergone preoperative therapy, those with benign disease, and those with stoma formation in the subgroup analysis. Levels of Bacteroides species at the surgical site were significantly lower in the CBP group than in the non-CBP group. Postoperative hospital stay was significantly longer in the incisional SSI group than in the non-SSI group and was significantly longer in the organ-space SSI group than in the other groups. CONCLUSIONS: CBP, but not MBP, exerts an independent preventive effect on SSI, especially incisional SSI, in patients undergoing elective laparoscopic colorectal surgery.