Long-term outcomes of choledochoduodenostomy for choledocholithiasis: increased incidence of postoperative cholangitis after total or distal gastrectomy.

PURPOSE: Choledochoduodenostomy (CDD) is performed to treat choledocholithiasis (CDL) cases where endoscopic stone removal is difficult. Recognizing CDD characteristics is important for CDL treatment planning. METHODS: A total of 116 patients, including 33 patients ≥ 80 years old (29 with previous total gastrectomy, 19 with previous distal gastrectomy, 20 with built-up stones, 19 with periampullary diverticulum, 10 with confluence stones, 8 with repetitive recurrent stones, 4 with hard stones, 3 with endoscopic retrograde cholangiography [ERC] not available due to lack of cooperation, 2 with a history of pancreatitis post-ERC, and 2 in whom ERC could not be performed due to a disturbed anatomy) underwent CDD for CDL. Postoperative complications and long-term outcomes were evaluated. RESULTS: The in-hospital mortality rate was 0%. The morbidity (grade ≥ IIIA according to the Clavien-Dindo classification) rates in the elderly (≥ 80 years old) and non-elderly (51-79 years old) patients were 3.0% (1/33) and 2.4% (2/83), respectively (p = 0.85). Long-term complications included cholangitis in eight (7%) patients, of which three cases were repetitive and seven had an operative history of total or distal gastrectomy. The incidence of postoperative cholangitis after total or distal gastrectomy was 15% (7/48), which was significantly higher than that involving other causes (1.5%, 1/68; p < 0.01). Two patients with cholangitis after total gastrectomy experienced early recurrence of lithiasis at 2 and 9 months after surgery. CONCLUSIONS: CDD is safe, even in elderly patients. However, a history of total gastrectomy or distal gastrectomy may increase the incidence of postoperative cholangitis.

The effectiveness of adjuvant chemotherapy for Stage I pancreatic cancer based on the UICC 8th edition.

BACKGROUND: Adjuvant chemotherapy is recommended for patients with pancreatic cancer after curative resection. However, there is limited evidence regarding the efficacy and prognostic factors for adjuvant chemotherapy in patients with stage I pancreatic cancer. This study aimed to identify patients in whom chemotherapy was effective and to detect prognostic factors for stage I pancreatic cancer based on guidelines of the 8th edition of the Union for International Cancer Control (UICC). METHODS: Between 2009 and 2017, 108 patients diagnosed with stage I pancreatic cancer were enrolled in this study. They were distributed into invasion (n = 68) and non-invasion (n = 40) groups. The relationship between clinicopathological variables, including various prognostic factors, disease-free survival (DFS), and overall survival (OS), were investigated by univariate and multivariate analyses. RESULTS: Five-year survival in all patients with stage I pancreatic cancer was 38.9%. Adjuvant chemotherapy failed to improve DFS or OS in patients with stage I cancer (DFS, p = 0.26; OS, p = 0.30). In subgroup analysis, adjuvant chemotherapy significantly improved DFS (multivariate-adjusted hazard ratio (HR), 0.40; 95% confidence interval [CI], 0.21-0.78; p = 0.007) and OS (multivariate-adjusted HR, 0.32; 95% CI, 0.15-0.68; p = 0.003) in the invasion group than in non-invasion group. In contrast, in the non-invasion group, adjuvant chemotherapy failed to improve DFS and OS in univariate analysis (DFS, p = 0.992; OS, p = 0.808). CONCLUSION: For stage I pancreatic cancer, based on guidelines of the UICC 8th edition, adjuvant chemotherapy may benefit patients with extrapancreatic invasion.

The impact of S-1 for the patient with lymph nodal metastasis biliary tract cancer as adjuvant chemotherapy: a multicenter database analysis.

INTRODUCTION: Although adjuvant chemotherapy is expected to improve the prognosis for patients with biliary tract cancer after curative resection, there is limited evidence regarding the efficacy and prognostic factors of adjuvant chemotherapy. We investigated the effective subgroups for whom adjuvant chemotherapy with S-1 in biliary tract cancer patients. METHODS: 413 patients who underwent curative resection for biliary tract cancer at our four affiliated hospitals between 2009 and 2019 were included in this study. The association of adjuvant chemotherapy with long-term outcomes in overall and patient subgroups were investigated by univariate and multivariate analyses. RESULTS: Among overall patients, adjuvant chemotherapy with S-1 did not improve disease free survival (p = 0.29) and overall survival (p = 0.83). In the subgroup analysis, adjuvant chemotherapy with S-1 improved both disease-free and overall survival in patients with lymph node metastasis, advanced Stage (III and IV), and microscopic residual tumor. In 135 patients with lymph node metastasis, adjuvant chemotherapy with S-1 was given in 67 patients (50%). In the patients with lymph node metastasis, preoperative bile duct drainage (p = 0.01) and adjuvant chemotherapy (p = 0.04) were independent and significant predictors of disease-free survival, while preoperative bile duct drainage (p = 0.03), tumor differentiation (p = 0.03), and adjuvant chemotherapy (p = 0.03) were independent and significant predictors of overall survival. CONCLUSION: After resection of biliary tract cancer, adjuvant chemotherapy with S-1 appears to benefit those who had lymph node metastasis.

Impact of osteopenia on surgical and oncological outcomes in patients with pancreatic cancer.

INTRODUCTION: Osteopenia, which is defined as a decrease in bone mineral density, has been recently recognized as a metabolic and an oncological biomarker for surgery in patients with malignancy. We aimed to study the prognostic impact of osteopenia in patients with pancreatic cancer (PC) after resection. METHODS: A total of 56 patients who underwent curative resection of PC were retrospectively investigated. The skeletal muscle index at the third lumbar spine and bone mineral density at the 11th thoracic vertebra were measured using computed tomography. RESULTS: Sarcopenia and osteopenia were identified in 24 (43%) and 27 (48%) patients, respectively. The overall and disease-free survival rates were significantly lower in the sarcopenia group than in the non-sarcopenia group (p < 0.01 and p < 0.01, respectively) and in the osteopenia group than in the non-osteopenia group (p < 0.01 and p < 0.01, respectively). In multivariate analysis, sarcopenia (odds ratio [OR] 4.05; 95% confidence interval [CI] 1.23-13.38; p = 0.02) was a significant independent predictor of 1-year disease-free survival. Further, sarcopenia (OR 6.00; 95% CI 1.46-24.6; p = 0.01) and osteopenia (OR 4.66; 95% CI 1.15-18.82; p = 0.03) were significant independent predictors of 2-year overall survival. CONCLUSION: Osteopenia is a significant negative factor for 2-year overall survival after curative resection of PC.

A Preoperative Scoring System to Predict Carcinoma in Patients with Gallbladder Polyps.

INTRODUCTION: A preoperative scoring system to predict carcinoma in patients with gallbladder polyps (GBPs). METHODS: Preoperative parameters of patients with GBPs who underwent cholecystectomies were used to construct a scoring system to ascertain the risk of malignancy (reference group). The scoring system developed from this approach was applied to the validation group. RESULTS: In the reference group, 11.5% of patients had carcinomas, in whom the median age was 68 years and the polyp size was 16.9 mm. According to the univariate analysis, the significant factors for carcinoma were age ≥65 years, the presence of gallstones, polyp size ≥13 mm, solitary polyp, and sessile polyp. Age ≥65 years and polyp size ≥13 mm were significant factors according to the multivariate analysis. From these results, we developed a preoperative scoring system to predict carcinoma. The patients were divided into 1 of 2 groups: low-risk and high-risk and their malignancy rates were 4.1 and 61.1% respectively (p < 0.001). In the validation group, the malignancy rate was higher for those in the high-risk group (p = 0.016). CONCLUSIONS: The proposed preoperative scoring system based on simple clinical variables appears to be useful for predicting malignancy in patients with GBPs.

Risk Factors for Early Postoperative Small Bowel Obstruction After Anterior Resection for Rectal Cancer.

PURPOSE: The aim of the study was to evaluate risk factors for small bowel obstruction (SBO) in early postoperative period after anterior resection for rectal cancer. METHODS: Patients who underwent anterior resection (AR) [high AR (HAR) or low AR (LAR)] for rectal cancer between January 2009 and April 2016 were enrolled into the study after fulfilling selection criteria. In included patients, risk factors for early postoperative SBO (EPSBO) were analyzed by means of univariate and multivariate analysis. Cases with perioperative major complications other than intestinal obstruction and with simultaneous resection of other organs were excluded. The same analyses were also performed for cases of redo surgery due to EPSBO. EPSBO was defined as clinically and radiologically confirmed SBO that developed after resuming oral intake within 30 days following surgery. The logistic regression method was used for statistical analyses. RESULTS: In enrolled 180 patients, EPSBO occurred in 23 (12.8%). In univariate analysis, male sex [odds ratio (OR) = 2.17, 95% CI = 0.82-6.84, p < 0.0001], previous abdominal surgery (OR = 0.20, 95% CI = 0.03-0.73, p = 0.0117), low tumor (OR = 3.26, 95% CI = 1.28-8.13, p = 0.0140), LAR (OR = 17.25, 95% CI = 3.49-312.55, p < 0.0001), D3 node dissection (OR = 13.61, 95% CI = 2.75-246.69, p = 0.0002), defunctioning ileostomy (DI) formation (OR = 9.88, 95% = 3.80-29.14, p < 0.0001), and prolonged operation time (OR = 1.01, 95% CI = 1.00-1.01, p = 0.0122) were significantly related to EPSBO. Multivariate analysis demonstrated that D3 node dissection (OR = 10.93, 95% CI = 1.94-208.23, p = 0.0038) and DI formation (OR = 5.82, 95% CI = 1.55-25.31, p = 0.0083) were independent risk factors for EPSBO. Four cases (17.4%) with EPSBO required re-operation because conservative therapies failed; all were laparoscopic DI formation cases. In three of those four cases, stenosis of stoma at the level of the posterior sheath of rectus abdominis muscle was the reason of SBO, and in one case it was kinking of the stomal limb. CONCLUSIONS: D3 lymph node dissection and DI formation are independent risk factors for EPSBO in AR.

[Pulmonary Cryptcoccosis Mimicking Malignant Tumor;Report of a Case].

Pulmonary cryptococcosis is difficult to distinguish from lung cancer clinically, and is often diagnosed by surgery. A 72-year-old woman, who underwent distal pancreatectomy and splenectomy for pancreatic carcinoma. Four months after surgery, a tumor shadow was detected in the left lung as a groundglass nodule (GGN)of 12 mm in diameter, which was found to change to 15 mm with increased density by the computed tomography(CT)scan after 2 months. The nodule showed positive accumulation of fluorodeoxyglucose(FDG)by positron emission tomography(PET), and was suspected of malignant tumor. She underwent a partial resection of the left lung under thoracoscopy.

Laparoscopic modified Sugarbaker parastomal hernia repair with 2-point anchoring and zigzag tacking of Parietex™ Parastomal Mesh technique.

BACKGROUND: The ideal mesh and mesh fixation technique for laparoscopic Sugarbaker (SB) parastomal hernia repair have not yet been identified. METHODS: Sixteen patients with parastomal hernia who underwent laparoscopic modified SB repair (LSB) between June 2012 and October 2015 were retrospectively analyzed. LSB was performed using a developed standardized 2-point anchoring and zigzag tacking of Parietex™ Parastomal Mesh (PCO-PM) technique. RESULTS: Out of 16 cases, 14 were primary and 2 recurrent hernias; 13 were para-end colostomy and 3 were para-ileal conduit (PIC) hernias. The median longitudinal and transverse diameters of the hernia orifice were 5 cm (2.5-7 cm) and 4.2 cm (2-6 cm), respectively. Five cases had a concomitant midline incisional hernia, which was simultaneously repaired. In all cases, the mesh was placed without deflection. The median operation time was 193 (75-386) min. Perioperative complications occurred in two cases (13 %) with PIC, one intra-operatively and the other postoperatively. The intra-operative complication was enterotomy close to the ureteroenteric anastomosis of the ileal conduit; it was repaired through a mini-laparotomy. LSB was accomplished without any subsequent postoperative complications. The postoperative complication was ureteral obstruction that required creation of nephrostomy. Mini-laparotomy was necessary in those two cases (13 %) because of intra-operative enterotomy and severe intra-abdominal adhesions. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed with a median follow-up of 14.5 (2-41) months. CONCLUSIONS: Our LSB using standardized mesh fixation technique is safe and feasible, and the PCO-PM seems to be the most optimal prosthesis.

Closure versus non-closure of fascial defects in laparoscopic ventral and incisional hernia repairs: a review of the literature.

The laparoscopic technique for repairing ventral and incisional hernias (VIH) is now well established. However, several issues related to laparoscopic VIH repair, such as the high recurrence rate for hernias with large fascial defects and in extremely obese patients, are yet to be resolved. Additional problems include seroma formation, mesh bulging/eventration, and non-restoration of the abdominal wall rigidity/function with only bridging of the hernial orifice using standard laparoscopic intraperitoneal onlay mesh repair (sIPOM). To solve these problems, laparoscopic fascial defect closure with IPOM reinforcement (IPOM-Plus) has been introduced in the past decade, and a few studies have reported satisfactory outcomes. Although detailed techniques for fascial defect closure and handling of the mesh have been published, standardized techniques are yet to be established. We reviewed the literature on IPOM-Plus in the PubMed database and identified 16 reports in which the recurrence rate, incidence of seroma formation, and incidence of mesh bulging were 0-7.7, 0-11.4, and 0 %, respectively. Several comparison studies between sIPOM and IPOM-Plus seem to suggest that IPOM-Plus is associated with more favorable surgical outcomes; however, larger-scale studies are essential.

Navigation surgery using an augmented reality for pancreatectomy.

AIM: The aim of this study was to evaluate the utility of navigation surgery using augmented reality technology (AR-based NS) for pancreatectomy. METHODS: The 3D reconstructed images from CT were created by segmentation. The initial registration was performed by using the optical location sensor. The reconstructed images were superimposed onto the real organs in the monitor display. Of the 19 patients who had undergone hepatobiliary and pancreatic surgery using AR-based NS, the accuracy, visualization ability, and utility of our system were assessed in five cases with pancreatectomy. RESULTS: The position of each organ in the surface-rendering image corresponded almost to that of the actual organ. Reference to the display image allowed for safe dissection while preserving the adjacent vessels or organs. The locations of the lesions and resection line on the targeted organ were overlaid on the operating field. The initial mean registration error was improved to approximately 5 mm by our refinements. However, several problems such as registration accuracy, portability and cost still remain. CONCLUSION: AR-based NS contributed to accurate and effective surgical resection in pancreatectomy. The pancreas appears to be a suitable organ for further investigations. This technology is promising to improve surgical quality, training, and education.

Clinical application of navigation surgery using augmented reality in the abdominal field.

This article presents general principles and recent advancements in the clinical application of augmented reality-based navigation surgery (AR based NS) for abdominal procedures and includes a description of our clinical trial and subsequent outcomes. Moreover, current problems and future aspects are discussed. The development of AR-based NS in the abdomen is delayed compared with another field because of the problem of intraoperative organ deformations or the existence of established modalities. Although there are a few reports on the clinical use of AR-based NS for digestive surgery, sophisticated technologies in urology have often been reported. However, the rapid widespread use of video- or robot assisted surgeries requires this technology. We have worked to develop a system of AR-based NS for hepatobiliary and pancreatic surgery. Then we developed a short rigid scope that enables surgeons to obtain 3D view. We recently focused on pancreatic surgery, because intraoperative organ shifting is minimal. The position of each organ in overlaid image almost corresponded with that of the actual organ with about 5 mm of mean registration errors. Intraoperative information generated from this system provided us with useful navigation. However, AR-based NS has several problems to overcome such as organ deformity, evaluation of utility, portability or cost.

["Let's become the surgeon" the present status of the medical course beside teaching in Department of surgery, Daisan Hospital the Jikei University School of medicine: based on the experience OF clinical Clark ship for 5 years].

In Department of Surgery, Daisan Hospital, The Jikei University School of Medicine, Clinical Clark ship (C.C.) is positively taken in the bedside teaching of the medical course fifth and sixth grader from April, 2010. We think that the C.C. is a good opportunity to tell the charm of the surgeon to the students. We introduce a bedside teaching going in our Department, based on the experience of the C.C. for 5 years. In the bedside teaching of our department, there are many tasks not to advance before when students do not have discussion with preceptors, about participation in surgery, presentation of the preoperative conference, visiting of outpatient care and night practice. Moreover, students decide the theme about submitting report and research presentation. For our department which built a bedside teaching with on the job training as a concept from 2010, "students in the C.C." is welcome and beneficial for the doctors, the students itself and the patients. When C.C. will be introduced into all Department of our university in earnest from 2016, we have to examine the merits and demerits in future so that C.C. functions going well.

Breast hemangioma with difficulty in preoperative diagnosis: a case report.

We report a rare case of breast hemangioma found in a 70-year-old Japanese female. Before seeking medical attention, the patient noticed a hard mass in her right breast but denied associated symptoms. A mammography revealed a well-circumscribed, highly dense, lobular nodule located in the middle inter portion of the right breast. To verify this finding, we used ultrasonography which revealed an irregular, iso-echoic nodule measuring 10 mm in the same portion. Based on these findings, we suspected a malignancy and performed a core needle biopsy. Unexpectedly, a histological examination of the biopsy displayed normal vasculature, adipose, and mammary tissues. In order to make an accurate diagnosis, the mass was surgically excised under general anesthesia and sent to pathology. Pathological findings of the mass were positive for breast hemangioma, and the patient has had no recurrence of the disease for the past 24 months.

Osteosarcopenia impacts treatment outcomes for Barcelona Cancer Liver Classification stage A hepatocellular carcinoma.

AIM: To study the effect of preoperative osteosarcopenia (OSP) on the prognosis of treatment (surgery or radiofrequency ablation (RFA)) in patients with Barcelona Cancer Liver Classification stage A hepatocellular carcinoma (BCLC A HCC). METHODS: This study enrolled 102 patients with BCLC A HCC who underwent surgical resection (n = 45) and RFA (n = 57); the patients were divided into two groups: OSP (n = 33) and non-OSP (n = 69). Overall survival (OS) and disease-free survival (DFS) curves for both the groups and treatment methods (surgery and RFA) were generated using the Kaplan-Meier method and compared using the log-rank test. Univariate analyses for OS and DFS were performed using log-rank test. Multivariate analyses were performed for factors that were significant at univariate analysis by Cox proportional hazard model. RESULTS: Multivariate analysis showed that OSP (HR 2.44; 95 % CI 1.30-4.55; p < 0.01) and treatment (HR 0.57; 95 % CI 0.31-0.99; p = 0.05) were significant independent predictors of DFS; and treatment (HR, 0.30; 95 % CI 0.10-0.85; p = 0.03) was a significant independent predictor of OS in the non-OSP group, in which the OS rate was significantly lower in patients treated with RFA than in those treated by resection (p = 0.01). CONCLUSIONS: OSP is a prognostic factor for BCLC A HCC treatment. Surgical approach was associated with a significantly better prognosis in patients without OSP compared to those who underwent RFA.

Effect of Risk Factor Score on Early Recurrence After Pancreatectomy for Invasive Pancreatic Ductal Adenocarcinoma.

BACKGROUND/AIM: This study aimed to identify the risk factors for early recurrence (ER) after pancreatic ductal adenocarcinoma (PDAC) resection to create a novel scoring system for ER and analyze their effect on the recurrence pattern. PATIENTS AND METHODS: Sixty patients with PDAC who underwent pancreatectomy were included. The predicted risk factors for ER were analyzed. A new score defining ER was created and analyzed for recurrence pattern and prognosis. RESULTS: Independent predictors included high CA 19-9 (≥147 U/ml), high lymph node ratio (LNR of ≥0.1277), and no adjuvant chemotherapy (AC). The 5-year overall survival rates with a score of 0, 1, and 2 were 55.8%, 11.0%, and 0%, respectively. In the moderate- risk score group, prognosis was improved by induction of AC within 58 days. CONCLUSION: Preoperative high CA19-9, high LNR, and no AC could be ER predictors. Induction of postoperative chemotherapy within 58 days may improve prognosis.

Primary upper lumbar hernia repaired by transabdominal preperitoneal approach technique using a self-expanding mesh with a memory-recoil ring, report of a case.

BACKGROUND: Upper lumber hernia is a rare entity which can cause obstruction and strangulation. Laparoscopic technique has been considered effective for such hernia repairs; however, there is no report of use of the self-expanding mesh. CASE PRESENTATION: A 77-year-old woman visited to our hospital complaining of a bulge of about 5 cm in the left lumbar dorsal region while standing. Abdominal CT and MRI scans showed a fascial defect in the left lumbar abdominal wall and confirmed the presence of a hernia, in which retroperitoneal fatty tissue and the descending colon protruded. Transabdominal preperitoneal repair (TAPP) was performed and the operative findings revealed the hernia orifice, 3 × 2.5 cm in diameter, between two intercostal nerves. To avoid nerve injury or entrapment, the number of mesh fixation was desirable minimum; therefore, a self-expanding mesh with a memory-recoil ring was used. The mesh, 9.5 × 13 cm in diameter, was placed and tacked to the abdominal wall at two points, 1 cm ventral and dorsal to the hernia orifice. The postoperative course was uneventful and no pain or recurrence was observed with follow-up of 6 months. CONCLUSION: We herein present a case of upper lumber hernia successfully repaired by TAPP with a self-expanding mesh.

Transperineal Repair of Secondary Perineal Hernia Using a Mesh with a Memory-recoil Ring.

Objectives: The aim of this study was to evaluate the effectiveness of transperineal repair of secondary perineal hernia (SPH) using a mesh with a memory-recoil ring. Methods: Seven patients with SPH who underwent transperineal repair (TPR) between July 2010 and May 2022 were retrospectively analyzed. TPR was performed using a mesh with a memory-recoil ring. Results: All SPHs developed after abdominoperineal resections in patients with anorectal malignancies. The median longitudinal and transverse diameters of the hernia orifice were 8 (7-10) cm and 6 (5-7) cm, respectively. In all cases, the mesh was fixed to the ischial tuberosity, residual levator muscle, coccygeus muscle, and coccyx after thorough dissection of the sac. The median operation time was 154 (142-280) min. Perioperative complications occurred in 2 cases (29%). One was enterotomy, which caused postoperative mesh infection requiring extraction of the mesh. The other was vaginal injury, which resulted in vaginal fistula but closed spontaneously. The median postoperative length of stay was 9 (5-14) days. No recurrence was observed during a median follow-up of 35 (9-151) months. Conclusions: TPR using a mesh with a memory-recoil ring is safe, feasible and promising technique for SPH repairs.

Efficacy and Cost-effectiveness of Pegfilgrastim for Preventing Febrile Neutropenia During Docetaxel, Cisplatin, and 5-Fluorouracil Therapy for Esophageal Cancer.

BACKGROUND/AIM: The docetaxel, 5-fluorouracil, and cisplatin (DCF) regimen is an effective form of chemotherapy for advanced esophageal cancer. However, the incidence of adverse events, such as febrile neutropenia (FN), is high. This study retrospectively examined whether pegfilgrastim treatment reduces FN development during DCF therapy. PATIENTS AND METHODS: This study evaluated 52 patients who were diagnosed with esophageal cancer and underwent DCF therapy at Jikei Daisan Hospital, Tokyo, Japan, between 2016 and 2020. They were divided into non-pegfilgrastim and pegfilgrastim-treated groups, and side-effects of chemotherapy and cost-effectiveness of pegfilgrastim were examined. RESULTS: Eighty-six cycles of DCF therapy were conducted (33 and 53 cycles, respectively). FN was observed in 20 (60.6%) and seven (13.2%) cases, respectively (p<0.001). The lowest absolute neutrophil count during chemotherapy was significantly lower in the non-pegfilgrastim group (p<0.001), and the number of days until improvement from nadir was significantly shorter in the pegfilgrastim group (9 vs. 11 days; p<0.001). No significant difference was found in the onset of grade 2 or more adverse events by Common Terminology Criteria for Adverse Events. However, renal dysfunction was significantly lower in the pegfilgrastim group (30.7% vs. 60.6%, p=0.038). Hospitalization costs were also significantly lower in this group (692,839 vs. 879,431 Japanese yen, p=0.028). CONCLUSION: This study revealed the usefulness and cost-effectiveness of pegfilgrastim in prevention of FN in patients treated with DCF.

A Novel Observational Strategy for Nonfunctional Pancreatic Neuroendocrine Neoplasms With Texture Analysis: A Multicenter Retrospective Study.

Background/Aim: Surgical resection is recommended for nonfunctional pancreatic neuroendocrine neoplasms (NF-pNENs). However, metastasis is rare in patients with small lesions with histological grade 1 (G1); thus, observation is an optional treatment approach for small NF-pNENs. Texture analysis (TA) is an imaging analysis mode for quantification of heterogeneity by extracting quantitative parameters from images. We retrospectively evaluated the utility of TA in predicting histological grade of resected NF-pNENs in a multicenter retrospective study. Patients and Methods: The utility of TA in preoperative prediction of grade were evaluated with 29 patients treated by pancreatectomy for NF-pNEN who underwent preoperative dynamic computed tomography scan between January 1, 2013 and December 31, 2020 at three hospitals affiliated with the Jikei University School of Medicine. TA was performed with dedicated software for medical imaging processing for determining histological tumor grade using dynamic computed tomography images. Results: Histological tumor grades based on the 2017 World Health Organization Classification for Pancreatic Neuroendocrine Neoplasms were grade 1, 2 and 3 in 18, 10 and one patient, respectively. Preoperative grades by TA were 1 and 2/3 in 15 and 14 patients, respectively. The sensitivity, specificity and area under the curve for TA-oriented grade 1 lesions were 1.00, 0.889 and 0.965 (95% confidence interval=0.901-1.000), respectively. Conclusion: TA is useful for predicting grade 2/3 NF-pNEN and can provide a safe option for observation for patients with small grade 1 lesions.