Laparoscopic cholecystectomy for a gallbladder with a short cystic duct draining to the accessory right anterior hepatic duct using indocyanine green fluorescence imaging: A case report.

INTRODUCTION: Gallbladder with a short cystic duct draining to the accessory right anterior hepatic duct is a rare variation. It is frequently associated with bile duct injury during laparoscopic cholecystectomy. We present a case of a gallbladder with this variation safely treated with laparoscopic cholecystectomy using indocyanine green (ICG) fluorescence imaging. PRESENTATION OF CASE: A 57-year-old man had right upper quadrant pain and showed a gallbladder stone on a preoperative computed tomography. Bile duct anomaly was not detected before operation. However, a short cystic duct draining to the accessory right anterior hepatic duct intraoperatively was found using ICG fluorescence imaging. To confirm the exact anatomy, we firstly detached the gallbladder from the liver with a "fundus first technique" and visualized the whole course of the short cystic duct and the accessory right anterior with ICG fluorescence imaging. Laparoscopic cholecystectomy was completed safely. No bile leakage was detected on ICG fluorescence imaging. The patient had no postoperative complication. DISCUSSION: Accessory right hepatic duct is one of the rare variations of bile duct. It can be related to bile duct injury during laparoscopic cholecystectomy. Although it can be injured easily because of its smaller size, we can identify the short cystic duct from it with the aid of ICG fluorescence imaging without injuring the accessory right anterior hepatic duct. CONCLUSION: Laparoscopic cholecystectomy for gallbladder with a short cystic duct draining to the accessory right anterior hepatic duct can be safely performed by identifying biliary anatomy with ICG fluorescence imaging.

Clinical implication of the geometric location (fundal end versus cystic ductal end) of gallbladder cancer.

BACKGROUND: Management of early-stage gallbladder cancer is becoming more important as the rate of early detection is increasing. Although there have been many studies about the clinical implication of the invasion depth or peritoneal/hepatic location of gallbladder cancers, there is no study on the clinical implication of the geometric location of cancer along the longitudinal length of the gallbladder. METHODS: The location of gallbladder cancer was defined as the geometric center of the primary site of a tumour, which lies on the longitudinal diameter of the surgical specimens. We compared the oncologic outcomes following surgery between gallbladder cancers located on the fundal end and those located on the cystic ductal end. We also analysed patients with stage 1 gallbladder cancer who recurred after surgery. RESULTS: A total of 575 patients with gallbladder cancer were included in this study. Patients with gallbladder cancer on the cystic ductal end had significantly lower rates of recurrence-free survival (P = 0.016) and overall survival (P = 0.023) compared to those with gallbladder cancer on the fundal end. Among 90 patients with stage 1 gallbladder cancer, three patients had a recurrence, all of whom had cystic ductal end gallbladder cancer and showed cystic duct invasion or concomitant xanthogranulomatous cholecystitis in permanent pathology. CONCLUSIONS: Gallbladder cancers on the cystic ductal end had worse postoperative oncologic outcomes compared with those on the fundal end.

Risk of Ischemic Heart Disease in Patients With Postpancreatectomy Diabetes and Pancreatic Cancer: A Population-Based Study.

BACKGROUND: Postpancreatectomy diabetes can be caused by resection of functioning pancreatic tissue and is associated with postoperative pancreatic islet cell mass loss and subsequent endocrine dysfunction. Diabetes is a well-known risk factor for ischemic heart disease. However, no previous studies have investigated ischemic heart disease in patients with postpancreatectomy diabetes and pancreatic cancer. METHODS AND RESULTS: Rates of patients with diabetes diagnosed with pancreatic cancer who underwent pancreatectomy between 2002 and 2019 in South Korea were obtained from the Korean National Health Insurance Service database. Patient-level propensity score matching was conducted to reduce the possibility of selection bias, and multivariate Cox proportional hazards models were used to determine the association between postpancreatectomy diabetes and ischemic heart disease. In total, 30 242 patients were initially enrolled in the study. After applying exclusion criteria and propensity score matching, 2952 patients were included in the comparative analysis between the postpancreatectomy group with diabetes and the group without diabetes. Patients in the postpancreatectomy group with diabetes had significantly higher rates of ischemic heart disease than those in the group without diabetes. In total, 3432 patients were included in the comparison between the postpancreatectomy and prepancreatectomy groups with diabetes. There was no significant difference in the risk of ischemic heart disease between the postpancreatectomy and prepancreatectomy groups with diabetes. CONCLUSIONS: Patients who developed diabetes after pancreatectomy had a higher risk of ischemic heart disease than patients who did not develop diabetes after pancreatectomy, and the rate of ischemic heart disease in these patients was similar to that in patients preoperatively diagnosed with diabetes.

Laparoscopic choledocholithotomy and transductal T-tube insertion with indocyanine green fluorescence imaging and laparoscopic ultrasound: A case report.

BACKGROUND: Laparoscopic choledocholithotomy for a large impacted common bile duct (CBD) stone is a challenging procedure because of the technical difficulty and the possibility of postoperative complications, even in this era of minimally invasive surgery. Herein, we present a case of large impacted CBD stones. CASE SUMMARY: A 71-year-old man showed a distal CBD stone (45 mm × 20 mm) and a middle CBD stone (20 mm × 15 mm) on computed tomography. Endoscopic retrograde cholangiopancreatography failed due to the large size of the impacted stone and the presence of a large duodenal diverticulum. Laparoscopic choledocholithotomy was decided, and we used a near-infrared indocyanine green fluorescence scope to detect and expose the supraduodenal CBD more accurately. Then, the location, size, and shape of the stones were detected using a laparoscopic intraoperative ultrasound. The CBD was opened with a 2-cm-sized vertical incision. After irrigating several times, two CBD stones were removed with the Endo BabcockTM. T-tube insertion was done for postoperative cholangiography and delayed the removal of remnant sludge. The patient had no postoperative complications. CONCLUSION: Laparoscopic choledocholithotomy by transcholedochal approach and transductal T-tube insertion is a safe and feasible option for large-sized impacted CBD stones.

Comparison between radiofrequency ablation and CHIVA procedure in patients with varicose veins.

OBJECTIVE: Conservatrice et Hémodynamique de l'Insuffisance Veineuse en Ambulatoire, the French acronym for CHIVA, is a strategy aimed to convert a venous reflux into a physiological drainage. We compared CHIVA with radiofrequency ablation and determined its possible advantages. METHODS: We retrospectively analyzed the clinical recurrence, ultrasound recurrence, quality of life scores, and complications. They were compared after propensity score matching. RESULTS: 212 limbs of 166 patients were included: 42 limbs underwent radiofrequency ablation and 170 limbs underwent CHIVA. The hospital stay was shorter in the CHIVA group. There was no difference in clinical, ultrasound recurrence, quality of life scores and complications between the two groups. The preoperative saphenous vein diameter was larger in the recurrence cases. CONCLUSIONS: CHIVA showed comparable results to radiofrequency ablation. There was more ultrasound recurrence with larger vein diameters. The CHIVA appears to be a simple and more efficient treatment method when performed on select patients.

Lack of Association between Postoperative Pancreatitis and Other Postoperative Complications Following Pancreaticoduodenectomy.

BACKGROUND: Prediction of post-pancreaticoduodenectomy (PD) morbidity is difficult, especially in the early postoperative period when CT (Computed Tomography) scans are not available. Elevated serum amylase and lipase in postoperative day 0 or 1 may be used to define postoperative acute pancreatitis (POAP), but the existing literature does not agree on whether POAP is significantly associated with postoperative pancreatic fistula (POPF). METHODS: We analyzed the data obtained from a previously published randomized controlled trial. POAP was defined as elevations in serum amylase above 110 U/L on postoperative day 0 or 1. Clinically relevant POAP (CR-POAP) was defined as elevations in C-reactive protein level (CRP) on postoperative day 2 in those with POAP. Postoperative complications including severe complications (Clavien-Dindo ≥ IIIa), POPF, and clinically relevant POPF (CR-POPF) were analyzed. RESULTS: In 246 patients, POAP did not show significant associations with total postoperative complications (odds ratio (OR) 0.697; 95% CI, 0.360-1.313; p = 0.271), severe complications (OR 0.647; 95% CI, 0.258-1.747; p = 0.367), and CR-POPF (OR 0.998; 95% CI, 0.310-3.886; p = 0.998) in multivariable analysis. CONCLUSIONS: In patients undergoing PD, POAP was not significantly associated with postoperative complications including POPF. Caution should be taken when using POAP as a predictor of POPF.

Arterial resection during pancreatectomy for pancreatic ductal adenocarcinoma with arterial invasion: A single-center experience with 109 patients.

Pancreatectomy for pancreatic cancer with arterial invasion is controversial and performed infrequently. As its indication evolves and neoadjuvant chemotherapy also evolves, it is meaningful to identify short- and long-term outcomes of pancreatectomy with arterial resection (AR). This study aimed to retrospectively analyze the clinical outcomes of pancreatectomy with AR for pancreatic ductal adenocarcinoma.Patients with pancreatic ductal adenocarcinoma treated with pancreatectomy with AR at our institute between January 2000 and April 2017 were retrospectively reviewed. Operative outcome and survival were compared according to the presence of neoadjuvant chemotherapy.This study included 109 patients (38 underwent surgery after neoadjuvant chemotherapy, 71 underwent upfront surgery). The median hospital stay was 17 (interquartile range, 12-26.5) days. Clinically relevant postoperative pancreatic fistula (grade B or C) occurred in 14 patients (12.8%). The major morbidity (≥grade III) and mortality rates were 26.6% and 0.9%, respectively. R0 resection was achieved in 80 patients (73.4%). Microscopic actual tumor invasion into the arterial wall was identified in 25 patients (22.9%). The median overall survival (OS) of all patients was 18.4 months. The neoadjuvant chemotherapy group showed better OS than the upfront surgery group, without statistical significance (25.3 vs 16.2 months, P = .06). Progression-free survival was better in patients with neoadjuvant chemotherapy (13.2 vs 7.1 months, P = .01). Patients with partial response to neoadjuvant chemotherapy showed better OS than those with stable disease (33.7 vs 17.5 months, P = .04).Pancreatectomy with AR for advanced pancreatic cancer showed acceptable procedure-related morbidity and mortality. A survival benefit of neoadjuvant chemotherapy was identified, compared to upfront surgery.

A Comparative Study of Laparoscopic versus Open Pancreaticoduodenectomy for Ampulla of Vater Carcinoma.

Several studies have compared laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in patients with periampullary carcinoma; however, only a few studies have made such a comparison on patients with ampulla of Vater cancer (AVC). We compared the perioperative and oncologic outcomes between LPD and OPD in patients with AVC using propensity-score-matched analysis. A total of 359 patients underwent PD due to AVC during the study period (76 LPD, 283 OPD). After propensity score matching, the LPD group showed significantly longer operation time than did the OPD group (400.2 vs. 344.6 min, p < 0.001). Nevertheless, the LPD group had fewer painkiller administrations (8.3 vs. 11.1, p < 0.049), fewer Grade II or more severe postoperative complications (15.9% vs. 34.8%, p = 0.012), and shorter postoperative hospital stays (13.7 vs. 17.3 days, p = 0.048), compared with the OPD group. There was no significant difference in recurrence-free outcomes and overall survival between the two groups (p = 0.754 and 0.768, respectively). Compared with OPD, LPD for AVC had comparative oncologic outcomes with less pain, less postoperative morbidity, and shorter hospital stays. LPD may serve as a promising alternative to OPD in patients with AVC.

Association between Metformin Use and Clinical Outcomes Following Pancreaticoduodenectomy in Patients with Type 2 Diabetes and Pancreatic Ductal Adenocarcinoma.

Retrospective studies on the association between metformin and clinical outcomes have mainly been performed on patients with non-resectable pancreatic ductal adenocarcinoma and may have been affected by time-related bias. To avoid this bias, recent studies have used time-varying analysis; however, they have only considered the start date of metformin use and not the stop date. We studied 283 patients with type 2 diabetes and pancreatic ductal adenocarcinoma following pancreaticoduodenectomy, and performed analysis using a Cox model with time-varying covariates, while considering both start and stop dates of metformin use. When start and stop dates were not considered, the metformin group showed significantly better survival. Compared with previous studies, adjusted analysis based on Cox models with time-varying covariates only considering the start date of postoperative metformin use showed no significant differences in survival. However, although adjusted analysis considering both start and stop dates showed no significant difference in recurrence-free survival, the overall survival was significantly better in the metformin group (Hazard ratio (HR), 0.747; 95% confidence interval (CI), 0.562-0.993; p = 0.045). Time-varying analysis incorporating both start and stop dates thus revealed that metformin use is associated with a higher overall survival following pancreaticoduodenectomy in patients with type 2 diabetes and pancreatic ductal adenocarcinoma.

Robotic versus laparoscopic distal pancreatectomy for left-sided pancreatic tumors: a single surgeon's experience of 228 consecutive cases.

BACKGROUND: Laparoscopic distal pancreatectomy (LDP) has gained popularity for the treatment of left-sided pancreatic tumors. Robotic systems represent the most recent advancement in minimally invasive surgical treatment for such tumors. Theoretically, robotic systems are considered to have several advantages over laparoscopic systems. However, there have been few studies comparing both systems in the treatment of distal pancreatectomy. We compared perioperative and oncological outcomes between the two treatment modalities. METHODS: A retrospective analysis was conducted of all consecutive minimally invasive distal pancreatectomy cases performed by a single surgeon at a high-volume center between January 2015 and December 2017. RESULTS: The analysis included 228 consecutive patients (LDP, n = 182; Robotic-assisted laparoscopic distal pancreatectomy [R-LDP], n = 46). Operative time was significantly longer in the R-LDP group than in the LDP group (166.4 vs. 140.7 min; p = 0.001). In a subgroup analysis of patients who underwent the spleen-preserving approach, the spleen preservation rate associated with R-LDP was significantly higher than that associated with LDP (96.8% vs. 82.5%; p = 0.02). In another subgroup analysis of patients with pancreatic cancer, there were no significant differences in median overall and disease-free survival between the two groups. CONCLUSIONS: R-LDP is a safe and feasible approach with perioperative and oncological outcomes comparable to those of LDP. R-LDP offers an added technical advantage that enables the surgeon to perform a complex procedure with good ergonomic comfort.

Comparative analysis of afferent loop obstruction between laparoscopic and open approach in pancreaticoduodenectomy.

BACKGROUND: Afferent loop obstruction (ALO) is a rare mechanical complication of pancreaticoduodenectomy (PD) and is associated with a high rate of morbidity and mortality. METHODS: Data from patients who underwent PD between May 2007 and July 2017 at a single large-volume center were retrospectively reviewed. RESULTS: Of the 3,223 patients who underwent PD, 67 developed ALO. More patients in the laparoscopic PD (LPD) group had developed ALO due to internal herniation than did those in the open PD (OPD) group (46.2 vs. 4.7%, P < 0.001). Patients in the LPD group also showed earlier occurrence of ALO (ALO occurrence within 60 days: 76.9 vs. 22.2%, P < 0.001) and more frequent requirement for surgical treatment (76.9 vs. 18.9%, P < 0.001) than did those in the OPD group. CONCLUSIONS: The characteristics of ALO were significantly different between patients who had received LPD and OPD. The most common cause of ALO in the LPD group was internal herniation occurring in the early postoperative period. Internal herniation following LPD may be prevented by routine closure of mesocolic window and should be treated by emergency surgery if it occurs.

Prognostic value of adjacent organ resection in patients with left-sided pancreatic ductal adenocarcinoma following distal pancreatectomy.

BACKGROUND: We evaluated whether distal pancreatectomy (DP) with adjacent organ resection (AOR) affected perioperative outcomes and survival in patients with left-sided pancreatic ductal adenocarcinoma (PDAC). METHODS: Retrospective cohort study was conducted at single large volume academic medical center from January 2000 to December 2016. RESULTS: Five hundred and twenty-three patients had undergone standard DP (without additional vessel/organ resection) and 40 had undergone DP with AOR due to adjacent organ infiltration. There were no differences of postoperative morbidity and hospital stay between the two groups. In the patients with AJCC 8th stage I and II PDAC, there were significant differences of median disease-specific and progression-free survivals between the standard and AOR groups (37.9 vs. 20.2 months; P = 0.05, 20 vs. 10 months; P = 0.028, respectively). DP with AOR was identified as independent prognostic factor of stage I and II PDAC by multivariate Cox regression analysis. CONCLUSIONS: Distal pancreatectomy with AOR could be an acceptable surgical treatment for left-sided PDAC. However, AOR group shows poor prognosis than that of the standard group in patients with AJCC 8th stage I and II PDAC. AOR should be considered indicative of a more aggressive tumor in AJCC 8th stage I and II PDAC.

Prevalence analysis of de novo hepatic steatosis following pylorus-preserving pancreaticoduodenectomy.

BACKGROUND: Prevalence of hepatic steatosis following pylorus-preserving pancreaticoduodenectomy (PPPD) is high. This study intended to reveal the prevalence and patterns of de novo hepatic steatosis following PPPD. METHODS: We investigated postoperative de novo hepatic steatosis following PPPD (n = 101) with a control group of bile duct resection (BDR) (n = 54). RESULTS: At postoperative 1 year, hepatic steatosis occurred in 21 of 82 patients (25.6%) of PPPD group and in 2 of 47 patients (4.3%) of BDR group (p = 0.001). Thereafter, at 2 to 5 years, a high prevalence of hepatic steatosis persisted in the PPPD group, but no further occurrence developed in BDR group. Once steatosis developed, it persisted until the end of the study period or patient death. Five-year cumulative incidence of hepatic steatosis was 26.7% in the PPPD group and 3.7% in BDR group (p < 0.001). Univariate analyses showed that patient sex, age, body mass index, blood lipid profile, recurrence of tumor, and diabetes did not have significant influence on the development of hepatic steatosis following PPPD. CONCLUSIONS: De novo hepatic steatosis may develop in a not negligible proportion of patients undergone PPPD. Multicenter studies with a high number of patients are needed to elucidate its pathogenesis and to find effective treatment for pancreaticoduodenectomy-associated hepatic steatosis.

Pancreatic atrophy relative to external versus internal drainage of the pancreatic duct after pylorus-preserving pancreaticoduodenectomy.

BACKGROUND: Atrophy of the pancreatic parenchyma, which occurs frequently after pylorus-preserving pancreaticoduodenectomy (PPPD), is often associated with pancreatic exocrine insufficiency. Many surgeons prefer to insert a drainage tube into the remnant pancreatic duct primarily to prevent pancreatic leakage at the pancreaticojejunostomy (PJ) after PPPD. Drainage methods vary widely but can be roughly classified as internal or external drainage. This study intended to evaluate their effects on pancreatic parenchymal atrophy following PPPD. METHODS: Fifty-seven patients who underwent PPPD were retrospectively divided into two groups, 28 who underwent external and 29 who underwent internal pancreatic drainage. External drainage tubes were removed 4 weeks after PPPD. The volume of the pancreatic parenchyma was serially measured on abdominal computed tomography (CT) scans before PPPD, as well as 7 days and 3, 6, and 12 months after surgery. Degree of pancreatic parenchymal atrophy was determined by calculating pancreatic volume relative to that on day 7. RESULTS: Univariate analysis showed that patient sex, age, body mass index, concurrent pancreatitis, pathology, and types of PJ did not significantly affect changes in pancreatic volume following PPPD. The degree of pancreatic volume atrophy did not differ significantly in the external and internal drainage groups. No patient in the external drainage group experienced drainage-related surgical complications. The incidence of PJ leak was comparable in the two groups. Postoperative pancreatic atrophy did not induce new-onset diabetes mellitus at 1 year. CONCLUSIONS: Both external and internal pancreatic drainage methods showed similar atrophy rate of the pancreatic parenchyma following PPPD.

Case report of a pancreatic squamoid cyst.

Squamoid cyst of the pancreas is a very rare disease and it has been proposed only recently as a distinct pathologic lesion. We herein present a case of pancreatic squamoid cyst in a patient who underwent laparoscopic resection. A 60-year-old woman had an abdominal computed tomography (CT) scan for a routine check-up, and a multi-cystic lesion of 1.8-cm in size was incidentally found in the tail of the pancreas. Biochemical laboratory tests were within normal limits. At first, we presumed that the most likely diagnosis of the cystic lesion was an intraductal papillary mucinous neoplasm. To treat this lesion, we performed laparoscopic spleen-saving distal pancreatectomy. The patient showed the usual routine postoperative course and she was discharged 10 days after surgery. On examination of the resected specimen, a well-defined, oligolocular cystic mass was found in the pancreatic tail, without a solid portion. Histologic examination revealed that the cysts had linings ranging from flat squamoid cells to transitional cells with non-keratinization. After immunohistochemical staining, the final diagnosis was confirmed to be squamoid cyst of the pancreas. This lesion appears to be regarded as a benign entity, thus an extended operation should be avoided and resection of the lesion can be performed minimally.

Vibration response imaging in prediction of pulmonary function after pulmonary resection.

BACKGROUND: Vibration response imaging (VRI) is a new technique that captures lung sounds generated by the flow of air through the lungs. It predicts postoperative values for an intended lung resection. In this study, we measured the predicted postoperative pulmonary function as determined by a perfusion lung scan and the VRI, and compared with results from the postoperative pulmonary function. METHODS: This study was performed prospectively in patients who were candidates for major pulmonary resection. Each patient underwent a pulmonary function test, perfusion scintigraphy, and VRI within 1 week before operation. Postoperative lung function was measured at 4 to 6 weeks. RESULTS: The study enrolled 44 patients. There were no significant differences for predicted postoperative forced expiratory volume in 1 second (ppoFEV(1)) and predicted postoperative diffusion capacity of the lung for carbon monoxide (ppoDlco) between scan and VRI. Both ppoFEV(1) and ppoDlco using a scan and VRI predicted the postoperative results well, respectively. The postoperative FEV(1) was correlated with ppoFEV(1) using a scan (r = 0.83, p < 0.001), and the ppoFEV(1) using a VRI (r = 0.83, p < 0.001). The postoperative Dlco was correlated with the ppoDlco using a scan (r = 0.85, p < 0.001), and the ppoDlco using a VRI (r = 0.80, p < 0.001). CONCLUSIONS: The VRI was highly predictive of postoperative FEV(1) and Dlco for lung resection.