Late-onset lethal complication of non-surgically managed massive gastric conduit necrosis after esophagectomy: a case report.

BACKGROUND: Gastric conduit necrosis (GCN) after esophagectomy is a serious complication that can prove fatal. Herein, we report a rare case of GCN with a severe course that improved with conservative treatment. CASE PRESENTATION: We present the case of a 78-year-old male patient who underwent an Ivor Lewis esophagectomy and developed a massive GCN. The patient was critically ill in the initial phase but recovered quickly; he also had a ruptured gallbladder and a bleeding jejunal ulcer. On the 22nd postoperative day, massive GCN was revealed on endoscopy. Considering the recovery course, careful observation with a decompressing nasal gastric tube was the treatment of choice. The GCN was managed successfully, having been completely replaced by fine mucosa within 9 months postoperatively. The patient completed his follow-up visit 5 years after surgery without any evident disease recurrence. Five and a half years after the surgery, the patient presented with progressive weakness and deterioration of renal function. Gastrointestinal endoscopy revealed a large ulcer at the anastomotic site. Three months later, computed tomography revealed a markedly thin esophageal wall, accompanied by adjacent lung consolidation. An esophagopulmonary fistula was diagnosed; surgery was not considered, owing to the patient's age and markedly deteriorating performance status. He died 2013 days after the diagnosis. CONCLUSIONS: Massive GCN after esophagectomy often requires emergency surgery to remove the necrotic conduit. However, this report suggests that a conservative approach can save lives and preserve the gastric conduit in these cases, thereby augmenting the quality of life.

Radical antegrade modular pancreatosplenectomy enhances local control of the disease in patients with left-sided pancreatic cancer.

BACKGROUND: Radical antegrade modular pancreatosplenectomy (RAMPS) was developed to enhance curability in patients with left-sided pancreatic cancer. However, no evidence is available regarding the prognostic superiority of RAMPS compared with conventional distal pancreatectomy (cDP). Here, we aimed to assess the oncological benefit of RAMPS by comparing surgical outcomes between patients who underwent cDP and RAMPS with propensity score (PS) adjustment. METHODS: Clinical data of 174 patients undergoing cDP and RAMPS between 2009 and 2016 at two high-volume centers were analyzed with PS matching. Recurrence-free survival (RFS), overall survival (OS), and local recurrence rates were compared between patients who underwent cDP and RAMPS. RESULTS: The cDP and RAMPS groups were successfully matched with baseline characteristics. No differences were found in the 3-year RFS and OS rates between the two groups (3-year RFS: cDP 46% vs RAMPS 40%, p = 0.451, 3-year OS: cDP 57% vs RAMPS 53%, p = 0.692). However, the 3-year local recurrence rate was lower in the RAMPS (10%) than that in the cDP group (34%) (hazard ratio 0.275, 95% confidence interval 0.090-0.842, p = 0.02). CONCLUSION: RAMPS is oncologically superior to conventional procedure in achieving local control of the disease in patients with left-sided pancreatic cancer.

Survival comparison of invasive intraductal papillary mucinous neoplasm versus pancreatic ductal adenocarcinoma.

BACKGROUND: The aim of this study was to assess the relevance of highlighting T1a invasive intraductal papillary mucinous carcinoma as a separate subcategory and to compare the tumor biology between invasive intraductal papillary mucinous carcinoma and pancreatic ductal adenocarcinoma. METHODS: A total of 144 and 328 consecutive patients with intraductal papillary mucinous neoplasms and pancreatic ductal adenocarcinoma, respectively, were analyzed. RESULTS: Patients with T1a invasive intraductal papillary mucinous carcinoma comprised 25% (11/44) of the overall subject population with invasive intraductal papillary mucinous carcinoma with 5-year disease-specific survival rate being 100%. None of the patients with pancreatic ductal adenocarcinoma were classified as having T1a disease. When patients with invasive intraductal papillary mucinous carcinoma and pancreatic ductal adenocarcinoma were compared after excluding patients with T1a invasive intraductal papillary mucinous carcinoma, the 5-year disease-specific survival rates were 63% vs 40% in node-negative status (P = .018); and they were 20% vs 13% in node-positive status (P = .385). Subsequent analyses revealed that this survival superiority was limited to patients without evidence of lymphatic invasion. CONCLUSION: T1a invasive intraductal papillary mucinous carcinoma is a clinical entity specifically observed in patients with intraductal papillary mucinous carcinoma, but not in patients with pancreatic ductal adenocarcinoma, and is associated with excellent postoperative survival outcomes. In the survival comparison after exclusion of patients with T1a tumors, when the analysis was limited to patients without lymphatic invasion or lymph node metastasis, the disease-specific survival rate remained higher in patients with invasive intraductal papillary mucinous carcinoma compared with those with pancreatic ductal adenocarcinoma, and this difference was considered as being attributable to the intrinsic indolent biological behavior of invasive intraductal papillary mucinous carcinoma. However, this survival advantage was lost once lymphatic invasion occurred.

Photoinduced Charge Transfer and Trapping on Single Gold Metal Nanoparticles on TiO2.

We present a study of the effect of gold nanoparticles (Au NPs) on TiO2 on charge generation and trapping during illumination with photons of energy larger than the substrate band gap. We used a novel characterization technique, photoassisted Kelvin probe force microscopy, to study the process at the single Au NP level. We found that the photoinduced electron transfer from TiO2 to the Au NP increases logarithmically with light intensity due to the combined contribution of electron-hole pair generation in the space charge region in the TiO2-air interface and in the metal-semiconductor junction. Our measurements on single particles provide direct evidence for electron trapping that hinders electron-hole recombination, a key factor in the enhancement of photo(electro)catalytic activity.

Arterial chemoembolisation with cisplatin versus epirubicin for hepatocellular carcinoma (ACE 500 study): A multicentre, randomised controlled phase 2/3 trial.

BACKGROUND: Transarterial chemoembolisation (TACE) is a treatment option for hepatocellular carcinoma (HCC), but the optimum agent for TACE remains unclear. We compared the efficacy of TACE with cisplatin versus with epirubicin in patients with unresectable HCC. METHODS: This multicentre, randomised, phase 2/3 trial was performed at 21 hospitals in Japan. Patients with liver-confined HCC, performance status 0-2, and Child-Pugh class A/B were randomised to receive TACE with cisplatin or epirubicin. Patients were stratified in accordance with the institution, Child-Pugh class, tumour size, tumour thrombosis, α-fetoprotein and prior treatment. The primary end-point was overall survival in the intention-to-treat population. Tumour response was evaluated in accordance with the Response evaluation criteria in solid tumours criteria. FINDINGS: Between 2008 and 2012, 455 patients were randomly assigned to undergo TACE with cisplatin (n = 228) or epirubicin (n = 227). Eleven patients were ineligible, and 444 patients were included in the full analysis. Twelve patients not receiving TACE were excluded, and 432 patients were included in the safety analysis set. In phase 2, disease control rates in cisplatin (91·7%) and epirubicin (91·8%) groups exceeded the predefined threshold of 70%, and the study proceeded to phase 3. After a median follow-up of 32·7 months (IQR = 15·3-49·3), median overall survival periods were 2·93 years (95% CI 2·60-3·79) and 2·74 years (95%CI 2·26-3·21), respectively (hazard ratio 0·90 [95% CI 0·71-1·15], p = 0·22). Median times to treatment failure were 1·38 and 1·46 years (hazard ratio 1·09 [95% CI 0·88-1·35], p = 0·88), response rates were 65·3% and 60·6% (p = 0·31), and serious adverse event rates were 49·8% and 48·3% (p = 0·56), respectively. No treatment-related deaths occurred in either group. INTERPRETATION: In our phase 2/3 randomised trial, cisplatin is not significantly superior to epirubicin in TACE for patients with HCC.

Adjuvant chemotherapy can prolong recurrence-free survival but did not influence the type of recurrence or subsequent treatment in patients with colorectal liver metastases.

BACKGROUND: Although liver resection is the only potentially curative treatment for colorectal liver metastases, recurrence is frequent. We previously published the early results of a randomized controlled phase 3 trial showing that adjuvant therapy with uracil-tegafur and leucovorin significantly prolongs recurrence-free survival. This study sought to elucidate the impact of adjuvant chemotherapy on patient survival after an additional follow-up period, building upon the results of our previous study. METHODS: After resection for colorectal liver metastases, patients were randomly assigned in a 1:1 ratio to receive adjuvant uracil-tegafur and leucovorin or surgery alone. Patients assigned to the uracil-tegafur and leucovorin group received 5 cycles of uracil-tegafur and leucovorin within 8 weeks after surgery. RESULTS: Patients were assigned to an adjuvant uracil-tegafur and leucovorin (n = 90) or a surgery alone (n = 90) group; 3 patients were excluded because of protocol violations. After a median follow-up period of 7.36 years (95% confidence interval, 6.93-7.87), 60 (68.2%) patients in the uracil-tegafur and leucovorin group and 61 (68.5%) patients in the surgery alone group developed recurrences. The median recurrence-free survival was 1.45 years (95% confidence interval, 0.96-2.16) in the uracil-tegafur and leucovorin group and 0.70 years (95% confidence interval, 0.44-1.07) in the surgery alone group. The locations and treatments of the first recurrences did not differ between the groups, nor did the overall survival (hazard ratio, 0.86; 95% confidence interval, 0.54-1.38; P = .54). The overall survival was significantly longer in patients who underwent curative repeated resection than in patients who received non-surgical treatment (hazard ratio, 0.25; 95% confidence interval, 0.15-0.40; P < .0001). CONCLUSION: Adjuvant uracil-tegafur and leucovorin significantly prolonged the recurrence-free survival but not the overall survival. The repeated resection was the most important factor influencing overall survival.

Significance of postoperative adjuvant chemotherapy with an oxaliplatin-based regimen after simultaneous curative resection for colorectal cancer and synchronous colorectal liver metastasis: a propensity score matching analysis.

BACKGROUND: Expansion of the indication for liver resection and new regimens for systemic chemotherapy have improved postoperative outcomes for synchronous colorectal liver metastases (CRLM). However, such cases can still have a high recurrence rate, even after curative resection. Therefore, there is a need for postoperative adjuvant chemotherapy (POAC) after liver resection in patients with CRLM. There are few studies of the efficacy of POAC with an oxaliplatin-based regimen after simultaneous resection for colorectal cancer and CRLM with curative intent. The goal of the study was to compare POAC with oxaliplatin-based and fluoropyrimidine regimens using propensity score (PS) matching analysis. METHODS: The subjects were 94 patients who received POAC after simultaneous resection for colorectal cancer and synchronous CRLM, and were enrolled retrospectively. The patients were placed in a L-OHP (+) group (POAC with an oxaliplatin-based regimen, n = 47) and a L-OHP (-) group (POAC with a fluoropyrimidine regimen, n = 47). Recurrence-free (RFS), cancer-specific (CSS), unresectable recurrence-free (URRFS), remnant liver recurrence-free (RLRFS), and extrahepatic recurrence-free (EHRFS) survival were analyzed. RESULTS: Before PS matching, the L-OHP (+) and (-) groups had no significant differences in RFS, CSS, URRFS, RLRFS, and EHRFS. Univariate analysis indicated significant differences in age, preoperative serum CEA (≤ 30.0 ng/mL/ > 30.0 ng/mL), differentiation of primary tumor (differentiated/undifferentiated), T classification (T1-3/T4), number of hepatic lesions and maximum diameter of the hepatic lesion between the L-OHP (+) and (-) groups. After PS matching using these confounders, RFS was significantly better among patients in the L-OHP (+) group compared with the L-OHP (-) group (HR 0.40, 95% CI 0.17-0.96, p = 0.04). In addition, there was a trend towards better RLRFS among patients in the L-OHP (+) group compared with the L-OHP (-) group (HR 0.42, 95% CI 0.17-1.02, p = 0.055). However, there were no significant differences in CSS, URRFS and EHRFS between the L-OHP (+) and (-) groups. CONCLUSIONS: PS matching analysis demonstrated the efficacy of POAC with an oxaliplatin-based regimen in RFS and RLRFS.

Re-evaluation of the Couinaud classification for segmental anatomy of the right liver, with particular attention to the relevance of cranio-caudal boundaries.

BACKGROUND: Although the Couinaud classification of liver segments has been challenged by several studies, whether the cranio-caudal boundaries can be delineated in the right liver has not yet been assessed. This study scrutinized the third-order branching pattern of the portal vein in the right liver with attention to the validity of cranio-caudal segmentation. METHODS: Three-dimensional reconstruction of the portal vein and hepatic vein, using non-contrast-enhanced magnetic resonance imaging was performed in 50 healthy participants. RESULTS: In the right paramedian sector, the portal vein ramified into 2 thick P8s (P8vent and P8dor) in all the participants. Additional thick P8s that ran laterally and/or medially (P8lat and/or P8med) were observed in 18 (32%) participants. In contrast, multiple thin P5s, ranging in number from 2 to 6 (median, 4), branched from the right paramedian trunk, the right portal trunk, and/or even from P8s. In the right lateral sector, an arch-like type in which multiple P6s ramified from a single thick P7 was observed in 26 (52%) participants. A bifurcation type composed of a single P7 and a single P6 was observed in 23 (46%) participants, and a trifurcation type was observed in 1 participant. CONCLUSION: No clear cranio-caudal intersegmental plane could be delineated in the right liver in most of the participants. The resection of a whole Couinaud segment in the right liver should not be regarded as a systematic, anatomic resection from an oncologic viewpoint. In contrast, detailed information on the third-order portal vein ramification pattern is likely to be helpful when performing smaller anatomic resections.

Preoperative Decision to Perform Portal Vein Resection Improves Survival in Patients With Resectable Pancreatic Head Cancer Adjacent to Portal Vein.

Objective: We hypothesized that preoperatively planned portal vein resection (PVR), which prevents from approaching tumors, improves survival in patients with resectable pancreatic head cancer adjacent to the portal vein (PhC-PV). Summary: The decision to perform PVR is difficult in patients with resectable PhC-PV. Methods: This is a retrospective, bi-institutional study of patients undergoing pancreatoduodenectomy (PD) for resectable PhC-PV from 2009 to 2018. We compared clinical data of patients who underwent PD with preoperatively planned PVR (planned PVR group) and those who underwent conventional PD (cPD) in which decision to perform PVR was made intraoperatively (cPD group). Results: Among the study population of 176 patients, 53 patients (30.1%) underwent PD with planned PVR. The remaining 123 patients (69.9%) underwent cPD. Tumor characteristics were similar between the 2 groups. Operation time and major complication rates did not differ between the 2 groups. The local recurrence rate of patients in the planned PVR group (28.3%) was lower than that of the cPD group (44.7%; P = 0.041). Median overall survival (OS) was longer in the planned PVR group than in the cPD group (32 vs 27 months; P = 0.011). Multivariate analysis revealed that having undergone planned PVR was an independent factor for favorable OS (hazard ratio = 1.65; 95% confidence interval = 1.08-2.61; P = 0.021). Conclusions: The preoperative decision to perform PVR improves survival by enhancing local control of resectable PhC-PV.

Outcome of patients with acute liver failure awaiting liver transplantation in Japan.

AIM: To clarify the outcome and predictive factors in patients with acute liver failure (ALF) awaiting deceased donor liver transplantation (DDLT) in Japan. METHODS: Of the DDLT candidates in Japan between 2007 and 2016, 264 adult patients with ALF were retrospectively enrolled in this study. Factors associated with DDLT and waiting-list mortality were assessed using the Cox proportional hazard model. The DDLT and transplant-free survival probabilities were evaluated using Kaplan-Meier analysis and the log-rank test. RESULTS: The waiting-list registration year after the Transplant Law revision in 2010 was a significant factor associated with DDLT. The adjusted hazard ratio indicated that DDLT probability after 2010 was four times higher than that before, and the 28-day cumulative DDLT probability was more than 35%. The median survival time of the entire cohort was 40 days. Multivariate analysis identified the following three factors associated with waiting-list mortality: age, coma grade, and international normalized ratio. The transplant-free survival probabilities were significantly stratified by the number of risks, and patients with all three risks showed extremely poor short-term prognosis (median survival time = 23 days). CONCLUSIONS: The DDLT probability of ALF patients increased after the law revision in 2010; however, patients at high risk of short-term waiting-list mortality might need emergent living donor transplantation.

A scoring system based on computed tomography for the correct diagnosis of xanthogranulomatous cholecystitis.

BACKGROUND: Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis. The differential diagnoses of XGC include gallbladder cancer (GBC), adenomyomatosis, and actinomycosis of the gallbladder. PURPOSE: To assess the usefulness of computed tomography (CT) findings in the diagnosis of XGC and differentiation from GBC. MATERIAL AND METHODS: We retrospectively assessed the pathological and radiological records of 13 patients with pathologically proven XGC and 33 patients with GBC. RESULTS: Significant differences were observed for the following five CT findings: diffuse wall thickening (XGC = 85%, GBC = 15%, P < 0.01); absence of polypoid lesions (XGC = 100%, GBC = 48%, P < 0.01); intramural nodules or bands (XGC = 54%, GBC = 9%, P < 0.01); pericholecystic infiltration (XGC = 69%, GBC = 9%, P < 0.01); and pericholecystic abscess (XGC = 23%, GBC = 0%, P = 0.018). We defined the scoring system based on how many of the five CT findings were observed. Our scoring system, which included these findings, revealed that patients with three or more findings had sensitivity of 77% (95% confidence interval [CI] = 57-87) and specificity of 94% (95% CI = 86-98). CONCLUSION: Our scoring system can assist in the differentiation of XGC from GBC.

[Development and Evaluation of Screening Culture Medium for Detection of Drug-Resistant Gram Negative Rods Containing Stealth Type CPE].

There is a report that an infection by medicine resistant bacteria will be the number one cause of death in 2050 according to the recommendation of WHO, and the CPE (carbapenem-producing Enterobacteriaceae) infection is regarded as a problem in particular. When detecting CPE, it is important how to detect stealth type CPE sensitive to carbapenem series medicines. So we used the 2 types of screening culture medium, "KBM" CRE-JU culture medium (CRE-JU culture medium) and the FRPM culture medium, and tried to detect drug-resistant gram-negative bacilli such as CPE, stealth type CPE, ESBL-producing bacteria, and excess AmpC-producing bacteria (AmpC-producing bacteria), etc. in combination of this culture mediums. As a result, CRE-JU culture medium showed a difference in the growth of CPE depending on the amount of inoculated bacteria while ß-lactamase non-producing strain and other strains except for high concentration ESBL-producing bacteria and AmpC-producing bacteria were un-growing. Most of the CRE, stealth type CPE, ESBL-producing bacteria and AmpC-producing bacteria grew in the FRPM culture medium while most of the ß-lactamase non-producing strains with a MIC value of meropenem (MEPM) of 2 µg/mL or less were un-growing. From these results, it was suggested that when a strain grown on CRE-JU and FRPM culture mediums, it could be distinguished as CPE, and when strains grown on FRPM culture medium which were un-grown on CRE-JU culture medium, it could be distinguished as drug-resistant bacteria such as stealth type CPE, ESBL-producing bacteria, and AmpC-producing bacteria. When strains not grown on CRE-JU and FRPM culture mediums, it could be distinguished as sensitive.

Displacement of the transverse colon is a highly specific computed tomography finding for the preoperative diagnosis of a transomental hernia.

PURPOSE: A transomental hernia (TOH) is a rare type of internal hernia and is associated with a high strangulation rate and high mortality rate. Displacement of the transverse colon on computed tomography (CT) may be specific to a TOH and may facilitate an early diagnosis. The aim of this study was to verify the effectiveness of a novel approach assessing displacement of the transverse colon for the preoperative diagnosis of a TOH. MATERIALS AND METHODS: We retrospectively reviewed the CT and operative data of 113 patients who underwent surgery for small bowel obstruction (SBO) between 2011 and 2018. The proportion of transverse colon loops posterior to dilated intestinal loops (PTPI) was calculated. RESULTS: The patients were divided into a TOH group (n = 7) and other SBO group (n = 106). The median PTPI was significantly higher in the TOH group than in the other SBO group (67% [0-97%] vs. 0% [0-100%], Wilcoxon's test, p = 0.03). A receiver operating characteristic curve showed that when the PTPI was ≥ 57%, its sensitivity and specificity for a TOH were 71% and 94%, respectively. CONCLUSION: The PTPI is a reliable quantitative measure to distinguish a TOH from other types of SBOs.

Factors Affecting Persistent Splenomegaly After Adult-to-Adult Living Donor Liver Transplantation Using a Left Lobe.

BACKGROUND: The aim of the present study was to evaluate spleen volume (SV) and the factors influencing it after adult-to-adult living donor liver transplantation (A2LDLT) using a left lobe. METHODS: Pretransplant computed tomography (CT) and post-transplant CT 2 years after A2LDLT were examined by volumetric analysis in 24 patients. We divided the recipients into the following 2 groups according to the post-transplant SV: >500 mL (Group A) and ≤500 mL (Group B). The factors affecting the change in post-transplant SV were compared between the 2 groups. RESULTS: The mean pretransplant SV decreased significantly after A2LDLT. Platelet counts after living donor liver transplantation increased significantly relative to the pretransplant values. Post-transplant SV was >500 mL in 9 patients (Group A) and ≤500 mL in 15 (Group B). Pretransplant SV, platelet count, anhepatic time, operative time, intraoperative blood loss, post-transplant portal vein pressure >20 mm Hg, and post-transplant portal vein flow >250 mL/min/100 g graft weight showed significant differences between the 2 groups. Actual graft volume (GV) and GV/standard liver volume ratio showed no intergroup differences. Multivariate analysis showed that the only significant factor related to a post-transplant SV of >500 mL was the pretransplant SV. Post-transplant platelet counts were significantly increased from the pretransplant values in both Group A and Group B. CONCLUSIONS: Pretransplant SV is the only significant factor predicting a SV of >500 mL after A2LDLT. However, even in patients with a SV of >500 mL, the platelet count increased significantly from the pretransplant value.

Significance of hypovascular lesions on dynamic computed tomography and/or gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging in patients with hepatocellular carcinoma.

BACKGROUND AND AIM: The natural course and clinical implications of hypovascular lesions on dynamic computed tomography and/or gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging were investigated. METHODS: We followed the patients with hepatocellular carcinoma (HCC) who underwent hepatectomy between April 2009 and August 2012 to determine whether new classical HCCs developed from these unresected borderline lesions or emerged in different areas. RESULTS: One hundred and eleven patients with HCC were identified to have undergone examinations using both imaging methods before hepatic resection. A total of 54 hypovascular lesions were detected. Gadolinium ethoxybenzyl-enhanced magnetic resonance imaging detected 51 lesions, while dynamic computed tomography identified 21 lesions. Eleven lesions were resected at the time of the hepatectomy together with the main HCCs. Classical HCCs had developed from 52.5% of the 43 unresected lesions at 3 years after hepatic resection. Subsequently, we conducted a patient-by-patient analysis to compare the development of classical HCC from these hypovascular lesions and the emergence of de novo classical HCC in other areas. The 3-year occurrence rate was 62.2% for the former group and 55.0% for the latter group (P = 0.83). Thus, although 52.2% of these hypovascular lesions had developed into classical HCCs at 3 years after the initial hepatectomy, de novo HCCs also occurred at other sites. Furthermore, new hypovascular lesions emerged after hepatectomy in 18-29% of patients irrespective of the presence or absence of hypovascular lesions at hepatectomy. CONCLUSIONS: It remains uncertain whether these hypovascular lesions should be resected together with the main tumors at the time of hepatectomy.

Expanded living-donor liver transplantation criteria for patients with hepatocellular carcinoma based on the Japanese nationwide survey: the 5-5-500 rule - a retrospective study.

Expansion of the liver transplantation indication criteria for patients with hepatocellular carcinoma (HCC) has long been debated. Here we propose new, expanded living-donor liver transplantation (LDLT) criteria for HCC patients based on a retrospective data analysis of the Japanese nationwide survey. A total of 965 HCC patients undergoing LDLT were included, 301 (31%) of whom were beyond the Milan criteria. Here, we applied the Greenwood formula to investigate new criteria enabling the maximal enrollment of candidates while securing a 5-year recurrence rate (95% upper confidence limit) below 10% by examining various combinations of tumor numbers and serum alpha-fetoprotein values, and maintaining the maximal nodule diameter at 5 cm. Finally, new expanded criteria for LDLT candidates with HCC, the 5-5-500 rule (nodule size ≤5 cm in diameter, nodule number ≤5, and alfa-fetoprotein value ≤500 ng/ml), were established as a new regulation with a 95% confidence interval of a 5-year recurrence rate of 7.3% (5.2-9.3) and a 19% increase in the number of eligible patients. In addition, the 5-5-500 rule could identify patients at high risk of recurrence, among those within and beyond the Milan criteria. In conclusion, the new criteria - the 5-5-500 rule - might provide rational expansion for LDLT candidates with HCC.

Clinical significance of macroscopic no-margin hepatectomy for hepatocellular carcinoma.

BACKGROUND: Hepatectomy with a sufficient margin is often impossible for hepatocellular carcinomas that are close to the large intrahepatic vascular structures, and macroscopically complete resection along the tumor capsule is the only choice. The aim of this retrospective study was to evaluate the clinical significance of macroscopic no-margin hepatectomy (MNMH). METHODS: Among patients undergoing macroscopically curative resection for untreated hepatocellular carcinoma, outcomes were compared between patients undergoing MNMH (n = 87) and those undergoing hepatectomy with a macroscopic margin (n = 192). RESULTS: MNMH was significantly associated with a longer operation time (P < 0.001), greater intraoperative blood loss (P < 0.001), a greater need for blood transfusion (P = 0.018), a higher incidence of major postoperative complications (P = 0.031), multiple tumors (P = 0.015), tumor capsule formation (P = 0.030), and a microscopically positive surgical margin (P = 0.021). There was no significant difference between the groups in terms of recurrence-free survival (P = 0.946) and overall survival (P = 0.259). DISCUSSION: MNMH is technically demanding and results more frequently in a microscopically positive surgical margin, however, it can yield a long-term outcome comparable to hepatectomy with a macroscopic margin even in patients with otherwise unresectable hepatocellular carcinoma.

Current Status of Surgical Incisions Used in Donors During Living Related Liver Transplantation-A Nationwide Survey in Japan.

BACKGROUND: Smaller surgical incisions have recently been introduced in living donor liver procurement. This study used national data from Japan to clarify the present status of surgical incisions in living donor liver procurement. METHODS: A nationwide, questionnaire-based survey related to 3121 donors and recipients was used. Donors were divided into 2 groups: left lateral segment graft (LLSG) procurement (n = 690) and other types (n = 2431). Incisions were classified into 6 types: type I, upper midline and bilateral subcostal; type II, upper midline and right subcostal; type III, upper midline and right subcostal to the right lateral margin of the abdominal rectus muscle; type IV, upper midline without laparoscopy; type V, upper midline with laparoscopy; and type VI, lower abdominal using the full laparoscopic technique. Types I, II, and III were regarded as standard, and types IV, V, and VI as small incisions. RESULTS: In LLSGs, blood transfusion and postoperative complication rates were significantly less frequent in the small incision group than in the standard group. In other graft types, there were no significant differences in blood transfusion, postoperative complication, and recipients' graft loss rates. The rates of wound extension during surgery were 2.8% and 2.1% in the small incision group in LLSGs and in other graft types, respectively. A small incision was adapted more frequently and postoperative complications were less common in high-volume centers. CONCLUSIONS: Various incisions have been adopted in living donor liver procurement. Donor safety and graft integrity appear to have been retained for donors receiving small incisions.