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.

Preoperative Therapy for Unresectable Locally Advanced Pancreatic Cancer for ≥6 Months Improves Prognosis After Pancreatectomy.

BACKGROUND/AIM: This study aimed to identify the optimal duration of pretreatment for unresectable locally advanced (UR-LA) pancreatic cancer and analyze its effect on the prognosis. PATIENTS AND METHODS: This retrospective study included 39 patients with UR-LA pancreatic cancer after pancreatectomy. The cutoff period of preoperative therapy was determined using a receiver operating characteristic curve. We investigated the relationship between preoperative and intraoperative clinical variables and overall survival (OS) in univariate and multivariate analyses. The relationship between the preoperative therapy duration and the clinicopathological variables was investigated. OS was compared according to preoperative therapy duration and the presence or absence of adjuvant surgery. RESULTS: After pretreatment, 15 patients underwent adjuvant surgery and 24 patients continued on chemotherapy without surgery. The multivariate analysis demonstrated preoperative therapy duration ≥6 months was an independent prognostic factor [hazard ratio (HR)=0.10, p=0.04]. No significant difference in the clinicopathological variables was observed between the two groups according to preoperative therapy duration. The OS was significantly better in patients who underwent adjuvant surgery after preoperative therapy duration ≥6 months than in those after preoperative therapy duration <6 months and in those without adjuvant surgery (5-year OS rates: 80% vs. 0%; p=0.01 and 5-year OS rates: 80% vs. 0%; p=0.004, respectively). The OS was not significantly better in patients with adjuvant surgery after preoperative therapy duration <6 months than in those without adjuvant surgery (2-year OS rates: 45.7% vs. 38.1%; p=0.98). CONCLUSION: Preoperative therapy for UR-LA pancreatic cancer for ≥6 months is necessary to improve prognosis after adjuvant surgery.

Dynamics of the prognostic nutritional index in preoperative chemotherapy in patients with colorectal liver metastases.

BACKGROUND: Identifying the prognostic indicators that reflect the efficacy of preoperative chemotherapy is necessary. In this study, we investigated the prognostic indicators targeting the systemic inflammatory response for the administration of preoperative chemotherapy in patients with colorectal liver metastases. METHODS: Data for 192 patients were retrospectively analyzed. The relationship between overall survival and clinicopathological variables, including biomarkers such as the prognostic nutritional index, was investigated in patients who underwent upfront surgery or preoperative chemotherapy. RESULTS: In the upfront surgery group, extrahepatic lesion (p=0.01) and low prognostic nutritional index (p < 0.01) were significant prognostic indicators, whereas a decrease in the prognostic nutritional index (p=0.01) during preoperative chemotherapy were independent poor prognostic factors in the preoperative chemotherapy group. In particular, a decrease in the prognostic nutritional index was a significant prognostic marker in patients aged <75 years (p=0.04). In patients with a low prognostic nutritional index aged <75 years, preoperative chemotherapy significantly prolonged overall survival (p=0.02). CONCLUSION: A decrease in the prognostic nutritional index during preoperative chemotherapy predicted overall survival of patients with colorectal liver metastases after hepatic resection, and preoperative chemotherapy may be effective for patients aged <75 years with a low prognostic nutritional index.

A Multidisciplinary Treatment Strategy With Conversion Surgery for Hepatocellular Carcinoma.

BACKGROUND/AIM: Sorafenib was previously the only targeted therapy for hepatocellular carcinoma (HCC). However, pharmaceutical therapy for HCC has undergone remarkable advances in recent years. Herein, we report cases of unresectable advanced HCC responding to pharmaceutical therapy resulting in improved prognosis through surgical intervention. PATIENTS AND METHODS: Five patients with intermediate and advanced stage HCC treated with lenvatinib followed by hepatectomy between October 2019 and September 2022 were retrospectively reviewed. Patient characteristics, tumor factors, and treatment factors were compared. RESULTS: The median patient age was 66 (60-79) years, and all patients (100%) were male. The median follow-up period was 10.4 months. All five patients received lenvatinib treatment for more than 2 months before surgery. Three patients achieved partial responses and 2 patients had stable disease with modified RESIST in response to lenvatinib. Three patients had a partial pathological response (50% or more tumor necrosis). Four patients underwent R0 resection and 3 cases had no recurrence. CONCLUSION: Lenvatinib might be useful for intermediate and advanced HCC and long-term survival may be obtained by combining lenvatinib therapy with surgery.

D1 Distal Pancreatectomy for Left-sided Pancreatic Ductal Adenocarcinoma Is Justifiable: A Propensity-score Matched Multicenter Study.

BACKGROUND/AIM: Evidence on the optimal extent of lymph node dissection for left-sided pancreatic ductal adenocarcinoma (PDAC) is scarce. The aim of the current study was to compare the long-term outcomes of patients who underwent D1 distal pancreatectomy (DP) with D2 DP for left-sided PDAC. PATIENTS AND METHODS: Patients undergoing DP for left-sided PDAC at the four institutions affiliated to The Jikei University were enrolled in this study. Patients were divided into D1 and D2 groups. Patients' clinical characteristics, overall survival (OS), and relapse-free survival (RFS) were compared between the two groups before and after propensity-score matched (PSM) analysis. RESULTS: Of 145 patients with left-sided PDAC, 55 patients underwent D1 DP and 90 underwent D2 DP, of whom 38 matched pairs were included in the PSM analytic cohort. In the unmatched cohort, no significant difference was found between the D1 and D2 groups for both OS (median 2.51 vs. 3.07 years; p=0.709) and RFS (median 1.47 vs. 1.27 years; p=0.565). After PSM, OS (median 2.37 vs. 3.56 years; p=0.407) and RFS (median 1.35 vs. 1.11 years; p=0.542) were not significantly different between the two groups. In a comparison of regional and systemic recurrence sites, no significant difference was observed between the two groups (p=0.500). CONCLUSION: The long-term survival of D1 DP for left-sided PDAC was not inferior to D2 DP. In an era in which the importance of multidisciplinary treatment for PDAC has been documented, unnecessary extended surgery should be avoided.

Usefulness of the mesopancreas-first approach using isolating tape in conversion surgery for pancreatic cancer.

BACKGROUND: R0 resection is an important prognostic factor in patients with pancreatic cancer (PC). Advances in chemotherapy have improved the R0 resection rate for unresectable locally advanced (UR-LA) PC. There is a limit to determine on imaging whether R0 resection is possible due to chemotherapy effects. Therefore, we rely on intraoperative frozen section diagnosis (FSD). We devised a mesopancreas-first approach using isolating tape (iTape) to ensure the assessment of resectability before organ dissection. PATIENTS: The mesopancreas-first approach using iTape was performed in patients with UR-LA PC who were determined to be able to achieve R0 resection by pancreaticoduodenectomy after chemotherapy. METHODS: In this method, the mesopancreas is taped before organ dissection, and subsequent mesopancreas separation is performed by pulling the tape. The iTape is first placed through the retroperitoneal space between the mesopancreas and the inferior vena cava followed by extraction from the common hepatic artery, body of the pancreas, and splenic vein on the cranial side of the pancreas and from the superior mesenteric artery on the caudal side of the pancreas. As a result, the iTape is individually enmeshed in the mesopancreas. This way, only the mesopancreas can be dissected, while sparing other organs and tissues. If R0 resection is judged to be difficult by intraoperative FSD, the procedure is converted into bypass surgery. CONCLUSION: This method may be useful for pancreaticoduodenectomy in conversion cases and the resectability can be evaluated prior to organ dissection.

Dysbiosis of the Fecal and Biliary Microbiota in Biliary Tract Cancer.

Characteristic bile duct and gut microbiota have been identified in patients with chronic biliary tract disease. This study aimed to characterize the fecal and bile microbiota in biliary tract cancer (BTC) patients and their relationship. Patients with BTC (n = 30) and benign biliary disease (BBD) without cholangitis (n = 11) were included. Ten healthy, age-matched subjects were also recruited for fecal microbiota comparison. The fecal and bile duct microbiotas were analyzed by sequencing the 16S rRNA gene V3-V4 region. Live bacteria were obtained in the bile from three BTC patients by culture, and metagenomics-based identification was performed. Linear discriminant analysis effect size showed a higher Enterobacteriaceae abundance and a lower Clostridia abundance, including that of Faecalibacterium and Coprococcus, in the BTC patients than in the other subjects. Ten of 17 operational taxonomic units (OTUs) assigned to Enterobacteriaceae in the bile were matched with the OTUs found in the BTC subject fecal samples. Furthermore, a bile-isolated strain possessed the carcinogenic bacterial colipolyketide synthase-encoding gene. Enterobacteriaceae was enriched in the BTC feces, and more than half of Enterobacteriaceae in the bile matched that in the feces at the OTU level. Our data suggests that fecal microbiota dysbiosis may contribute to BTC onset.

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.

Clinical Features and Treatment Outcomes of Pseudoaneurysm Following Pancreatic Resection.

BACKGROUND/AIM: Management strategies for pseudoaneurysm rupture after pancreatic resection have not yet been firmly established due to its low incidence and effects of environmental variability among centers. This study aimed to provide a basis for treatment strategy improvement. PATIENTS AND METHODS: Clinical features and outcomes of 29 patients who experienced pseudoaneurysm formation or rupture following pancreatic resection were retrospectively reviewed. RESULTS: The incidence of pseudoaneurysm formation was 2.8%. In 28 of 29 patients, pseudoaneurysm was identified via emergent dynamic computed tomography (CT). The rates of complete cessation of bleeding by interventional radiology (IVR) and surgical intervention were 88% and 100%, respectively. Mortality rate was 13.8%. Four patients treated by IVR died, including three of massive bleeding and one of liver failure. CONCLUSION: Patients with suspected pseudoaneurysm rupture after pancreatic resection should undergo immediate CT. Open surgery is preferable for patients with incomplete hemostasis by IVR or those who cannot immediately undergo IVR, however, IVR is an effective alternative.

Transcatheter arterial embolization followed by surgical laparotomy for hemorrhagic shock due to intestinal bleeding: a case report.

BACKGROUND: Acquired jejunal diverticula are relatively rare conditions. While mostly asymptomatic, they can occasionally cause life-threatening complications requiring surgical treatment. We herein report a case of hemorrhagic shock due to jejunal diverticulum with intestinal amyloidosis that was successfully managed via transcatheter arterial embolization (TAE) and surgery. CASE PRESENTATION: An 80-year-old female presenting with hematochezia and hemorrhagic shock was transferred to our institution. Contrast-enhanced computed tomography revealed extravasation in the small bowel around the upper jejunum. Massive transfusion was performed with subsequently planning for TAE to control bleeding followed by surgical laparotomy to evaluate the ischemic intestine. First, the second jejunal artery was selectively embolized with a 1:3 mixture of N-butyl cyanoacrylate (NBCA) and iodize oil, after which laparotomy was performed. Multiple jejunal diverticula were detected near Treitz' ligament, and an induration of NBCA was palpable in the nearby mesentery. The intraoperative diagnosis was massive bleeding from acquired jejunal diverticula for which jejunectomy including the nearby diverticulum was performed to prevent future bleeding. Her postoperative course was stable. Histological examination of the specimen revealed several false diverticula with intestinal amyloidosis. CONCLUSION: Hemorrhagic shock due to jejunal diverticulum with intestinal amyloidosis is extremely rare. Combined treatment of TAE and surgical laparotomy appears to be effective, because the bleeding point can be identified by palpation of the embolic material.

Application of a novel surgical difficulty grading system during laparoscopic cholecystectomy.

BACKGROUND: Prevention of bile duct injury and vasculo-biliary injury while performing laparoscopic cholecystectomy (LC) is an unsolved problem. Clarifying the surgical difficulty using intraoperative findings can greatly contribute to the pursuit of best practices for acute cholecystitis. In this study, multiple evaluators assessed surgical difficulty items in unedited videos and then constructed a proposed surgical difficulty grading. METHODS: We previously assembled a library of typical video clips of the intraoperative findings for all LC surgical difficulty items in acute cholecystitis. Fifty-one experts on LC assessed unedited surgical videos. Inter-rater agreement was assessed by Fleiss's κ and Gwet's agreement coefficient (AC). RESULTS: Except for one item ("edematous change"), κ or AC exceeded 0.5, so the typical videos were judged to be applicable. The conceivable surgical difficulty gradings were analyzed. According to the assessment of difficulty factors, we created a surgical difficulty grading system (agreement probability = 0.923, κ = 0.712, 90% CI: 0.587-0.837; AC2  = 0.870, 90% CI: 0.768-0.972). CONCLUSION: The previously published video clip library and our novel surgical difficulty grading system should serve as a universal objective tool to assess surgical difficulty in LC.

Supraceliac aortic cross-clamping to control bleeding from the celiac axis during pancreatic surgery: a case report.

BACKGROUND: Intraoperative bleeding from the celiac axis (CA) can occur during pancreatic surgery, and appropriate management is essential to avoid critical complications. Here, we have reported a case that was managed with supraceliac aortic cross-clamping (SAC) for arterial bleeding from the CA during pancreatic surgery. CASE PRESENTATION: A 70-year-old man was diagnosed with pancreatic cancer located in the pancreatic head and body. Preoperative computed tomography showed a stricture at the root of the CA, which may have been caused by a median arcuate ligament. Pancreaticoduodenectomy with division of the median arcuate ligament was scheduled. Uncontrollable bleeding from the root of the CA was observed during surgery. The bleeding was controlled by performing SAC, and a defect in the CA was confirmed. Arterial wall repair was successfully performed under temporal blood control using SAC. The aortic clamp time was 2 min and 51 s, and the intraoperative blood loss was 480 ml. CONCLUSIONS: Although SAC is primarily a procedure for ruptured abdominal aortic aneurysm, it can be useful for the management of CA injuries during pancreatic surgery.

Prognostic value of immune factors in the tumor microenvironment of patients with pancreatic ductal adenocarcinoma.

BACKGROUND: Both activated tumor-infiltrating lymphocytes (TILs) and immune-suppressive cells, such as regulatory T cells (Tregs), in the tumor microenvironment (TME) play an important role in the prognosis of patients with pancreatic ductal adenocarcinoma (PDAC). METHODS: The densities of TILs, programmed death receptor 1 (PD-1) + T cells, and forkhead box P3 (Foxp3) + T cells were analyzed by immunohistochemical staining. The associations of the immunological status of the PDAC microenvironment with overall survival (OS) time and disease-free survival (DFS) time were evaluated. RESULTS: PDAC patients with a high density of TILs in the TME or PD-1-positive T cells in tertiary lymphoid aggregates (TLAs) demonstrated a significantly better prognosis than those with a low density of TILs or PD-1-negativity, respectively. Moreover, PDAC patients with high levels of Foxp3-expressing T cells showed a worse prognosis than those with low levels of Foxp3-expressing T cells. Importantly, even with a high density of the TILs in TME or PD-1-positive T cells in TLAs, PDAC patients with high levels of Foxp3-expressing T cells showed a worse prognosis than patients with low levels of Foxp3-expressing T cells. A PDAC TME with a high density of TILs/high PD-1 positivity/low Foxp3 expression was an independent predictive marker associated with superior prognosis. CONCLUSION: Combined assessment of TILs, PD-1+ cells, and Foxp3+ T cells in the TME may predict the prognosis of PDAC patients following surgical resection.

Effectiveness of Anatomical Resection for Small Hepatocellular Carcinoma: a Propensity Score-Matched Analysis of a Multi-institutional Database.

BACKGROUND: The superiority of outcomes associated with anatomical resection (AR) versus those associated with non-anatomical resection (NAR) remains controversial in patients with hepatocellular carcinoma (HCC). The aim of this study was to evaluate the significance of AR on therapeutic outcomes of patients with small HCCs (≤ 5 cm), using propensity score-matched (PSM) analysis. METHODS: A total of 195 patients who had undergone elective hepatic resection for small HCCs (≤ 5 cm) were included in this study. We conducted PSM analysis for baseline characteristics (age, sex, hepatitis virus status, retention rate of indocyanine green at 15 min, and Child-Pugh grade), preoperative serum α-fetoprotein, and tumor characteristics (tumor size, tumor number, portal vein invasion, and surgical margin status) to eliminate potential selection bias. The prognostic significance of AR on the disease-free and overall survival was analyzed in patients selected by PSM analysis. RESULTS: Applying PSM analysis, the patients were divided into PSM-AR (N = 66) and PSM-NAR (N = 66) groups. Disease-free survival was significantly better in the PSM-AR group than that of the PSM-NAR group (P = 0.018), while there was no significant difference in the overall survival between the PSM-AR and PSM-NAR groups (P = 0.292). The univariate HRs of the PSM-AR group were 0.55 (95% CI, 0.33-0.90) for disease-free survival and 0.61 (95% CI, 0.24-1.53) for overall survival, respectively. Remnant liver recurrence was significantly lower in the AR group (P = 0.014). CONCLUSIONS: AR may improve the disease-free survival in HCC patients with tumors of ≤5 cm diameter.

The segment IV approach: a useful method for achieving the critical view of safety during laparoscopic cholecystectomy in patients with anomalous bile duct.

BACKGROUND: The critical view of safety (CVS) method can be achieved by avoiding vasculo-biliary injury resulting from misidentification during laparoscopic cholecystectomy (LC). Although achieving the CVS has become popular worldwide, there is no established standardized technique to achieve the CVS in patients with an anomalous bile duct (ABD). We recently reported our original approach for securing the CVS using a new landmark, the diagonal line of the segment IV of the liver (D-line). The D-line is an imaginary line that lies on the right border of the hilar plate. The cystic structure can be securely isolated along the D-line without any misidentification, regardless of the existence of an ABD. We named this approach the segment IV approach in LC. METHODS: In this study, we adopted the segment IV approach in patients with an ABD. RESULTS: From October 2015 to June 2020, 209 patients underwent LC using the segment IV approach. Among them, three (1.4%) were preoperatively diagnosed with an ABD. The branching point of the cystic duct was the posterior sectional duct, anterior sectional duct, or left hepatic duct in each patient. The CVS was achieved in all cases without any complications. CONCLUSION: It is a promising technique, especially even for patients with an ABD during LC.

Segment IV approach for difficult laparoscopic cholecystectomy.

Although achieving the critical view of safety (CVS) is useful for avoiding vasculobiliary injury during laparoscopic cholecystectomy (LC), the CVS cannot always be achieved in cases of severe cholecystitis because of technical difficulties. Herein, we focused on segment IV of the liver and its diagonal line (D-line) as a feasible landmark for carrying out difficult LC. The D-line connects the right dorsal and left ventral corners of segment IV and is used as the vectoral landmark, which is where the gallbladder is first dissected to achieve CVS without misidentification. Conversion to subtotal cholecystectomy along the D-line is also feasible when gallbladder wall scarring is severe. We named this procedure the segment IV approach for LC. Sixty-two consecutive difficult LC (including 27 scheduled LC after percutaneous transhepatic gallbladder drainage [PTGBD] and 35 conservatively treated cases of Tokyo Guidelines [TG] grade II cholecystitis) were managed by the segment IV approach. Successful gallbladder extraction along the D-line was achieved in 44 (71%) cases; all of these cases also achieved CVS following total cholecystectomy. The other 18 (29%) cases were converted to subtotal cholecystectomy because gallbladder extraction along the D-line failed as a result of severe cholecystitis with inflammatory adhesion with surrounding structures. Median operative time and intraoperative blood loss were 135 (range, 54-290) min and 10 (range, 0-100) mL, respectively. No intra- or postoperative complications were observed. The segment IV approach is feasible for achieving CVS and for considering subtotal cholecystectomy in difficult LC cases where scarring of the gallbladder wall is present.

Impact of Bile Exposure Time on Organ/space Surgical Site Infections After Pancreaticoduodenectomy.

BACKGROUND/AIM: Organ/space surgical site infections (SSIs) are critical complications of pancreaticoduodenectomy. We investigated the impact of the time between division of the common hepatic duct and completion of biliary reconstruction [bile exposure (BE) time] on the occurrence of post-pancreaticoduodenectomy organ/space SSI. PATIENTS AND METHODS: Sixty-one patients who underwent pancreaticoduodenectomy were retrospectively studied. The impact of perioperative variables and BE time on organ/space SSI occurrence was analyzed. RESULTS: Organ/space SSIs occurred in 17 patients (28%). Patients were divided into two groups according to BE time. The incidence of organ/space SSIs was significantly higher in the long BE time group than in the short BE time group (42% versus 13%, p=0.0127). Multivariate analysis revealed that long BE times [odds ratio (OR)=4.8; p=0.0240] and soft pancreatic texture (OR=16.5; p=0.0106) were independent risk factors for organ/space SSIs. CONCLUSION: Long BE time is a risk factor for post-pancreaticoduodenectomy organ/space SSIs. Shortening BE time may reduce organ/space SSI occurrence.

Clinical Significance of Tumor-Infiltrating T Cells and Programed Death Ligand-1 in Patients with Pancreatic Cancer.

The associations of the immunological status of the pancreatic ductal adenocarcinoma (PDA) microenvironment with prognosis were assessed. A high tumor-infiltrating lymphocyte (TIL) density was associated with a better prognosis. Importantly, even with a high density of TILs, the PDA cells with programed cell death-ligand 1 (PD-L1) expression showed a worse prognosis than the patients with negative PD-L1 expression. A significant association between a better prognosis and a tumor microenvironment with a high TIL density/negative PD-L1 expression was observed. Assessments of a combined immunological status in the tumor microenvironment may predict the prognosis of PDA patients following surgical resection.

Effective method of gallbladder retraction for single-incision laparoscopic cholecystectomy.

INTRODUCTION: Recently, single-incision laparoscopic cholecystectomy has been accepted as an alternative to conventional laparoscopic cholecystectomy. The aim of this study was to retrospectively evaluate the safety and feasibility of unique gallbladder retraction methods using an ENDOLOOP® (Ethicon, Tokyo, Japan) and Lapaherclosure™ (Hakko Medical, Tokyo, Japan). MATERIALS AND SURGICAL TECHNIQUE: From May 2013 to April 2015, 77 patients underwent single-incision laparoscopic cholecystectomy with this retraction technique. During the same period, conventional laparoscopic cholecystectomy was performed in 85 patients; these patients were the control group. The patients' data, including the operative time, total blood loss, conversion rate to laparotomy, and perioperative complications, were compared. Alexis® Wound Retractor XS (Applied Medical, Tokyo, Japan) was inserted through a 25-30-mm vertical transumbilical incision to prevent bile contamination. Next, a SILS Port (Covidien, Tokyo, Japan) was inserted. A flexible 5-mm laparoscope was inserted through the port with a grasper (SILS Clinch, Covidien) and a normal 5-mm scalpel. The fundus of the gallbladder was tied by the ENDOLOOP. The Lapaherclosure was then directly inserted through a right lower intercostal space to capture and pull the Lapaherclosure out. After the cystic artery and duct were cut, the resected gallbladder was directly extracted from the umbilical incision. DISCUSSION: Several methods and devices have been developed to perform single-incision laparoscopic cholecystectomy, including the suturing method, the Mini Loop Retractor II (Covidien), and the EndoGrab (Virtual Ports, Caesarea, Israel). However, considering medical costs and safety, our retraction method seems to be feasible and comparable to existing methods.