Tailoring the Use of Central Pancreatectomy Through Prediction Models for Major Morbidity and Postoperative Diabetes: International Retrospective Multicenter Study.

OBJECTIVE: To develop a prediction model for major morbidity and endocrine dysfunction after CP which could help in tailoring the use of this procedure. SUMMARY BACKGROUND DATA: Central pancreatectomy (CP) is a parenchyma-sparing alternative to distal pancreatectomy for symptomatic benign and pre-malignant tumors in body and neck of the pancreas CP lowers the risk of new-onset diabetes and exocrine pancreatic insufficiency compared to distal pancreatectomy but it is thought to increase the risk of short-term complications including postoperative pancreatic fistula (POPF). METHODS: International multicenter retrospective cohort study including patients from 51 centers in 19 countries (2010-2021). Primary endpoint was major morbidity. Secondary endpoints included POPF grade B/C, endocrine dysfunction, and the use of pancreatic enzymes. Two risk model were designed for major morbidity and endocrine dysfunction utilizing multivariable logistic regression and internal and external validation. RESULTS: 838 patients after CP were included (301 (36%) minimally invasive) and major morbidity occurred in 248 (30%) patients, POPF B/C in 365 (44%), and 30-day mortality in 4 (1%). Endocrine dysfunction in 91 patients (11%) and use of pancreatic enzymes in 108 (12%). The risk model for major morbidity included male sex, age, BMI, and ASA score≥3. The model performed acceptable with an area under curve (AUC) of 0.72(CI:0.68-0.76). The risk model for endocrine dysfunction included higher BMI and male sex and performed well (AUC:0.83 (CI:0.77-0.89)). CONCLUSIONS: The proposed risk models help in tailoring the use of CP in patients with symptomatic benign and premalignant lesions in the body and neck of the pancreas and are readily available via www.pancreascalculator.com.

Impact of Sarcopenic Obesity on Severe Postoperative Complications in Patients with Gastric Cancer Undergoing Gastrectomy.

INTRODUCTION: Several studies have indicated that sarcopenia affects the short- and long-term outcomes of cancer patients, including those with gastric cancer. In recent years, sarcopenic obesity and its effects have been reported in cancer patients. This study aimed to evaluate the impact of sarcopenic obesity on postoperative complications in patients with gastric cancer undergoing gastrectomy. METHODS: This single-center, retrospective study included 155 patients who underwent curative gastrectomy for gastric cancer from January 2015 to July 2021. Sarcopenia was defined by the psoas muscle index (<6.36 cm2/m2 in men and <3.92 cm2/m2 in women), which measures the iliopsoas muscle area at the lumbar L3 level using computed tomography. Obesity was defined by body mass index (≥25). Patients with both sarcopenia and obesity were defined as the sarcopenic obesity group and others as the non-sarcopenic obesity group. Severe postoperative complications were defined as Clavien-Dindo classification grade IIIa or higher. RESULTS: Of the 155 patients, 26 (16.8%) had sarcopenic obesity. The incidence of severe postoperative complications was significantly higher in the sarcopenic obesity group (30.8% vs. 10.9%; p = 0.014). Multivariate analysis indicated that sarcopenic obesity was an independent risk factor for severe postoperative complications (odds ratio, 3.950; 95% confidence interval, 1.390-11.200; p = 0.010). CONCLUSION: Sarcopenic obesity is an independent risk factor for severe postoperative complications.

Significance of Zinc Replacement Therapy After Pancreaticoduodenectomy.

BACKGROUND/AIM: Recently, a decrease in serum zinc levels and the need for zinc preparations have been reported in the perioperative period of gastrointestinal surgery. In this study, we examined treatment outcomes among patients supplemented with zinc after pancreaticoduodenectomy (PD) and evaluated the significance of zinc replacement therapy. PATIENTS AND METHODS: From June 2020 to April 2021, 56 patients who received zinc acetate hydrate (50 mg/day) from postoperative day 3 after PD in our department were retrospectively reviewed. Patients' characteristics and preoperative as well as postoperative data, including serum zinc levels and surgical results at 1 month were reviewed. RESULTS: Preoperative zinc deficiency was present in 86.1% (46/56) of the patients. Moreover, despite zinc supplementation, 17.8% (10/56) of patients had postoperative zinc deficiency. A comparison between the low zinc level group (Zn <80 µg/dl) and the normal zinc level group (Zn ≥80 µg/dl) after surgery showed siginificant differences among patients with malignant diseases (vs. benign diseases, p=0.044), those undergoing open surgery (vs. minimally invasive surgery, p=0.036), and those with intraoperative blood loss ≥346 ml (vs. <346 ml: p=0.041) in the univariate analysis. Multivariate analysis revealed that zinc deficiency was significantly associated with open surgery [odds ratio (OR)=15.885, 95% confidence interval (CI)=1.77-142.01, p=0.013] and intraoperative blood loss (OR=9.329, 95% CI=1.50-57.74, p=0.016). CONCLUSION: In patients undergoing open PD for pancreatic cancer, zinc preparations of 50 mg may not be sufficient and further supplementation may be necessary.

Laparoscopic-assisted modified Kugel herniorrhaphy for obturator hernia: a case report.

Obturator hernia (OH) is a relatively rare disease and there are various surgical procedures for treating it. We report the case of a patient with an OH who underwent laparoscopic-assisted modified Kugel herniorrhaphy. The patient was a 74-year-old woman admitted to our hospital with nausea and abdominal distension. A diagnosis of intestinal obstruction was made because abdominal computed tomography revealed incarcerated right OH. No apparent strangulation findings were observed, and reduction was performed under ultrasound guidance. Laparoscopic-assisted modified Kugel herniorrhaphy for OH was performed. There were no signs of the bowel necrosis. Pneumoperitoneum was temporarily discontinued, and the OH was repaired by the modified Kugel herniorrhaphy. Laparoscopy confirmed that the direct Kugel patch was placed at the appropriate position. Laparoscopic-assisted modified Kugel herniorrhaphy is considered to be safe and useful for patients with OH and is considered as one of the treatment options.

Subcuticular Sutures Versus Staples for Wound Closure in Open Liver Resection: A Randomised Clinical Trial.

BACKGROUND: Subcuticular sutures reduce wound complication rates only in clean surgeries. Repeat resection is frequently required in liver surgery, due to the high recurrence rate (30-50%) of liver cancers. The aim of this study is to assess that subcuticular sutures is superior to staples in liver surgery. METHODS: This single-centre, single-blinded, randomised controlled trial was conducted at a university hospital between January 2015 and October 2018. Patients were randomly assigned (1:1) to receive either subcuticular sutures or staples for skin closure. Three risk factors (repeat resection, diabetes mellitus and liver function) were matched preoperatively for equal allocation. The primary endpoint was the wound complication rate, while secondary endpoints were surgical site infection (SSI), duration of postoperative hospitalisation and total medical cost. Subset analyses were performed only for the 3 factors allocated as secondary endpoints. RESULTS: Of the 581 enrolled patients, 281 patients with subcuticular sutures and 283 patients with staples were analysed. As the primary outcome, the wound complication rate with subcuticular sutures (12.5%) did not differ from that with staples [15.9%; odds ratio (OR), 1.33; 95% confidence interval (CI), 0.83-2.15; p = 0.241]. As secondary outcomes, no significant differences were identified between the two procedures in the overall cohort while overall wound complications [7 patients (8.5%) vs. 17 patients (20.0%); OR, 2.68; 95% CI, 1.08-7.29; p = 0.035] with repeat incision were significantly less frequent with subcuticular sutures. CONCLUSION: Subcuticular sutures were not shown to reduce wound complications compared to staples in open liver resection, but appear beneficial for repeat incisions.

Criteria for liver resection for metastasis from bile duct cancer.

BACKGROUND: The surgical indications for liver metastasis from bile duct cancer remain contentious, because surgery is generally thought unlikely to improve survival. However, recent reports show that long-term survival has been achieved with liver resection of metastasis from recurrent bile duct cancer in selected patients. METHODS: Liver resection for liver metastasis from bile duct cancer was proposed only when the following criteria were met: liver-only metastasis, a solitary tumor, and no increase in the number of lesions during 3 months of observation. This study aimed to validate our criteria and to analyze which factors impact on survival. RESULT: Between 2003 and 2017, 164 patients underwent pathologically curative resection for bile duct cancer. Recurrence developed in 98 of these patients, as liver-only metastasis in 25. Eleven of these 25 patients underwent liver resection (liver resection group), and 14 did not (non-liver resection group). The median overall survival was longer in the liver resection group than in all the patients (44 months vs. 17.8 months, respectively p = 0.040). The median overall survival was better in the liver resection group than in the non-liver resection group (44 months vs. 19.9 months, p = 0.012). The disease-free interval was also significantly longer in the liver resection group than in the non-liver resection group [22 months (range; 4-34 months) vs. 3 months (2-11), p < 0.001]. CONCLUSION: Potentially, metachronous solitary liver metastasis from bile duct cancer is an indication for liver resection when the patient has had a long disease-free interval. Observation for 3 months from first detection of metastasis may optimize the selection for this surgery.

Comparison of the surgical outcomes in patients with synchronous versus metachronous multiple hepatocellular carcinoma.

Multiplicity is one of the characteristics of hepatocellular carcinoma (HCC), and patients with multiple HCC (≤ 3 nodules) are recommended as candidates for liver resection. To confirm the validity of resecting multiple HCC, we compared the surgical outcomes in patients with synchronous and metachronous multiple HCC. Patients who underwent resection for multiple HCC (2 or 3 nodules) were classified into the "synchronous multiple HCC" group, while those undergoing resection for solitary HCC and repeated resection for 1 or 2 recurrent nodules within 2 years after initial operation were classified into the "metachronous multiple HCC" group. After one-to-one matching, longer operation time and more bleeding were seen in the synchronous multiple HCC group (n = 98) than those in the metachronous multiple HCC group (n = 98); however, the complication rates were not different between the two groups. The median overall survival times were 4.0 years (95% CI, 3.0-5.9) and 5.9 years (4.0-NA) for the synchronous and metachronous multiple HCC (after second operation) groups, respectively (P = 0.041). The recurrence-free survival times were shorter in the synchronous multiple HCC group than in the metachronous multiple HCC group (median, 1.5 years [95% CI, 0.9-1.8] versus 1.8 years, [1.3-2.2]) (P = 0.039). On multivariate analysis, independent factors for overall survivals in the synchronous multiple HCC group were older age, cirrhosis, larger tumor, and tumor thrombus. Taken together, resection of metachronous multiple HCC still has good therapeutic effect, even better than synchronous multiple HCC, so resection is suggested for metachronous multiple HCC.

Subcuticular sutures reduce surgical site infection after repeat liver resection: a matched cohort analysis.

Liver cancer frequently requires repeated liver resections due to the high recurrence rate. The aim of this study was to clarify whether subcuticular sutures reduce wound complication rates following repeat incisions. Data from 382 repeated liver resections in 1,245 consecutive patients were assessed. Patients were divided into a Subcuticular sutures group and a Skin staples group on the basis of the wound-closure method. To avoid bias in analysing wound complications, data were matched to adjust for patient background and operation variables. After matching, 82 matched, paired patients with subcuticular sutures or skin staples were compared. Total wound complication rate was significantly lower with subcuticular sutures than with skin staples (8.5% vs. 20.7%, p = 0.027). Incisional surgical site infection was also lower with subcuticular sutures than with skin staples (6.1% vs. 17.1, p = 0.028). Univariate analysis revealed 4 factors associated with wound complications: body mass index; serum albumin concentration; wound length; and closure with skin staples. Multivariate analysis revealed closure with skin staples (odds ratio, 2.91; 95% confidence interval, 1.07-7.94; p = 0.037) as the only independent factor negatively associated with wound complications. Subcuticular sutures appear to reduce wound complications compared to skin staples following repeat incision for liver resection.

Time interval-based indication for liver resection of metastasis from pancreatic cancer.

BACKGROUND: Surgical indications for liver metastases from pancreatic ductal adenocarcinoma (PDAC) are lacking because outcomes are usually poor. However, liver resection and the recent progress in perioperative chemotherapy have been observed to improve survival. METHODS: We performed liver resection for liver metastases from PDAC only under the following criteria: (1) liver-only metastasis, (2) up to three tumors, and (3) no increase in the number of metastases during the 3-month observation period. No limitations were placed on the location or size of liver metastasis. In this study, we aimed to validate our surgical criteria and analyze factors affecting survival in patients with PDAC. RESULTS: Seventy-nine patients underwent curative resection for PDAC between 2005 and 2015. Seventy-one patients experienced recurrence, with liver-only recurrence in 17 patients. Among these, nine patients underwent liver resection and eight did not. The median survival time was significantly better for patients who underwent liver resection (55 months) than for those with other recurrences (17.5 months, p = 0.016). The median survival after liver recurrence was significantly better in the liver resection group (31 months) than in the non-liver resection group (7 months, p = 0.0008). The median disease-free interval (DFI) after pancreatectomy was significantly longer in the liver resection group (21 months; range, 3-44 months) than in the non-liver resection group (3 months; range, 2-7 months; p = 0.02). CONCLUSION: Good indications for liver metastases from PDAC include solitary metachronous tumors and longer DFIs.

Predictive value of perfusion CT for blood loss in liver resection.

Blood loss is associated with the degree of damage in liver stiffness. Severe liver steatosis is a matter of concern in liver surgery, but does not correlate with liver stiffness. This study aimed to assess the relationship between blood perfusion of the liver and blood loss in liver pathologies. Data from elective liver resection for liver cancer were analyzed. All patients underwent preoperative assessments including perfusion CT. Patients were divided into 4 groups in accordance with the pathological background of liver parenchyma. Relationships between portal flow as assessed by perfusion CT and perioperative variables were compared. Factors correlating with blood loss were analyzed. In 166 patients, portal flow from perfusion CT correlated positively with platelet count and negatively with indocyanine green retention rate at 15 min. Background liver pathology was normal liver (NL) in 43 cases, chronic hepatitis (CH) in 56, liver cirrhosis (LC) in 42, and liver steatosis (LS) in 25. Rates of hepatitis viral infection and pathological hepatocellular carcinoma were more frequent in LC and CH groups than in the other groups (p < 0.05). LC and LS showed significantly worse liver function than the NL and CH groups. Portal flow from perfusion CT correlated positively with damage to liver parenchyma and negatively with blood loss at liver transection. Low portal flow on perfusion CT predicts blood loss during liver transection.

Next-generation des-r-carboxy prothrombin for immunohistochemical assessment of vascular invasion by hepatocellular carcinoma.

BACKGROUND: We have previously shown the value of next-generation des-r-carboxy prothrombin (NX-DCP) for predicting vascular invasion in hepatocellular carcinoma (HCC). Since conventional DCP is inaccurate under some conditions, this study aimed to assess whether NX-DCP immunohistochemical staining was related to vascular invasion in HCC. METHODS: Fifty-six patients scheduled to undergo resection for single HCC were divided into two groups, with and without pathological portal vein invasion. Immunohistochemical features of HCC and sites of vascular invasion were assessed using alpha-fetoprotein (AFP), conventional DCP, and NX-DCP. RESULTS: Pathological portal vein invasion was absent in 43 patients and present in 13 patients. Patient characteristics, pathological background of the liver parenchyma, and tumor-related factors did not differ significantly between the groups. There was no significant difference in the serum AFP level between the groups, whereas levels of conventional DCP (p < 0.0001) and NX-DCP (p < 0.0001) were significantly higher in the vascular invasion group. Immunohistochemical staining showed no significant difference in the staining rate of tumor (67.9% vs. 80.7%, p = 0.08), but NX-DCP stained significantly more at the sites of vascular invasion (15.4% vs. 46.2%, p = 0.01) than conventional DCP. No vascular invasion was stained by AFP. CONCLUSIONS: NX-DCP offers better sensitivity for detecting sites of vascular invasion than AFP and conventional DCP.

Aberrant anterior branch of segment V traveling ventrally across the gallbladder: a case of critical anatomy.

This paper presents a case of critical anatomic variation in laparoscopic cholecystectomy, as an anterior segmental branch of segment V from the left hepatic artery passing anterior to the fundus of the gallbladder and coursing to the anterior hepatic segment. A 46-year-old man was admitted to our hospital complaining of hypochondralgia attributed to gallbladder stones. An aberrant artery crossed the ventral side of the neck of the gallbladder and ran into the right liver Glissonean sheath of segment V. During laparoscopic cholecystectomy, this artery was taped and exposed from proximal to distal ends, revealing an origin from the left hepatic artery with the vessel acting as the anterior branch of segment V to the liver. The cystic artery branching from the aberrant artery was found on the left side of the gallbladder. Laparoscopic cholecystectomy was performed with no injury to the hepatic arteries and the patient was discharged 3 days postoperatively. In general laparoscopic cholecystectomy, we expose only the area inside Calot's triangle. With such an approach, this type of aberrant hepatic artery may be injured intraoperatively without consequences. Detailed preoperative evaluation using modalities such as 3-dimensional reconstruction of CT and knowledge of variations in the hepatic artery will help avoid vessel injury.

Platelet recovery correlates parenchymal volume recovery after liver resection.

AIM: Platelet count seems to assess liver function and predict liver regeneration, but factors associated with liver regeneration remain unclear. This study analyzed the relationship between platelet recovery and postresection liver regeneration. METHODS: Data from 343 candidates from 1245 consecutive patients with liver resection of more than Couinaud's segments were analyzed. Patients were divided into a low-platelet-recovery rate (LPRR) group (lowest 25%) or a control group on the basis of the platelet recovery rate on postoperative day (POD)7. Data were matched before analysis to adjust for operation scale. Trends in liver functional recovery were assessed, and liver volume recovery and remnant ischemic area was calculated using computed tomography volumetry. Factors predicting liver regeneration were analyzed. RESULTS: In 78 matched-pair patients, the all-complications rate (42.3% vs. 26.9%, P = 0.002) and infectious complications rate (21.8% vs. 9.0%, P = 0.027) were significantly higher in the LPRR group than in controls. Trends in liver functional recovery did not differ significantly, whereas significant differences remained for platelet recovery. Parenchyma volume recovery was delayed in the LPRR group from POD7 (84.5% vs. 78.1, P < 0.01) to POD30 (92.5% vs. 85.6, P < 0.01). Platelet recovery rate on POD7 correlated negatively with ischemic liver volume as evaluated on POD2 by computed tomography (r = 0.691). Postoperative ischemic volume on POD2 (5.41 [1.98-11.21], P < 0.001), infectious complications (3.48 [1.44-7.37], P < 0.001), and multiple resection (1.67 [1.10-4.11], P = 0.011) predicted delayed platelet recovery rate on multivariate analysis. CONCLUSION: Platelet recovery correlated with liver volume recovery and occurrence of complications. Large ischemic area might negatively impact regeneration after liver resection.

Feasibility of Hyaluronate Carboxymethylcellulose-Based Bioresorbable Membrane in Two-Staged Pancreatojejunostomy.

BACKGROUND: Two-staged pancreatoduodenectomy with exteriorization of pancreatic juice is a safe procedure for high-risk patients. However, two-staged pancreatoduodenectomy requires complex re-laparotomy and adhesion removal. We analyzed whether using hyaluronate carboxymethylcellulose-based bioresorbable membrane (HCM) reduced the time required for the second operation and facilitated good fistula formation in two-staged pancreatoduodenectomy. METHODS: Between April 2011 and December 2018, data were collected from 206 consecutive patients who underwent two-staged pancreatoduodenectomy. HCM has been used for all patients since 2015. Patients for whom HCM was used (HCM group; n = 61) were compared to historical controls (before 2015) without HCM (control group; n = 145) in terms of feasibility of the second operation (operation time, adhesion grade, and complications) and optimal granulation around the external tube at the second laparotomy. RESULTS: The HCM group showed significantly shorter median operation time [105 min (30-228 min) vs. 151 min (30-331 min); p < 0.001] and smaller median blood loss [36 mL (8-118 mL) vs. 58 mL (12-355 mL); p < 0.001] for the second operation. Neither overall postoperative complication rate (p = 0.811) nor severe-grade complication rate (p = 0.857) differed significantly. Both groups showed good fistula formation, with no significant difference in rate of optimal fistula formation (HCM group, 95.1% vs. control, 95.9%; p = 0.867). CONCLUSION: HCM placement significantly improved safety and duration for the second operation, while preserving good fistula formation.

Neither ischemic parenchymal volume nor severe grade complication correlate transient high transaminase elevation after liver resection.

To clarify whether high transient elevation of serum transaminase predicts severe complications and is related to the ischemic area on CT. Postoperative laboratory data and ischemia area on CT were analyzed on the basis of the presence of high transaminase elevation (aspartate aminotransferase (AST) > 1,000 IU/L within postoperative day (POD) 2 after liver resection. In the high elevation group, volume of ischemic areas was assessed by CT on POD2. The 538 patients were divided into a high transaminase group (n = 51) and a control group (n = 487). Median operation time (527 min vs. 360 min, p < 0.01) and liver ischemia time (121 min vs. 70 min, p < 0.01) were significantly longer, and intraoperative blood loss (478 mL [85-1572 mL] vs. 269 mL [5-4491 mL], p < 0.01) was significantly greater in the high transaminase group. No significant differences observed in frequency of severe complications (Clavien-Dindo classification Grade III or more) or postoperative hospitalization. Operation time (> 500 min; odds ratio (OR), 4.86; 95% confidence interval (CI), 2.40-9.89; p < 0.01) and liver ischemia time (> 120 min; OR, 3.47; 95%CI, 1.67-7.17; p < 0.01) were independent predictors of high transaminase elevation. No relationship was observed between degree of transaminase elevation and ischemic area (correlation coefficients: AST, R2 < 0.001; alanine aminotransferase, R2 = 0.005) CT volumetry on POD2. In conclusions, high transaminase elevations do not predict severe complications or reflect remnant ischemic area.

A prediction model for the grade of liver fibrosis using magnetic resonance elastography.

BACKGROUND: Liver stiffness measurement (LSM) has recently become available for assessment of liver fibrosis. We aimed to develop a prediction model for liver fibrosis using clinical variables, including LSM. METHODS: We performed a prospective study to compare liver fibrosis grade with fibrosis score. LSM was measured using magnetic resonance elastography in 184 patients that underwent liver resection, and liver fibrosis grade was diagnosed histologically after surgery. Using the prediction model established in the training group, we validated the classification accuracy in the independent test group. RESULTS: First, we determined a cut-off value for stratifying fibrosis grade using LSM in 122 patients in the training group, and correctly diagnosed fibrosis grades of 62 patients in the test group with a total accuracy of 69.3%. Next, on least absolute shrinkage and selection operator analysis in the training group, LSM (r = 0.687, P < 0.001), indocyanine green clearance rate at 15 min (ICGR15) (r = 0.527, P < 0.001), platelet count (r = -0.537, P < 0.001) were selected as variables for the liver fibrosis prediction model. This prediction model applied to the test group correctly diagnosed 32 of 36 (88.8%) Grade I (F0 and F1) patients, 13 of 18 (72.2%) Grade II (F2 and F3) patients, and 7 of 8 (87.5%) Grade III (F4) patients in the test group, with a total accuracy of 83.8%. CONCLUSIONS: The prediction model based on LSM, ICGR15, and platelet count can accurately and reproducibly predict liver fibrosis grade.

Predicting postoperative outcomes of liver resection by magnetic resonance elastography.

BACKGROUND: Cirrhosis is associated with blood loss during liver resection and postoperative complications. The liver stiffness measurement has recently become available for assessment of liver fibrosis. METHODS: This prospective study was performed to predict postoperative outcomes of liver resection. The liver stiffness measurement was measured prospectively using magnetic resonance elastography for patients who had undergone liver resection for malignancy. We investigated whether the liver stiffness measurement by magnetic resonance elastography is correlated with liver fibrosis and postoperative outcomes. RESULTS: The median liver stiffness measurement by magnetic resonance elastography in 175 patients was 3.4 (range: 1.5-11.3) kPa, and the pathologic grade of liver fibrosis was significantly correlated with the liver stiffness measurement (r = 0.68, P < .001). The median blood loss during transection per unit area was 4.1 mL/cm2 (range: 0.1-37.0 mL/cm2), and the frequency of major complications was 16.0%. The liver stiffness measurement was the only independent prognostic factor for both blood loss (regression coefficient: 1.14, 95% confidence interval: 0.45-1.83, P = .001) and major complications (odds ratio: 2.14, 95% confidence interval: 1.63-2.93, P < .001). Receiver operating characteristic curve analysis indicated a significant correlation between the liver stiffness measurement and major complications with calculated area under the curve of 0.81 (P < .001), and the sensitivity and specificity for prediction of major complications (cutoff value: 5.3 kPa) were 64.3% and 87.8%, respectively. On the other hand, the amount of blood loss was significantly correlated with the frequency of major complications (P = .003). CONCLUSION: The liver stiffness measurement by magnetic resonance elastography could be used as a predictive marker for the risk of major complications due to blood loss during liver resection.

Prospective Validation of Optimal Drain Management "The 3 × 3 Rule" after Liver Resection.

BACKGROUND: We previously established an optimal postoperative drain management rule after liver resection (i.e., drain removal on postoperative day 3 if the drain fluid bilirubin concentration is <3 mg/dl) from the results of 514 drains of 316 consecutive patients. This test set predicts that 274 of 316 patients (87.0 %) will be safely managed without adverse events when drain management is performed without deviation from the rule. OBJECTIVE: To validate the feasibility of our rule in recent time period. METHODS: The data from 493 drains of 274 consecutive patients were prospectively collected. Drain fluid volumes, bilirubin levels, and bacteriological cultures were measured on postoperative days (POD) 1, 3, 5, and 7. The drains were removed according to the management rule. The achievement rate of the rule, postoperative adverse events, hospital stay, medical costs, and predictive value for reoperation according to the rule were validated. RESULTS: The rule was achieved in 255 of 274 (93.1 %) patients. The drain removal time was significantly shorter [3 days (1-30) vs. 7 (2-105), p < 0.01], drain fluid infection was less frequent [4 patients (1.5 %) vs. 58 (18.4 %), p < 0.01], postoperative hospital stay was shorter [11 days (6-73) vs. 16 (9-59), p = 0.04], and medical costs were decreased [1453 USD (968-6859) vs. 1847 (4667-9498), p < 0.01] in the validation set compared with the test set. Five patients who required reoperation were predicted by the drain-based information and treated within 2 days after operation. CONCLUSIONS: Our 3 × 3 rule is clinically feasible and allows for the early removal of the drain tube with minimum infection risk after liver resection.

Prediction of vascular invasion in hepatocellular carcinoma by next-generation des-r-carboxy prothrombin.

BACKGROUND: In hepatocellular carcinoma (HCC), des-r-carboxy prothrombin (DCP) more accurately reflects the malignant potential than alpha-fetoprotein (AFP). Next-generation DCP (NX-DCP) was created to overcome some of the limitations of conventional DCP. This study assessed the predictive value of NX-DCP for vascular invasion in HCC. METHODS: We prospectively studied 82 consecutive patients who were scheduled to undergo resection for HCC. Patients were divided into two groups according to the presence or absence of pathological vascular invasion. The predictive powers of AFP, conventional DCP, and NX-DCP for vascular invasion were compared by receiver operating characteristic curve analysis, and correlations with tumour markers and the presence of vascular invasion were assessed. RESULTS: Vascular invasion was pathologically confirmed in 21 patients (positive group) and absent in 61 patients (negative group). The NX-DCP level was significantly higher in the positive group than in the negative group (510.0 mAU ml(-1) (10-98 450) vs 34.0 mAU ml(-1) (12-541), P<0.0001), while the AFP level did not differ significantly between the groups (9.7 ng ml(-1) (1.6-43 960.0) vs 11.0 ng ml(-1) (1.6-1650.0), P=0.49). The area under the curve (AUC) of NX-DCP (AUC=0.813, sensitivity=71.4%, 1-specificity=13.1%) had good sensitivity for the prediction of vascular invasion, while the AUC of AFP was 0.550 (sensitivity=28.6%, 1-specificity=1.60%). The suitable cutoff value for identifying pathological vascular invasion in HCC was 33 mm (AUC: 0.783, sensitivity=71.43%, 1-specificity=11.48%). CONCLUSIONS: The NX-DCP level can be used to predict the presence of vascular invasion in HCC.

A Longitudinal Computed Tomography Imaging in the Diagnosis of Gallbladder Cancer.

Background/Aim. To assess whether the diagnostic power of longitudinal multiplanar reformat (MPR) images is superior to that of conventional horizontal images for gallbladder cancer (GBC). Methods. Between 2006 and 2010, a total of 54 consecutive patients with preoperatively diagnosed gallbladder neoplasms located in gallbladder bed were analyzed. These patients underwent cholecystectomy with resection of the adjacent liver parenchyma. The patients were divided into the GBC group (n = 30) and the benign group (n = 24). MPR images obtained by preoperative multidetector row CT (MDCT) were assessed. Results. Mucosal line was more significantly disrupted in GBC group than that in benign group (93% [28/30 patients] versus 13% [3/24], p < 0.001). Maximum (9.3 [4.2-24.8] versus 7.0 mm [2.4-22.6], p = 0.29) and minimum (1.2 [1.0-2.4] versus 1.3 mm [1.0-2.6], p = 0.23) wall thicknesses on a single MPR plane did not differ significantly; however, the wall thickness ratio (max/min) differed significantly (6.8 [1.92-14.0] versus 5.83 [2.3-8.69], p = 0.04). Partial liver enhancement adjacent to tumor on longitudinal images was more common in GBC (40.0% [12/30 patients] versus 12.5% [3/24], p = 0.03). Mucosal line disruption was the most reliable independent predictor of diagnosis (odds ratio, 8.5; 95% CI, 5.99-28.1, p < 0.001). Conclusion. Longitudinal MPR images are more useful than horizontal images for the diagnosis of GBC.