Outcomes after laparoscopic or open liver resection for nonalcoholic fatty liver disease-associated hepatocellular carcinoma: a propensity score-matching study.

BACKGROUND: Laparoscopic liver resection (LLR) is rapidly gaining popularity; however, its efficacy for nonalcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC) (NAFLD-HCC) has been not evaluated. The purpose of this study was to compare short- and long-term outcomes between LLR and open liver resection (OLR) among patients with NAFLD-HCC. METHODS: We used a single-institution database to analyze data for patients who underwent LLR or OLR for NAFLD-HCC from January 2007 to December 2022. We performed propensity score-matching analyses to compare overall postoperative complications, major morbidities, duration of surgery, blood loss, transfusion, length of stay, recurrence, and survival between the two groups. RESULTS: Among 210 eligible patients, 46 pairs were created by propensity score matching. Complication rates were 28% for OLR and 11% for LLR (p = 0.036). There were no significant differences in major morbidities (15% vs. 8.7%, p = 0.522) or duration of surgery (199 min vs. 189 min, p = 0.785). LLR was associated with a lower incidence of blood transfusion (22% vs. 4.4%, p = 0.013), less blood loss (415 vs. 54 mL, p < 0.001), and shorter postoperative hospital stay (9 vs. 6 days, p < 0.001). Differences in recurrence-free survival and overall survival between the two groups were not statistically significant (p = 0.222 and 0.301, respectively). CONCLUSIONS: LLR was superior to OLR for NAFLD-HCC in terms of overall postoperative complications, blood loss, blood transfusion, and postoperative length of stay. Moreover, recurrence-free survival and overall survival were comparable between LLR and OLR. Although there is a need for careful LLR candidate selection according to tumor size and location, LLR can be regarded as a preferred treatment for NAFLD-HCC over OLR.

Influence of Child-Pugh B7 and B8/9 cirrhosis on laparoscopic liver resection for hepatocellular carcinoma: a retrospective cohort study.

BACKGROUND: Laparoscopic liver resection for hepatocellular carcinoma (HCC) in patients with Child-Pugh A cirrhosis has been shown to be beneficial. However, less is known regarding the outcomes of such treatment in patients with Child-Pugh B cirrhosis. We conducted a retrospective study to evaluate the outcomes of laparoscopic liver resection for HCC in patients with Child-Pugh B cirrhosis, focusing on surgical risks, recurrence, and survival. METHODS: 357 patients with HCC who underwent laparoscopic liver resection from 2007 to 2021 were identified from our single-institute database. The patients were divided into three groups by their Child-Pugh score: the Child-Pugh A (n = 280), Child-Pugh B7 (n = 42), and Child-Pugh B8/9 groups (n = 35). Multivariable Cox regression models for recurrence-free survival (RFS) and overall survival (OS) were constructed with adjustment for preoperative and postoperative clinicopathological factors. RESULTS: The Child-Pugh B8/9 group had a significantly higher complication rate, but the complication rates were comparable between the Child-Pugh B7 and Child-Pugh A groups (Child-Pugh A vs. B7 vs. B8/9: 8.2% vs. 9.6% vs. 26%, respectively; P = 0.010). Compared with the Child-Pugh A group, the risk-adjusted hazard ratios (95% confidence intervals) in the Child-Pugh B7 and B8/9 groups for RFS were 1.39 (0.77-2.50) and 3.15 (1.87-5.31), respectively, and those for OS were 0.60 (0.21-1.73) and 1.80 (0.86-3.74), respectively. There were no significant differences in major morbidities (Clavien-Dindo grade > II) (P = 0.117) or the proportion of retreatment after HCC recurrence (P = 0.367) among the three groups. CONCLUSION: Among patients with HCC, those with Child-Pugh A and B7 cirrhosis can be good candidates for laparoscopic liver resection in terms of complications and recurrence. Despite poor postoperative outcomes in patients with Child-Pugh B8/9 cirrhosis, laparoscopic liver resection is less likely to interfere with retreatment and can be performed as part of multidisciplinary treatment.

Short- and long-term outcomes of laparoscopic liver resection for non-alcoholic fatty liver disease-associated hepatocellular carcinoma: a retrospective cohort study.

BACKGROUND: We compared the recurrence-free survival (RFS), overall survival (OS), and safety of laparoscopic liver resection (LLR) between non-alcoholic fatty liver disease (NAFLD) and non-NAFLD hepatocellular carcinoma (HCC) patients. METHODS: Patients with HCC (n = 349) were divided into four groups based on the HCC etiology (NAFLD [n = 71], hepatitis B [n = 27], hepatitis C [n = 187], alcohol/autoimmune hepatitis [AIH] [n = 64]). RFS and OS were assessed by multivariate analysis after adjustment for clinicopathological variables. A subgroup analysis was performed based on the presence (n = 248) or absence (n = 101) of cirrhosis. RESULTS: Compared with the NAFLD group, the hazard ratios (95% confidence intervals) for RFS in the hepatitis B, hepatitis C, and alcohol/AIH groups were 0.49 (0.22-1.09), 0.90 (0.54-1.48), and 1.08 (0.60-1.94), respectively. For OS, the values were 0.28 (0.09-0.84), 0.52 (0.28-0.95), and 0.59 (0.27-1.30), respectively. With cirrhosis, NAFLD was associated with worse OS than hepatitis C (P = 0.010). Without cirrhosis, NAFLD had significantly more complications (P = 0.034), but comparable survival than others. DISCUSSION: Patients with NAFLD-HCC have some disadvantages after LLR. In patients with cirrhosis, LLR is safe, but survival is poor. In patients without cirrhosis, the complication risk is high.

Impact of the coronavirus disease 2019 pandemic on first-visit patients with oesophageal cancer in the first infection wave in Saitama prefecture near Tokyo: a single-centre retrospective study.

BACKGROUND: Although the novel coronavirus disease 2019 did not lead to a serious medical collapse in Japan, its impact on treatment of oesophageal cancer has rarely been investigated. This study aimed to investigate the influence of the pandemic on consultation status and initial treatment in patients with primary oesophageal cancer. METHODS: A retrospective study was conducted among 546 patients with oesophageal cancer who visited our hospital from April 2018 to March 2021. Pre-pandemic and pandemic data were compared with the clinical features, oncological factors and initial treatment as outcome measures. RESULTS: Diagnoses of oesophageal cancer decreased during the early phase of the pandemic from April to June (P = 0.048); however, there was no significant difference between the pre-pandemic and pandemic periods throughout the year. The proportion of patients diagnosed with distant metastases significantly increased during the pandemic (P = 0.026), while the proportion of those who underwent initial radical treatment decreased (P = 0.044). The rate of definitive chemoradiotherapy decreased by 58.6% relative to pre-pandemic levels (P = 0.001). CONCLUSIONS: Patients may have refrained from consultation during the early phase of the coronavirus disease 2019 pandemic. The resultant delay in diagnosis may have led to an increase in the number of patients who were not indicated for radical treatment, as well as a decrease in the number of those who underwent definitive chemoradiotherapy. Our findings highlight the need to maintain the health care system and raise awareness on the importance of consultation.

Linear stapler anastomosis for esophagogastrostomy in laparoscopic proximal gastrectomy reduce reflux esophagitis.

PURPOSE: There are various reconstruction methods for Laparoscopic proximal gastrectomy (LPG), such as esophagogastrostomy (EG), double-tract reconstruction, and jejunal interposition. We have performed EG using a circular stapler (OrVil) from 2013 and using a linear stapler from 2017. The aim of this retrospective study was to clarify which stapler is better for EG for LPG. METHODS: The data of 84 patients who underwent EG for LPG between January 2013 and September 2019 were analyzed. EG with fundoplication was done using a circular stapler (OrVil) in 45 patients (CS group) and a linear stapler in 39 patients (LS group). The patients' medical records were reviewed. Clinical symptoms were obtained by interview at each outpatient consultation. All patients underwent postoperative 1-year follow-up endoscopy. To minimize bias between the two groups, propensity scores were calculated using a logistic regression model. After propensity-score matching, 60 patients (30 in the CS group and 30 in the LS group) were studied. RESULTS: Patient characteristics, operative outcomes were similar in two groups. Anastomotic leakage occurred in one patient (3.3%) in both groups. Anastomotic stenosis occurred in five patients (16.7%) in the CS group and two patients (6.7%) in the LS group. The rate of patients with severe reflux esophagitis (grade C or D) was significantly lower in the LS group (3.4%) than in the CS group (26.7%) (p = 0.026). CONCLUSIONS: EG with a linear stapler could reduce the risk of severe reflux esophagitis, and it could be a safe and feasible anastomosis for patients after LPG.

Is prophylactic lateral lymph node dissection needed for lower rectal cancer? A single-center retrospective study.

BACKGROUND: The effectiveness of prophylactic lateral lymph node dissection (LLND) in treating patients with lower rectal cancer remains controversial and has not been clearly established. Therefore, we aimed to retrospectively analyze the survival impact of prophylactic LLND in patients with lower rectal cancer. METHODS: Data of 301 patients with lower rectal cancer (tumor's lower edge on the anal side of the peritoneal reflexion) with clinical T3 disease and negative preoperative lateral lymph node metastasis, who underwent radical resection (R0) at our hospital between April 2007 and March 2017, were included in this study. Patients who received preoperative chemotherapy or radiotherapy were excluded. The relapse-free survival (RFS) and overall survival (OS) rates were compared between the dissection (prophylactic LLND, n = 37) and non-dissection (no prophylactic LLND, n = 264) groups. RESULTS: Significantly fewer men and younger patients were noted in the dissection group than in the non-dissection group. Post-surgery 3- and 5-year RFS rates were 69.6% and 66.8% in the dissection group and 75.1% and 72.5% in the non-dissection group, respectively (5-year post-surgery RFS, p = 0.58). In the dissection and non-dissection groups, the 5-year OS rates were 86.5% and 79.7%, respectively (p = 0.29), and the 5-year cancer-specific survival rates were 88.9% and 86.0%, respectively (p = 0.29), with no significant differences. Lateral lymph node recurrence was observed in one (2.7%) and 10 patients (3.8%) in the dissection and non-dissection groups, respectively, and there was no significant difference between the groups. CONCLUSIONS: In this study, the effectiveness of prophylactic LLND was limited in patients with > T3 lower rectal cancer with no evidence of preoperative lymph node metastasis. Prophylactic LLND may not be necessary if there is no preoperative lymph node metastasis, even if the invasion depth is T3 or higher.

Verification of oncological local control for hand-assisted laparoscopic abdominal lymph node dissection in esophageal cancer surgery: a propensity score-matched analysis.

BACKGROUND: In esophageal cancer, long-term outcomes of minimally invasive surgery using endoscopic surgery are currently being verified. However, most trials have compared thoracic procedures; few studies have focused on the abdominal procedures, which are important for lymph node dissection in radical esophageal cancer surgery. Hand-assisted laparoscopic surgery (HALS) is a simple and minimally invasive procedure. Although HALS superiority in short-term outcomes has been reported, its oncological safety in esophageal cancer remains unclear. Therefore, we retrospectively evaluated oncological safety of HALS compared with that of conventional open laparotomy (OL) in radical surgery for thoracic and abdominal esophageal cancer. METHODS: We retrospectively analyzed the postoperative survival in 142 patients who underwent radical esophageal cancer surgery at our hospital between May 2012 and May 2017, with and without propensity score matching (PSM) between groups. RESULTS: Before PSM, OL (n = 65) and HALS (n = 77) groups differed significantly in overall survival (OS) (3-year OS rate: 74.2% and 87.3%, respectively; log-rank p = 0.040). Additionally, clinical abdominal lymph node metastasis (cALNM) independently predicted OS (p = 0.031). After PSM, the OL and HALS groups did not differ significantly in OS (3-year OS rate: 80.5% and 89.8%, respectively; log-rank p = 0.716). There was no statistically significant difference in abdominal-specific recurrence-free survival between the OL and HALS group before and after PSM. CONCLUSION: HALS may be a well-accepted procedure for radical esophagectomy in esophageal cancer, with oncological safety, including local control specific to the abdomen, comparable to that of the conventional OL.

Evaluation of the Associations between Gastric Tube Preparation Methods and the Incidence of Cervical Anastomotic Leakage after Esophagectomy for Thoracic Esophageal Cancer.

BACKGROUND: A gastric tube (GT) is most often selected as a reconstruction conduit in esophageal reconstruction. Although some leakage from esophagogastric anastomoses is induced by blood flow failure in reconstruction conduits, the association between the GT and the anastomotic leakage (AL) is unclear. OBJECTIVES: We retrospectively evaluated the incidence of AL according to the GT shape. METHODS: Between February 2013 and September 2017, 188 consecutive patients who underwent esophagectomy with GT reconstruction were enrolled in this cohort study. We performed GT reconstruction using a narrow GT (Gr.N) until May 2016. Subsequently, we began preparing and using a stretched GT (Gr.S). RESULTS: AL occurred in 29 of 188 (15.4%) patients. The frequency of AL was lower with Gr.S than with Gr.N (p = 0.034). Sex, body mass index, Brinkman index, hypertension, and anemia were significantly associated with AL (p = 0.033, 0.041, 0.003, 0.030, and 0.042, respectively). In a multivariate logistic regression analysis, the GT shape and the Brinkman index were shown to be independent risk factors for AL (p = 0.016 and 0.020, respectively). CONCLUSIONS: The GT preparation method is an independent risk factor for AL after cervical esophagogastrostomy. Thus, improved GT preparation methods could contribute to the reduction of AL after esophagectomy.

Association of the primary tumor's SUVmax with survival after surgery for clinical stage IA esophageal cancer: a single-center retrospective study.

BACKGROUND: Compared to other esophageal cancers, clinical stage IA esophageal cancer generally has a good prognosis, although a subgroup of patients has a poor prognosis. Unfortunately, clinical diagnoses of invasion depth or lymph node metastasis are not always accurate, which make it difficult to identify patients with a high risk of postoperative recurrence using the tumor-node-metastasis staging system. Fluorodeoxyglucose-positron emission tomography may help guide the identification of malignant tumors and the evaluation of their malignant grade based on glucose metabolism. We aimed to evaluate the association between pre-operative fluorodeoxyglucose-positron emission tomography findings and the postoperative prognosis of patients with clinical stage IA esophageal cancer. METHODS: This single-center retrospective study evaluated pre-esophagectomy fluorodeoxyglucose-positron emission tomography findings from 38 patients with clinical stage IA esophageal cancer. Receiver operating characteristic curve analysis was performed to evaluate the prognostic significance of the primary tumor having low and high SUVmax values (cut-off: 3.56). RESULTS: Overall survival (log-rank p = 0.034) and progression-free survival (log-rank p = 0.008) were significantly different between the groups with low SUVmax values (n = 18) and high SUVmax values (n = 20). Furthermore, the primary tumor's SUVmax value was related to pathological vascular invasion (p = 0.045) and distant metastasis (p = 0.042). CONCLUSION: The SUVmax of the primary tumor is a predictor of postoperative survival for clinical stage IA esophageal cancer. Thus, using fluorodeoxyglucose-positron emission tomography to evaluate the primary tumor's glucose metabolism may reflect the tumor's grade and potentially compensate for inaccuracies in tumor-node-metastasis staging.

[A Case of Esophagogastric Junction(EGJ)Cancer for Which Pathological Complete Response(pCR)Was Obtained by Multidisciplinary Treatment].

We report the case of a 68-year-old male with EGJ cancer, who was treated with palliative radiotherapy for persistent bleeding, and for whom, pCR was ultimately obtained by chemotherapy. Chemotherapy was planned to treat the EGJ cancer with intramural metastasis of the esophagus, but anemia due to persistent bleeding from the tumor was noted. Even with frequent blood transfusions, the anemia was difficult to control. Palliative radiotherapy was performed at 30 Gy/10 Fr for hemostasis, followed by chemotherapy. After approximately 9 months of chemotherapy, reduction of the primary tumor, a metastatic lymph node, and disappearance of the intramural metastasis of the esophagus were noted, and conversion surgery was performed. In the final histopathological examination, pCR was obtained. Radiotherapy for persistent bleeding from advanced gastric cancer is a minimally invasive treatment, and therefore could be an effective treatment to enable chemother- apy without any loss of compliance.

Laparoscopic liver resection using a monopolar soft-coagulation device to provide maximum intraoperative bleeding control for the treatment of hepatocellular carcinoma.

BACKGROUND: The popularity of laparoscopic liver resection (LLR) is spreading, worldwide, because the intraoperative blood loss is less than for open hepatectomy and it is associated with a shorter hospitalization period [1-6]. During LLR, intraoperative hemostasis is difficult to achieve, unlike during laparotomy where bleeding can be stopped instantly [7-10]. Our LLR method for the treatment of hepatocellular carcinoma (HCC) includes maximal control of intraoperative bleeding using a monopolar soft-coagulation device. Although we use a monopolar soft-coagulation device to control bleeding during LLR, while coagulating the thin blood vessels, we also developed a maneuver (the hepatocyte crush method: HeCM) to allow liver transection to progress while liver parenchymal cells are being crushed. METHOD: Between January 2008 and March 2016, we performed total LLR on 150 hepatocellular carcinoma patients (144 partial liver resections and six left lateral sectionectomies) using the maneuver shown in the video. RESULTS: The patients had Child-Pugh Scores of grade A (n = 100), B (42), or C (n = 8) and the localizations of tumor were segment (S) 1(n = 7), S2 (19), S3 (23), S4 (28), S5 (17), S6 (26), S8 (17), and S8 (29). The median blood loss was 30 (range 0-490) g during a median surgical time of 207 (range 127-468) min. One patient required conversion to a laparotomy due to the presence of severe adhesions; none of the patients required conversion due to intraoperative hemorrhage. The peak aspartate aminotransferase (AST) level was 320 (range 57-1964) IU/L. Although some patients showed high AST levels, none showed signs of hepatic failure. The median postoperative hospital stay duration was 6 (range 3-21) days. Postoperative complications occurred in seven cases (4.7%), including intraabdominal abscesses (n = 2), wound infections (2), intraabdominal hemorrhage (1), bile duct stricture (1), and umbilical hernia (1). The mortality was zero. CONCLUSION: HeCM, combined with the use of a monopolar soft-coagulation device, is a good technique for reducing bleeding during liver resection in patients with HCC.

[The Efficacy of Definitive Chemoradiotherapy for Thoracic Esophageal Cancer on the Point of View Salvage Surgery].

INTRODUCTION: Salvage surgery(S-surgery)was performed for residual or relapse tumor after definitive chemoradiotherapy (dCRT)for resectable esophageal cancer. When it becomes possible to perform surgery after dCRT for unresectable cases is called conversion surgery(C-surgery). OBJECTIVE: To examine the outcomes of S-surgery and C-surgery after dCRT for thoracic esophageal cancer and clarify the significance as a multidisciplinary treatment. MATERIAL AND METHODS: We reviewed 27 patients who underwent S-surgery for thoracic esophageal cancer in our hospital. 23 cases were residual tumor, 4 were relapse after complete response. Sixteen cases(59%)were C-surgery. RESULTS: Five cases(19%)had non-radical resection. Two cases were postoperative hospital death(7%). Postoperative complications(Clavien-Dindo classification Grade II and more) 11 cases(41%). Four cases were anastomotic leakage, 4 cases vocal cord paralysis, etc. Pathological complete response cases 6 cases(22%). The recurrence cases were 7 except for 5 cases of non-radical resection. Three-year overall survival rate was 47%. Twelve cases(75%)in C-surgery could perform radical resection by down stage. CONCLUSIONS: The postoperative hospital mortality and complications can be considered as acceptable. dCRT is a powerful pre-operative treatment for such cases, and S-surgery plays an important role.

A case of aggressive solid pseudopapillary neoplasm: Comparison of clinical and pathologic features with non-aggressive cases.

Solid pseudopapillary neoplasms (SPNs) may have an aggressive clinical course, but clinical predictors of this condition have not been thoroughly evaluated. We performed a retrospective study of 11 cases of SPN managed in our hospital between January 2007 and April 2015. Of these 11 cases, we encountered a single case with an aggressive clinical course. Histological, immunohistochemical, and clinical features were compared to identify predictors of poor prognosis. The 11 patients comprised four women and seven men with a median age of 41 years (range, 26-58 years). Clinical symptoms were nonspecific and the median tumor size was 4.6 cm (range, 1.4-18 cm). The patient with an aggressive clinical course developed multiple liver metastases within three months and died seven months after surgery. Pathological features of the tumor in this case included lymph node metastases, a diffuse growth pattern, extensive tumor necrosis, high mitotic rate, and immunohistochemistry. These features were not observed in patients who survived without recurrence at a median follow-up of 25 months (range, 6-82 months). Characteristic pathological features and a high proliferative index, as assessed by Ki-67 staining, may predict poor outcome in cases of SPN.

[A Case Report of Laparoscopy Assisted Distal Gastrectomy for Gastric Cancer with an Adachi Type VI Anomaly (Group 27)Institution].

We report the case of a 79-year-old man, with gastric cancer detected on upper gastrointestinal endoscopic examination performed by a nearby medical clinic, and referred to our hospital, in April 201X. He was diagnosed with gastric cancer(ML, less, 0- II a+ II c, tub 1-2, cT1bN0M0, cStage I A). We performed laparoscopy assisted distal gastrectomy, D1+lymph node dissection, and Billroth I (B- I )reconstruction. Abdominal CT scan before surgery confirmed vascular anomaly of the celiac artery. We diagnosed Adachi type VI, preserved hepato-gastric artery trunk, and performed D1 plus dissection plus B- I reconstruction with small incision in the epigastrium. The operation time was 244 minutes and the blood loss was 5 mL. There were no postoperative complications, and the patient was discharged from hospital 7 days after the surgery. Pathological findings revealed pT4aN0M0, pStage II B, and the patient has been treated with TS-1®postoperative adjuvant chemotherapy. At present, there is no recurrence. As vascular anomalies of the celiac artery branch exhibit various forms, occasional blood vessel preventing surgery is required. Examining blood vessels through CT scan before the surgery made it possible to perform Laparoscopic gastrectomy safely.

Fibrin glue closure for intractable pancreatic fistulae after pancreaticoduodenectomy.

CONTEXT: Treatment of pancreatic fistulae after pancreaticoduodenectomy is extremely important because it determines the patient's postoperative course. In particular, treatment of grade B cases should be conducted in a timely manner to avoid deterioration to grade C. OBJECTIVE: We report the successful treatment of six cases of postoperative intractable, grade B pancreatic fistulae, in which fistula closure was achieved through the use of tissue adhesive. METHODS: Six subjects presented at our hospital with grade B pancreatic fistulae after pancreaticoduodenectomy. In all cases, the drain amylase values were high immediately after the operation, and the replacement of the drain was enforced. Closure of the fistula was performed by pouring tissue adhesive into the fistula from the drain, after the fistula had been straightened. RESULTS: Closure of the fistula was achieved in all six cases at the first attempt. The average fistula length was 13.2 cm, the average volume of pancreatic fluid discharge just before treatment was 63.3 mL, the average amylase value in the drainage was 40,338.5 IU/L, and the subjects were discharged from hospital an average of 8.8 days after treatment. There were no recurrences after treatment. CONCLUSION: Intractable pancreatic fistulae can be effectively treated using the tissue adhesive method.

Thoracoscopic hepatectomy for malignant liver tumor.

BACKGROUND: Anatomical position of the liver poses a difficulty in approaching the lesions using a laparoscopic approach. METHODS: The patient was a 79-year-old man with a surgical history of laparoscopic sigmoidectomy for colon cancer and posterior segmentectomy of the liver for metastatic liver tumor. On admission, he presented with another liver tumor (diameter, 1.5 cm) in the dome of segment VIII. Because of the high possibility of severe adhesion around the liver and difficulty of approaching the lesion from the abdomen, we selected the transthoracic approach rather than the abdominal approach; the patient consented to this procedure. The patient was placed in the left-lateral position under general anesthesia with single-lung ventilation. We placed three trocars into the right thoracic space. The intrathoracic space was observed using a flexible-tip rigid scope (Olympus, Tokyo, Japan). The tumor was detected by inserting a flexible laparoscopic ultrasound probe (Hitachi Aloka, Ltd., Tokyo, Japan) through the diaphragm; the diaphragm was dissected immediately above the tumor using a harmonic scalpel (Ethicon Endo-Surgery, Inc., Cornelia, GA). The liver surface was precoagulated using a low-voltage monopolar coagulator with a ball-shaped tip (Amco Inc., Tokyo, Japan) with the electrosurgical unit VIO300D (Erbe Elektromedizin, Tuebingen, Germany). The parenchyma was first sealed using BiClamp LAP forceps (Erbe Elektromedizin) and divided using the harmonic scalpel. The specimen was extracted using a retrieval bag. After complete hemostasis was achieved, the diaphragm was closed by continuous suturing. RESULTS: The operation lasted for 310 min and estimated blood loss was 10 mL. The patient was discharged on postoperative day 4. CONCLUSIONS: Although the duration of TH was long because of the narrow thoracic cavity space, TH was performed without any problems. As a rule, we should select TH for lesions located in the dorsal segment VII/VIII, with severe adhesion around the liver.

Long-term outcomes and risk factors of pancreatic insufficiency after a pancreatoduodenectomy: A retrospective study.

BACKGROUND: An increasing number of patients are achieving long-term survival after pancreatoduodenectomy, meaning that risk assessments of endocrine and exocrine pancreatic insufficiency are needed. Herein, we investigated the risk factors for pancreatic insufficiency after pancreatoduodenectomy by incorporating pancreatic morphologic changes and perioperative factors. METHODS: Patients who underwent pancreatoduodenectomy between January 2015 and December 2020 were enrolled in this single-center retrospective study. Clinicopathologic, surgical, and pancreatic morphologic factors were collected, and risk factors for exocrine pancreatic insufficiency and endocrine pancreatic insufficiency were analyzed. Exocrine pancreatic insufficiency was defined as steatorrhea requiring pancreatic enzymes and new onset steatosis, and endocrine pancreatic insufficiency was defined as postoperative new-onset diabetes mellitus. Multivariate analysis was performed. RESULTS: Among the 206 patients enrolled, 14% and 24% developed endocrine pancreatic insufficiency and exocrine pancreatic insufficiency, respectively. Multivariate analysis revealed residual pancreatic stent 1 year postoperatively, lymph node metastasis, and postoperative pancreatic atrophy (P-atrophy) as independent risk factors for exocrine pancreatic insufficiency, whereas preoperative glycated hemoglobin levels, residual pancreatic stent, and postoperative main pancreatic duct dilatation were risk factors for endocrine pancreatic insufficiency. Subgroup analysis of pancreatic ductal adenocarcinoma revealed that exocrine pancreatic insufficiency in patients with pancreatic ductal adenocarcinoma was caused by preoperative decreased pancreatic function (high glycated hemoglobin and a low postoperative pancreatic fistula rate), whereas the high incidence of POPF influenced the development of exocrine pancreatic insufficiency in patients without pancreatic ductal adenocarcinoma. CONCLUSION: Postoperative pancreatic atrophy and main pancreatic duct dilatation are risk factors for exocrine pancreatic insufficiency I and endocrine pancreatic insufficiency, respectively, and residual pancreatic stent affects both types of pancreatic dysfunction. Improving the surgical approach and stent management may help prevent these late complications.

Novel pancreatoenteric reconstruction using a bioabsorbable polymer sheet and biocompatible bond.

BACKGROUND: Pancreatoenteric reconstruction often induces severe complications. Although many techniques have been developed to prevent these complications, no standard technique has yet emerged. We developed a novel technique, sutureless pancreatoenteric anastomosis, that uses a bioabsorbable polymer sheet (BAPS) and biocompatible bond (BCB) to prevent the complications associated with pancreatoenteric anastomosis. We used large animals to investigate whether this technique is suitable for clinical use. MATERIALS AND METHODS: Six pigs were laparotomized under general anesthesia. The body of the pancreas was divided, and the proximal stump was closed by suture. A BAPS coated with BCB was rolled and fixed around the distal pancreatic stump to form a cylinder that was anastomosed to the duodenum without suturing the pancreas. Twenty weeks after the initial operation the operated sites were extirpated and evaluated grossly and histologically. RESULTS: All operated pigs survived without pancreatic juice leakage until they were killed. At 20 wk, the BAPS could not be identified. The pancreatic stump was tightly affixed to the duodenum. Histologic study revealed that the pancreatic stump and duodenal wall were continuous and the main pancreatic duct opened into the lumen of the duodenum. CONCLUSIONS: Sutureless pancreatoenterostomy with BAPS and BCB may be clinically feasible.

Newly designed bioabsorbable substitute for the treatment of diaphragmatic defects.

PURPOSE: Earlier studies have investigated the suitability of various materials and autologous grafts for the repair of diaphragmatic defects. Our group investigated the feasibility of using an artificial diaphragm (AD) to repair wide diaphragmatic defects. METHODS: Twelve pigs were laparotomized and, in each pig, a defect was fashioned by resecting a round 8-cm diameter hole in the left diaphragm. Next, the defect was repaired by implanting an AD. The animals were relaparotomized 8 or 24 weeks after implantation for gross, histological and radiological observation of the implanted sites. RESULTS: All recipient animals survived until killing for evaluation. Chest X-ray examinations showed no differences between the preoperative diaphragms and the grafted diaphragms at 8 and 24 weeks after implantation. At 8 weeks after implantation, the implanted sites exhibited fibrous adhesions to the liver and lungs without deformities or penetrations. Parts of the surface tissue at the graft sites had a varnished appearance similar to those of the native diaphragm. Histology performed at 8 weeks detected no trace of the ADs in the graft sites; however, numerous inflammatory cells and profuse fibrous connective tissue were observed. At 24 weeks after implantation, no differences were found in the thorax between the areas with the grafts and the unaffected areas. Histology of the graft sites in the thorax confirmed growth of mesothelial cells similar to that observed in the native diaphragm. CONCLUSIONS: Artificial diaphragms can be a novel substitute for diaphragmatic repair.

Feasibility of Surveillance for Mucinous Cystic Neoplasm of the Pancreas: A Multi-Institutional Retrospective Study of 328 Patients by the Japanese Pancreatic Society.

OBJECTIVE: We aimed to elucidate the feasibility of surveillance of patients with mucinous cystic neoplasm (MCN). METHODS: We performed a retrospective, multi-institutional study of 328 patients who underwent surgery for MCN at 18 Japanese institutions. Patients with MCN were divided into an immediate surgery group and a surveillance group, which underwent surgery after surveillance. RESULTS: The median surveillance period until surgery in the surveillance group was 27 months (range, 7-165 months). Compared with the immediate surgery group, the surveillance group showed smaller tumor diameter (46 vs 50 mm, P = 0.01), more frequent laparoscopic approach (58% vs 37%, P < 0.01), and less frequent malignancy (7% vs 15%, P = 0.03). The new appearance of mural nodules and elevation of serum tumor markers were associated with malignancy in the surveillance group. Two patients in the surveillance group experienced postoperative recurrence, although there was no significant difference in recurrence or disease-free survival between the two groups. In the surveillance group, the 1-, 5-, and 10-year cumulative incidence rates of malignant MCN were 0.8%, 5.6%, and 36.5%, respectively. CONCLUSION: As the risk of progression to malignant MCNs increases over the long term, MCNs should be resected rather than subjected to unnecessary surveillance.