Prognostic impact of osteosarcopenia in patients undergoing pancreatic resection for pancreatic ductal adenocarcinoma.

BACKGROUND: We investigated the prognostic impact of osteosarcopenia, defined as the combination of osteopenia and sarcopenia, in patients undergoing pancreatic resection for pancreatic ductal adenocarcinoma (PDAC). METHODS: The relationship of osteosarcopenia with disease-free survival and overall survival was analyzed in 183 patients who underwent elective pancreatic resection for PDAC. Computed tomography was used to measure the pixel density in the midvertebral core of the 11th thoracic vertebra for evaluation of osteopenia and in the psoas muscle area of the 3rd lumbar vertebra for evaluation of sarcopenia. Osteosarcopenia was defined as the simultaneous presence of both osteopenia and sarcopenia. The study employed a retrospective design to examine the relationship between osteosarcopenia and survival outcomes. RESULTS: Osteosarcopenia was identified in 61 (33%) patients. In the univariate analysis, disease-free survival was significantly worse in patients with male sex (p = 0.031), pathological stage ≥ III PDAC (p = 0.001), NLR, ≥ 2.71 (p = 0.041), sarcopenia (p = 0.027), osteopenia (p = 0.001), and osteosarcopenia (p < 0.001), and overall survival was significantly worse in patients with male sex (p = 0.001), pathological stage ≥ III PDAC (p = 0.001), distal pancreatectomy (p = 0.025), sarcopenia (p = 0.003), osteopenia (p < 0.001), and osteosarcopenia (p < 0.001). In the multivariate analysis, the independent predictors of disease-free survival were osteosarcopenia (p < 0.001) and pathological stage ≥ III PDAC (p = 0.002), and the independent predictors of overall survival were osteosarcopenia (p < 0.001), male sex (p = 0.006) and pathological stage ≥ III PDAC (p = 0.001). CONCLUSION: Osteosarcopenia has an adverse prognostic impact on long-term outcomes in patients undergoing pancreatic resection for PDAC.

Osteosarcopenia is a significant predictor of recurrence and the prognosis after resection for extrahepatic bile duct cancer.

PURPOSE: This study examined the impact of osteosarcopenia on recurrence and the prognosis after resection for extrahepatic biliary tract cancer (EBTC). METHODS: We retrospectively analyzed 138 patients after resection for perihilar cholangiocarcinoma (11), distal cholangiocarcinoma (54), gallbladder carcinoma (30), or ampullary carcinoma (43). Osteosarcopenia is defined as the concomitant occurrence of osteopenia and sarcopenia. We investigated the relationship between osteosarcopenia and the overall survival (OS) and disease-free survival (DFS) in univariate and multivariate analyses. RESULTS: Osteosarcopenia was identified in 38 patients (27.5%) before propensity score (PS) matching. In the multivariate analysis, the independent recurrence factors were the prognostic nutrition index (p = 0.015), osteosarcopenia (p < 0.001), poorly differentiated adenocarcinoma (p = 0.004), perineural invasion (p = 0.002), and non-curability (p = 0.008), whereas the independent prognostic factors were prognostic nutrition index (p = 0.030), osteosarcopenia (p < 0.001), poorly differentiated adenocarcinoma (p = 0.007), lymphatic invasion (p = 0.018), and non-curability (p = 0.004). After PS matching, there was no significant difference in the variables between the patients with and without osteosarcopenia (n = 34 each). The 5-year DFS and OS after PS matching in patients with osteosarcopenia were significantly worse than in patients without osteosarcopenia (17.6% vs. 38.8%, p = 0.013 and 20.6% vs. 57.4%, p = 0.0005, respectively). CONCLUSIONS: Preoperative osteosarcopenia could predict the DFS and OS of patients after resection for EBTC.

The postoperative platelet-to-lymphocyte ratio predicts the outcome of patients undergoing pancreaticoduodenectomy for pancreatic head cancer.

PURPOSE: The preoperative platelet-to-lymphocyte ratio (PLR) has been reported as an important prognostic index for pancreatic ductal adenocarcinoma (PDAC); however, the significance of the postoperative (post-op) PLR for this disease has not been elucidated. METHODS: We analyzed data on 118 patients who underwent pancreaticoduodenectomy for pancreatic head PDAC, collected from a prospectively maintained database. The post-op PLR was obtained by dividing the platelet count after surgery by the lymphocyte count on post-op day (POD) 14. The patients were divided into two groups according to a post-op PLR of < 310 or ≥ 310. Survival data were analyzed. RESULTS: A high post-op PLR was identified as a significant prognostic index on univariate analysis for disease-free survival (DFS) and overall survival (OS). The post-op PLR remained significant, along with tumor differentiation and adjuvant chemotherapy, on multivariate analysis for OS (hazard ratio = 2.077, 95% confidence interval: 1.220-3.537; p = 0.007). The post-op PLR was a significant independent prognostic index for poor DFS, along with tumor differentiation and lymphatic invasion, on multivariate analysis (hazard ratio = 1.678, 95% confidence interval: 1.056-2.667; p = 0.028). CONCLUSIONS: The post-op PLR in patients with pancreatic head PDAC was an independent predictor of DFS and OS after elective resection.

Prognostic impact of abdominal aortic calcification in patients who underwent hepatectomy for intrahepatic cholangiocarcinoma.

PURPOSE: Abdominal aortic calcification (AAC), an indicator of systemic arteriosclerosis, is associated with short- and long-term outcomes in malignancies. We investigated the prognostic impact of AAC in patients who underwent hepatectomy for intrahepatic cholangiocarcinoma (IHCC). METHODS: The study cohort comprised 46 patients who underwent hepatectomy for IHCC between January 2008 and September 2020. The AAC volume measured by preoperative computed tomography was used to construct a model of the calcified segment from the renal artery to the common iliac artery bifurcation. We investigated the relationship between AAC and the long-term outcomes. The AAC volume cutoff value was calculated from a receiver-operating characteristic curve based on the three-year survival. RESULTS: According to our cutoff AAC volume of 3,700 mm3, 11 patients (24%) had high AAC volumes. The high-AAC group was significantly older than the low-AAC group (73 vs. 62 years old, p < 0.01). A multivariate analysis of the cancer-specific survival showed that a high serum carbohydrate antigen 19-9 concentration (hazard ratio [HR] 5.57, p = 0.01), high AAC volume (HR 3.03, p = 0.04), and [high?] T3 or T4 levels (HR 9.05, p < 0.01) were independently associated with a poor prognosis. CONCLUSION: AAC is a useful predictor of the oncological prognosis in patients undergoing hepatectomy for IHCC.

Increased incidence of positive peritoneal lavage cytology early after fine needle aspiration in patients with pancreatic ducal adenocarcinoma.

BACKGROUND: The influence of fine needle aspiration (FNA) on peritoneal lavage cytology (CY) in pancreatic ductal adenocarcinoma (PDAC) is unknown. METHODS: We retrospectively analyzed 29 patients with resectable left-sided PDAC undergoing FNA prior to CY examination. We assessed clinical factors related to CY+, scored the tumor diameter (<20 mm = 0, ≥20 mm = 1) and examination interval between FNA and CY (>18 days = 0, ≤18 days = 1), and investigated the probability of CY + by the sum of each score (0-2). RESULTS: The probability of CY+ was 31%. The CY + group had larger tumors and shorter examination intervals than the CY- group. The CY + probability was 75%, 15%, and 13% for a score of 2, 1, and 0, respectively (P = 0.011). CONCLUSION: A short interval between FNA and CY examination for a large tumor may be a risk factor for CY+ in patients with left-sided PDAC.

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 clinical management of peripancreatic fluid collection after distal pancreatectomy.

PURPOSE: Peripancreatic fluid collection (PFC) is a frequent radiological finding on postoperative computed tomography (CT) after distal pancreatectomy (DP). We evaluated the risk factors for drainage of PFC after DP to clarify the optimal management of PFC. METHODS: This study included 85 patients who underwent elective DP between January 2010 and December 2020. PFC was defined as an area of fluid located at the pancreatic resection margin on postoperative routine CT on approximately postoperative day 7 (first CT). We retrospectively investigated the relationship between clinical variables, including CT findings and PFC drainage. RESULTS: Drainage was performed in 19 patients (22.4%). Drainage for PFC was significantly associated with a longer postoperative hospital stay, higher PFC volume, presence of air bubbles, and higher white blood cell (WBC) count at the time of the first CT. According to the multivariate analyses, a PFC volume ≥ 60 mL and WBC count ≥ 12,400/µL on the day of the first CT were independent risk factors for PFC drainage after DP. The combination of these 2 factors showed 73.7% sensitivity and 90.9% specificity. CONCLUSION: The PFC volume and WBC count at the first CT were significantly associated with PFC drainage and may help determine the appropriate treatment.

The Significance of the Rapid Turnover Protein Score as a Predictor of the Long-Term Outcomes in Hepatocellular Carcinoma After Hepatic Resection.

BACKGROUND: Nutritional status assessment is essential in cancer patients because a poor nutritional status has been associated with poor outcomes; however, the impact of rapid turnover proteins (RTPs), such as prealbumin, transferrin, and retinol-binding protein, on the outcomes of hepatocellular carcinoma (HCC) has not been well-investigated. We therefore examined the prognostic significance of RTPs in patients with HCC after curative resection. METHODS: This study included 150 patients who underwent elective hepatic resection for HCC between January 2011 and December 2018. The prealbumin, transferrin, and retinol-binding protein levels were classified into two groups (high vs. low); the RTP score (0-3) was calculated as the sum of each RTP measurement (high = 0; low = 1). We retrospectively investigated the relationship between the RTP score and disease-free and overall survival. RESULTS: Multivariate analysis showed that a high RTP score (P = 0.022), presence of sarcopenia (P = 0.001), and stage III or higher (P = 0.005) were independent predictors of disease-free survival, while a high RTP score (P < 0.001), presence of sarcopenia (P = 0.017), and stage III or higher (P = 0.012) were independent predictors of overall survival. In patients with high RTP scores, positive hepatitis B and C viral infection, high indocyanine green (ICG) at 15 min (ICGR15), Child-Pugh grade B, poorly differentiated carcinoma, and postoperative ascites were more common than in patients with low RTP scores. CONCLUSION: The preoperative RTP score may be a prognostic factor in patients with hepatocellular carcinoma after hepatic resection, suggesting an important role of RTP in the assessment of nutritional status in cancer patients.

Intraoperative amylase level of pancreatic juice as a simple predictor of pancreatic fistula after pancreaticoduodenectomy.

INTRODUCTION: A soft remnant texture of the pancreas is commonly accepted as a risk factor for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). However, its assessment is subjective. The aim of this study was to evaluate the significance of intraoperative amylase level of the pancreatic juice as a risk factor of POPF after PD. METHOD: This study included 75 patients who underwent PD between November 2014 and April 2020 at Jikei University Hospital. We investigated the relationship between pancreatic texture, intraoperative amylase level of pancreatic juice, results of the pathological evaluations, and the incidence of POPF. RESULTS: Twenty-three patients (31%) developed POPF. The significant predictors of POPF were non-ductal adenocarcinoma (p < 0.01), soft pancreatic remnant (p < 0.01), high intraoperative blood loss (p < 0.01), high intraoperative amylase level of pancreatic juice (p < 0.01), and low pancreatic fibrosis (p < 0.01). Multivariate analysis revealed that the significant independent predictors of POPF were high intraoperative blood loss (p < 0.01) and high intraoperative amylase level of pancreatic juice (p = 0.02). Receiver operating characteristic (ROC) analysis showed that the cut-off value for the intraoperative amylase level of pancreatic juice was 2.17 × 105 IU/L (area under the curve = 0.726, sensitivity = 95.7%, and specificity = 50.0%) CONCLUSIONS: The intraoperative amylase level of pancreatic juice is a reliable objective predictor for POPF after PD.

The Prognostic Significance of C-reactive Protein-To-Lymphocyte Ratio in Colorectal Liver Metastases.

BACKGROUND: The preoperative systemic inflammation has been reported to predict tumor recurrence and survival in various cancers, including colorectal liver metastases (CRLM). However, more sensitive biomarker is required to improve perioperative management of CRLM. Therefore, we developed a novel indicator; C-reactive protein-to-lymphocyte ratio (CLR). The aim of this study is to evaluate the prognostic significance of CLR in patients with CRLM after hepatic resection. MATERIALS AND METHODS: The study comprised 197 patients who had undergone hepatic resection for CRLM between January 2000 and December 2018. We retrospectively investigated the relation between CLR and disease-free survival and overall survival after hepatic resection and compared their prognostic significance with that of the C-reactive protein-to-albumin ratio and neutrophil-to-lymphocyte ratio. RESULTS: Optimal cutoff level of the CLR by receiver operating characteristics analysis was 62.8 × 10-6. By multivariate analysis, CLR was an independent predictor of disease-free survival [hazard ratio (HR): 1.463, 95% confidence interval (CI): 1.003-2.135, P = 0.048), whereas lymph node metastases>4 (HR: 1.804, 95% CI: 1.100-2.958, P = 0.019) and CLR (HR: 1.656, 95% CI: 1.007-2.724, P = 0.047) were independent predictors of overall survival, while the C-reactive protein-to-albumin ratio and neutrophil-to-lymphocyte ratio were not. CONCLUSIONS: CLR may be an independent and significant indicator of poor long-term outcomes in patients with CRLM after hepatic resection.

Transferrin predicts outcome in patients who underwent liver resection for colorectal liver metastases.

INTRODUCTION: The aim of this study is to investigate the relationship between preoperative serum transferrin level and long-term outcomes in patients with colorectal liver metastases after hepatic resection. METHODS: We retrospectively investigated 72 patients who underwent hepatic resection for colorectal liver metastases and explored the relationship between serum transferrin level and long-term outcomes. RESULTS: In multivariate analysis, H3 (odds ratio 3.43, 95% confidence interval 1.11-10.89 and P = 0.03) was an independent and significant predictor of the disease-free survival, and a transferrin level ≥ 190 mg/dl (odds ratio 0.20, 95% confidence interval 0.05-0.79 and P = 0.02) and the time to recurrence after hepatectomy <1 year (odds ratio 11.30, 95% confidence interval 2.63-48.59 and P < 0.01) were independent and significant predictors of the overall survival. CONCLUSIONS: The serum transferrin level is a useful predictor of poor overall survival in patients with colorectal liver metastases after hepatic reaction.

Newly-revised Pringle maneuver using laparoscopic Satinsky vascular clamp for repeat laparoscopic hepatectomy.

It has been known that repeat laparoscopic hepatectomy (RLH) after open hepatectomy is technically challenging because of adhesions around the hilum. It is quite often that conventional tourniquet technique for the Pringle maneuver is difficult in RLH, and we introduced Laparoscopic Satinsky Vascular Clamp (LSVC) for inflow control in RLH. The Spiegel lobe is the anatomical landmark in LSVC technique. If a space behind the hepatoduodenal ligament and the Spiegel lobe was obtained, LSVC was applied laterally from the left side of the hepatoduodenal ligament, whereas LSVC was vertically applied for those with obstruction of a space behind the hepatoduodenal ligament. We performed 14 cases of RLH for those with histories of open hepatectomies by lateral (n = 6) and vertical (n = 8) LSVC technique with successful inflow control, confirmed by intraoperative Doppler ultrasound. Five patients underwent 2 or more previous histories of hepatectomies. The RLH included segmentectomy (n = 1), subsegmentectomy (n = 2) and partial hepatectomy (n = 11). The median time for the Pringle maneuver, operative time, and blood loss was 47 min, 237.5 min, and 160 mL. All the patients completed pure laparoscopic hepatectomy. In conclusion, LSVC technique is a safe and reliable technique for the Pringle maneuver in RLH.

Practical significance of pancreatectomy with lymphadenectomy around the superior mesenteric artery for pancreatic cancer: comparison of prognosis after adjusting for major prognostic factors.

INTRODUCTION: Although pancreatectomy with lymph node (LN) and nerve plexus dissection has usually been performed for pancreatic cancer, recent randomized controlled trials have questioned its survival benefits. However, superior mesenteric artery (SMA) LN dissection has still been included in standard treatment guidelines. METHODS: A total of 94 patients who underwent pancreaticoduodenectomy for resectable pancreatic cancer without LN enlargement around the SMA on imaging were identified between 2008 and 2017. Disease-free survival (DFS), overall survival (OS), and complications were compared between those with LN and hemicircumferential nerve plexus dissection around the SMA (SMA ly+) and those without thorough LN and nerve plexus dissection around the SMA (SMA ly-) after adjusting for major prognostic factors. RESULTS: A total of 78 and 16 patients with SMA ly+ and SMA ly- were identified, respectively. Our data demonstrated no difference in DFS and OS rates between both groups (P = 0.18 and 0.83, respectively). Patients with SMA ly+ had significantly more complications, particularly severe diarrhea, compared to those with SMA ly- (P = 0.001). CONCLUSION: LN and nerve plexus dissection around the SMA did not prolong survival and significantly increased the frequency of severe diarrhea, suggesting that performing in all cases carries less practical significance.

Proposal for a revised system for classifying difficulty of laparoscopic partial liver resection.

PURPOSE: The aim of this retrospective study was to evaluate a revised classification system for predicting the difficulty of laparoscopic partial liver resection. METHODS: Patients who had undergone initial laparoscopic partial liver resection for a solitary lesion from January 2012 to February 2021were classified into two groups according to the type of procedure performed, "scooping-out" versus "cutting." The participants were then further divided into "small" and "large" subgroups according to the tumor's depth and diameter. Finally, they were categorized into two groups, namely "standard" and "advanced." Operative outcomes were compared between the two groups and the proposed revised system for classifying difficulty of laparoscopic partial liver resection compared with the existing scoring system. RESULTS: Of the 65 procedures assessed, 40 were categorized as standard and 25 as advanced. Tumor size (P < 0.001), operation time (P < 0.001), volume of intraoperative blood loss (P = 0.001), rate of the Pringle maneuver (P = 0.044), and resected liver weight (P < 0.001) were significantly greater in the advanced than in the standard group. Differences in operation time and intraoperative blood loss were not identified by the existing difficulty scoring system. CONCLUSION: The proposed revised classification is useful for predicting the difficulty of laparoscopic partial liver resection.

Preoperative controlling nutritional status (CONUT) score predicts long-term outcomes in patients with non-B non-C hepatocellular carcinoma after curative hepatic resection.

PURPOSE: The controlling nutritional status (CONUT) score has been reported to predict outcomes in patients with hepatocellular carcinoma (HCC). However, the prognostic significance of the CONUT score in patients with non-B non-C (NBNC) HCC remains to be established. METHODS: The study comprised 246 patients who had undergone elective hepatic resection for HCC between April 2003 and October 2017. We retrospectively investigated the relation between preoperative CONUT score as well as clinicopathological characteristics and disease-free survival (DFS) as well as overall survival (OS). RESULTS: In univariate analyses, CONUT score was associated with DFS and OS in patients with NBNC-HCC (p ≤ 0.01), while there was no significant association of CONUT score with DFS and OS in patients with HBV- and HCV-related HCC (p ≥ 0.1). Of the 111 patients with NBNC-HCC, 97 (87.4%) had CONUT score ≤ 3 (low CONUT score) and the other 14 (12.6%) had CONUT score ≥ 4 (high CONUT score). In the patients with NBNC-HCC, multivariate analysis identified age ≥ 65 years (p = 0.03), multiple tumors (p < 0.01), and high CONUT score (p = 0.03) as the independent and significant predictors of DFS, while multiple tumors (p = 0.01), microvascular invasion (p < 0.01), and high CONUT score (p = 0.01) were the independent and significant predictors of OS. CONCLUSIONS: The CONUT score seems to be a reliable and independent predictor of both DFS and OS after hepatic resection for NBNC-HCC.

D-dimer-based screening for early diagnosis of venous thromboembolism after hepatectomy.

PURPOSE: The aim of this study was to evaluate the clinical utility of a novel diagnostic algorithm based on serum D-dimer levels for venous thromboembolism (VTE) after hepatectomy. METHODS: We retrospectively analyzed 742 consecutive patients who underwent hepatectomy in our hospital from 2009 to 2019. From 2015, we routinely measured serum D-dimer level postoperatively and computed tomography was performed when D-dimer level was ≥ 20 µg/mL. RESULTS: VTE was diagnosed in 26 patients and pulmonary embolism (PE) was diagnosed in 18 patients. Multivariate analysis revealed that resected liver weight ≥ 120 g is a significant predictor of VTE (P = 0.011). The incidence of VTE from 2015 to 2019 was greater than that from 2009 to 2014 (5.0% versus 2.1%, P = 0.044). The number of low-risk PE patients between 2015 and 2019 was significantly greater than that between 2009 and 2014 (P = 0.013). There was no in-hospital mortality of patients with PE from 2015 to 2019. CONCLUSION: Patients who undergo hepatectomy are at high risk for VTE, especially when the resected liver weight is high. The proposed diagnostic algorithm based on serum D-dimer levels for VTE after hepatectomy can be useful for early diagnosis.

The novel index using preoperative C-reactive protein and neutrophil-to-lymphocyte ratio predicts poor prognosis in patients with pancreatic cancer.

BACKGROUND: Several kinds of systemic inflammatory response, classified into two types: C-reactive protein (CRP)-based type and blood cell count-based type, were reported as a prognostic indicator in patients with pancreatic cancer (PC). However, there is no consensus which types is more sensitive predictor in patients with PC. Therefore, we here developed a novel biomarker, C-NLR, which consists of both CRP and neutrophil-to-lymphocyte ratio (NLR), and we evaluated the prognostic significance of C-NLR in patients with PC after pancreatic resection. METHODS: A total of 217 patients was comprised in this study. We retrospectively investigated the relation between C-NLR and disease-free survival (DFS) and overall survival (OS) after pancreatic resection. RESULTS: Optimal cutoff level of C-NLR was defined as 0.206 by a ROC analysis. By multivariate analysis, age (P = 0.024), TNM stage (P < 0.001), and C-NLR (HR: 1.373, 95% CI: 1.005-1.874, P = 0.046) were independent predictors of DFS, whereas TNM stage (P = 0.016) and C-NLR (HR: 1.468, 95% CI: 1.042-2.067, P = 0.028) were independent predictors of OS. CONCLUSION: Preoperative C-NLR can be a prognostic indicator in patients with PC after pancreatic resection, suggesting the importance of both CRP and blood cell count in predicting therapeutic outcomes.

Double cone-unit laparoscopic hepatic resection using indocyanine green negative counterstaining (with video).

A hepatic cone-unit represents an anatomical unit dominated by a smaller Glissonean pedicle. Anatomical resection of a tumor located in an intersegmental plane is challenging, but could be achieved effectively by performing multiple cone-unit resection. We performed double cone-unit laparoscopic resection of hepatocellular carcinoma located on the intersegmental plane between segments 6a, b. The liver parenchyma covering the posterior Glissonean pedicle was divided along Rouviere's sulcus, the Glissonean branches of segments 6a, b were isolated and ligated, and indocyanine green (ICG) negative counterstaining was performed. The hepatic parenchyma was dissected along the demarcation line to identify the right hepatic vein and the double cone-unit resection was then completed with a negative surgical margin. Thus, double cone-unit laparoscopic hepatectomy with ICG negative counterstaining may be a feasible option for tumors located in an intersegmental plane.

Endovascular micro-arterial stenting for arterial pseudoaneurysm after pancreatic surgery.

Although arterial pseudoaneurysm is one of the most serious complications after pancreatic surgery, the best practice with maximum efficacy and minimum adverse effects to overcome such a serious situation has not yet been elucidated. We performed endovascular micro-arterial stenting (EMAS) to manage this serious situation while preserving a sufficient hepatic arterial flow, and herein report the technical details and challenges of the procedure. Dilation of the stent using a balloon catheter to adhere to the parent artery, and embolization of the surrounding artery to prevent type I and type II endo-leaks are the most important points for ensuring a successful procedure. We applied this technique to 6 cases of hepatic arterial pseudoaneurysm, with a mean size of 6.5 ± 1.3 mm. The mean time of the procedure was 81 ± 22 min, without adverse events, including hepatic necrosis or arterial bleeding. EMAS may be the ideal procedure for treating pseudoaneurysm after pancreatic surgery while preserving the hepatic arterial inflow.

A Preoperative Scoring System to Predict Carcinoma in Patients with Gallbladder Polyps.

INTRODUCTION: A preoperative scoring system to predict carcinoma in patients with gallbladder polyps (GBPs). METHODS: Preoperative parameters of patients with GBPs who underwent cholecystectomies were used to construct a scoring system to ascertain the risk of malignancy (reference group). The scoring system developed from this approach was applied to the validation group. RESULTS: In the reference group, 11.5% of patients had carcinomas, in whom the median age was 68 years and the polyp size was 16.9 mm. According to the univariate analysis, the significant factors for carcinoma were age ≥65 years, the presence of gallstones, polyp size ≥13 mm, solitary polyp, and sessile polyp. Age ≥65 years and polyp size ≥13 mm were significant factors according to the multivariate analysis. From these results, we developed a preoperative scoring system to predict carcinoma. The patients were divided into 1 of 2 groups: low-risk and high-risk and their malignancy rates were 4.1 and 61.1% respectively (p < 0.001). In the validation group, the malignancy rate was higher for those in the high-risk group (p = 0.016). CONCLUSIONS: The proposed preoperative scoring system based on simple clinical variables appears to be useful for predicting malignancy in patients with GBPs.