Factors affecting nonfunctioning small pancreatic neuroendocrine neoplasms and proposed new treatment strategies

BACKGROUND & AIMS

Despite previously reported treatment strategies for nonfunctioning small (≤20 mm) pancreatic neuroendocrine neoplasms (pNENs), uncertainties persist. We aimed to evaluate the surgically resected cases nonfunctioning small pNENs (NF-spNENs) in a large Japanese cohort to elucidate an optimal treatment strategy for NF-spNENs.

METHODS

In this Japanese multicenter study, data were retrospectively collected from patients who underwent pancreatectomy between January 1996 and December 2019, were pathologically diagnosed with pNEN, and were treated according to the WHO 2019 classification. Overall, 1,490 patients met the eligibility criteria, and 1,014 were included in the analysis cohort.

RESULTS

In the analysis cohort, 606 patients (59.8%) had NF-spNENs, with 82% classified as grade 1 (NET-G1) and 18% as grade 2 (NET-G2) or higher. The incidence of lymph node metastasis (N1) by grade was significantly higher in NET-G2 (G1: 3.1% vs. G2: 15.0%). Independent factors contributing to N1 were NET-G2 or higher and tumor diameter ≥15 mm. The predictive ability of tumor size for N1 was high. Independent factors contributing to recurrence included multiple lesions, NET-G2 or higher, tumor diameter ≥15 mm, and N1. However, the independent factor contributing to survival was tumor grade (NET-G2 or higher). The appropriate timing for surgical resection of NET-G1 and NET-G2 or higher was when tumors were >20 and >10 mm, respectively. For neoplasms with unknown preoperative grades, tumor size >15 mm was considered appropriate.

CONCLUSIONS

NF-spNENs are heterogeneous with varying levels of malignancy. Therefore, treatment strategies based on tumor size alone can be unreliable; personalized treatment strategies that consider tumor grading are preferable.

A clinical assessment of three-dimensional-printed liver model navigation for thrice or more repeated hepatectomy based on a conversation analysis

PURPOSES

We performed a conversation analysis of the speech conducted among the surgical team during three-dimensional (3D)-printed liver model navigation for thrice or more repeated hepatectomy (TMRH).

METHODS

Seventeen patients underwent 3D-printed liver navigation surgery for TMRH. After transcription of the utterances recorded during surgery, the transcribed utterances were coded by the utterer, utterance object, utterance content, sensor, and surgical process during conversation. We then analyzed the utterances and clarified the association between the surgical process and conversation through the intraoperative reference of the 3D-printed liver.

RESULTS

In total, 130 conversations including 1648 segments were recorded. Utterance coding showed that the operator/assistant, 3D-printed liver/real liver, fact check (F)/plan check (Pc), visual check/tactile check, and confirmation of planned resection or preservation target (T)/confirmation of planned or ongoing resection line (L) accounted for 791/857, 885/763, 1148/500, 1208/440, and 1304/344 segments, respectively. The utterance's proportions of assistants, F, F of T on 3D-printed liver, F of T on real liver, and Pc of L on 3D-printed liver were significantly higher during non-expert surgeries than during expert surgeries. Confirming the surgical process with both 3D-printed liver and real liver and performing planning using a 3D-printed liver facilitates the safe implementation of TMRH, regardless of the surgeon's experience.

CONCLUSIONS

The present study, using a unique conversation analysis, provided the first evidence for the clinical value of 3D-printed liver for TMRH for anatomical guidance of non-expert surgeons.

Intraductal papillary neoplasms of the bile ducts: a comparative study of a rare disease in Europe and Nagoya, Japan

BACKGROUND

Intraductal papillary neoplasm of the bile ducts (IPNB) is a rare disease in Western countries. The aim of this study was to compare tumor characteristics, management strategies, and outcomes between Western and Eastern patients who underwent surgical resection for IPNB.

METHODS

A multi-institutional retrospective series of patients with IPNB undergoing surgery between January 2010 and December 2020 was gathered under the auspices of the European-African Hepato-Pancreato-Biliary Association (E-AHPBA), and at Nagoya University Hospital, Japan.

RESULTS

A total of 85 patients (51% male; median age 66 years) from 28 E-AHPBA centers were compared to 91 patients (64% male; median age 71 years) from Nagoya. Patients in Europe had more multiple lesions (23% vs 2%, P < .001), less invasive carcinoma (42% vs 85%, P < .001), and more intrahepatic tumors (52% vs 24%, P < .001) than in Nagoya. Patients in Europe experienced less 90-day grade >3 Clavien-Dindo complications (33% vs 68%, P < .001), but higher 90-day mortality rate (7.0% vs 0%, P = .03). R0 resections (81% vs 82%) were similar. Overall survival, excluding 90-day postoperative deaths, was similar in both regions.

DISCUSSION

Despite performing more extensive resections, the low perioperative mortality rate observed in Nagoya was probably influenced by a combination of patient-, tumor-, and surgery-related factors.

Utility of modified pancreaticoduodenectomy (Hi-cut PD) for middle-third cholangiocarcinoma: an alternative to hepatopancreaticoduodenectomy

BACKGROUND

The standard procedure for middle-third cholangiocarcinoma (MCC) is pancreaticoduodenectomy (PD); hepatopancreaticoduodenectomy (HPD) is often performed despite its high risk. There is no clear selection guidance for these procedures.

METHODS

Patients with MCC who underwent HPD or PD were retrospectively evaluated. The conventional PD was modified (mPD) to transect the bile duct beyond or close to the cranial level of the portal bifurcation.

RESULTS

The mPD group (n = 55) was characterized by older age, shorter operation time, less blood loss, and less frequent complications than were observed in the HPD group (n = 34). The median grossly tumor-free margin of the proximal bile duct (GM) was 13 mm vs 20 mm (P = 0.006). Overall survival did not differ significantly between groups (48% vs 53% at 5 years, P = 0.399). Multivariate analysis identified positive surgical margin as a sole independent prognostic factor (hazard ratio, 1.89; P = 0.043), which was statistically associated with GM length. Five-year survival for mPD patients with GM ≥15 mm was significantly better than that for those who had GM <15 mm (69% vs 33%, P = 0.011) and comparable to that of HPD patients (53%, P = 0.450).

CONCLUSION

The mPD may be recommended in patients with MCC, provided that GM ≥15 mm is expected from the preoperative radiological imaging. Otherwise, HPD should be considered.

Liver remnant volume to body weight ratio of 0.65% as a lower limit in right hepatic trisectionectomy with bile duct resection

BACKGROUND

Previous studies have suggested the utility of an indocyanine green plasma clearance rate of the future liver remnant (FLR) (ICGK-F) ≥0.05 in hepatobiliary resection to reduce the surgical risk. The present study aimed to verify whether future liver remnant size rather than ICGK-F matters in extended hepatobiliary resection.

METHODS

Between 2004 and 2021, patients who underwent right hepatic trisectionectomy with bile duct resection were included. The effect of the FLR volume-to-body weight ratio (FLR/BW) and ICGK-F on posthepatectomy liver failure was evaluated along with other parameters.

RESULTS

Among 91 study patients, the median ICGK-F, FLR, and FLR/BW were 0.057 (range, 0.027-0.099), 392 mL (145-705), and 0.78% (0.40-1.37), respectively. Posthepatectomy liver failure occurred in 23 patients. The incidence was 10 (40%) in 25 patients with an ICGK-F <0.05 and 12 (18%) in 65 patients with an ICGK-F ≥0.05 (P = .053); 13 (52%) in 25 patients with a FLR/BW <0.65% and 10 (15%) in 66 patients with a FLR/BW ≥0.65% (P = .001). Multivariate analysis showed that a FLR/BW <0.65% (odds ratio, 11.7; P = .005), age ≥65 years (odds ratio, 31.7; P < .001), and blood loss ≥25 mL/kg (odds ratio, 22.1; P = .004) were independent predictors of posthepatectomy liver failure, but ICGK-F <0.05 was not (P = .499). According to the meeting number of 3 factors, posthepatectomy liver failure incidence was 0 of 22 (0%) in patients with 0 factors, 6 of 43 (14%) in patients with 1, and 17 of 26 (65%) in patients with 2 or 3 (P < .001).

CONCLUSION

A FLR/BW ≥0.65% may serve as a volumetric basis to reduce posthepatectomy liver failure after extended hepatobiliary resection.

Two-step arterial reconstruction technique for en bloc resection of a large retroperitoneal liposarcoma involving the common iliac artery

Retroperitoneal liposarcoma (RPLS) is a rare but challenging neoplasm, which is frequently associated with iliac vessel invasion. We describe how we used a two-step arterial reconstruction technique to perform en bloc resection of a large RPLS involving the iliac arteries in three patients. A temporal long in situ graft bypass was established using a prosthetic vascular graft during dissection of the tumor. This bypass provided an unobscured surgical field, while maintaining blood flow in the lower limb during the operation. After removal of the tumor and washing out the abdominal cavity, the new prosthetic vascular graft of a suitable length was placed. No graft-related complications, including vascular graft infection or graft occlusion, occurred during the follow-up period. This novel technique appears to provide a safe and effective way to remove large RPLSs involving the retroperitoneal major vessels.

The Goal of Intraoperative Blood Loss in Major Hepatobiliary Resection for Perihilar Cholangiocarcinoma: Saving Patients From a Heavy Complication Burden

OBJECTIVE

To determine the goal of intraoperative blood loss in hepatectomy for perihilar cholangiocarcinoma.

BACKGROUND

Although massive bleeding can negatively affect the postoperative course, the target value of intraoperative bleeding to reduce its adverse impact is unknown.

METHODS

Patients who underwent major hepatectomy for perihilar cholangiocarcinoma between 2010 and 2019 were included. Intraoperative blood loss was adjusted for body weight [adjusted blood loss (aBL)], and the overall postoperative complications were evaluated by the comprehensive complication index (CCI). The impact of aBL on CCI was assessed by the restricted cubic spline regression.

RESULTS

A total of 425 patients were included. The median aBL was 17.8 (interquartile range, 11.8-26.3) mL/kg, and the CCI was 40.6 (33.7-49.5). Sixty-three (14.8%) patients had an aBL<10 mL/kg, nearly half (45.4%) of the patients were in the range of 10 ≤aBL<20 mL/kg, and 37 (8.7%) patients had an aBL >40 mL/kg. The spline regression analysis showed a nonlinear incremental association between aBL and CCI; CCI remained flat with an aBL under 10 mL/kg; increased significantly with an aBL ranging from 10 to 20 mL/kg; grew gradually with an aBL over 20 mL/kg. These inflection points of ~10 and 20 mL/kg were almost consistent with the cutoff values identified by the recursive partitioning technique. After adjusting for other risk factors for the postoperative course, the spline regression identified a similar model.

CONCLUSIONS

aBL had a nonlinear aggravating effect on CCI after hepatectomy for perihilar cholangiocarcinoma. The primary goal of aBL should be <10 mL/kg to minimize CCI.

Clinical value of fluorescent cholangiography for the infraportal type of right posterior bile duct

BACKGROUND

The infraportal type of the right posterior bile duct (infraportal RPBD) is a well-known anatomical variation that increases the potential risk of intraoperative biliary injury. The aim of this study is to clarify the clinical value of fluorescent cholangiography during single-incision laparoscopic cholecystectomy (SILC) for patients with infraportal RPBD.

MATERIAL AND METHODS

Our procedure for SILC utilized the SILS-Port, and another 5-mm forceps was inserted via an umbilical incision. A laparoscopic fluorescence imaging system developed by Karl Storz Endoskope was utilized for fluorescent cholangiography. Between July 2010 and March 2022, 41 patients with infraportal RPBD underwent SILC. We conducted retrospective reviews of patient data, focusing on the clinical value of fluorescent cholangiography.

RESULTS

Thirty-one patients underwent fluorescent cholangiography during SILC, but the remaining ten did not. Only one patient who did not undergo fluorescent cholangiography developed an intraoperative biliary injury. The detectability of infraportal RPBD before and during the dissection of Calot's triangle was 16.1% and 45.2%, respectively. These visible infraportal RPBDs were characterized as connections to the common bile duct. The confluence pattern of infraportal RPBD significantly influenced its detectability during the dissection of Calot's triangle (p < 0.001).

CONCLUSIONS

The application of fluorescent cholangiography can lead to safe SILC, even for patients with infraportal RPBD. Its benefit is emphasized when infraportal RPBD is connected to the common bile duct.

Standard versus delayed initiation of S-1 adjuvant chemotherapy after surgery for pancreatic cancer: a secondary analysis of a nationwide cohort by the Japan Pancreas Society

BACKGROUND

Based on the Japan Adjuvant Study Group of Pancreatic Cancer-01 results, S-1 adjuvant chemotherapy has been the standard in resected pancreatic ductal adenocarcinoma (PDAC) patients in Japan and elsewhere, initiated within 10 weeks after surgery. To assess the clinical impact of this timing, we conducted a secondary analysis of a nationwide survey by the Japan Pancreas Society.

METHODS

A total of 3361 patients were divided into two groups: 2681 (79.8%) initiating the therapy within 10 weeks after surgery (standard) and 680 (20.2%) after 10 weeks (delayed). We compared recurrence-free survival (RFS) and overall survival (OS) using the log-rank test and Cox proportional hazards model with conditional landmark analysis between the groups. Results were verified by adjustment with inverse-probability-of-treatment weighting (IPTW) analysis.

RESULTS

The median timing of S-1 adjuvant chemotherapy initiation was 50 days (interquartile range: 38-66). In the standard group, 5-year RFS and OS rates were 32.3-48.7%, respectively, compared with 25.0-38.7% in the delayed group. Hazard ratios (HRs) and 95% confidence intervals were 0.84 (0.76-0.93) for RFS (p < 0.001) and 0.77 (0.69-0.87) for OS (p < 0.001). The IPTW analysis yielded 5-year RFS rates of 32.1% and 25.3% in the standard versus delayed group, respectively [HR = 0.86 (0.77-0.96), p < 0.001] and 5-year OS rates of 48.3% and 39.8%, respectively [HR = 0.81 (0.71-0.92), p < 0.001].

CONCLUSIONS

Initiation of S-1 adjuvant chemotherapy in resected PDAC patients within 10 weeks after surgery may offer survival benefit over later initiation.

Impact of skeletal muscle mass on the prognosis of patients undergoing neoadjuvant chemotherapy for resectable or borderline resectable pancreatic cancer

BACKGROUND

Neoadjuvant chemotherapy is a common therapeutic procedure for patients with pancreatic cancer. This study aimed to investigate the association between the total psoas area (TPA) and prognosis in patients undergoing neoadjuvant chemotherapy for resectable or borderline resectable pancreatic cancer.

STUDY DESIGN

This retrospective study included patients who underwent neoadjuvant chemotherapy for pancreatic cancer. TPA was measured at the level of the L3 vertebra using computed tomography. The patients were divided into low-TPA and normal-TPA groups. These dichotomizations were separately performed in patients with resectable and those with borderline resectable pancreatic cancer.

RESULTS

In total, 44 patients had resectable pancreatic cancer and 71 patients had borderline resectable pancreatic cancer. Overall survival among patients with resectable pancreatic cancer did not differ between the normal- and low-TPA groups (median, 19.8 vs. 21.8 months, p = 0.447), whereas among patients with borderline resectable pancreatic cancer, the low-TPA group had shorter overall survival than the normal-TPA group (median, 21.8 vs. 32.9 months, p = 0.006). Among patients with borderline resectable pancreatic cancer, the low-TPA group was predictive of poor overall survival (adjusted hazard ratio, 2.57, p = 0.037).

CONCLUSION

Low TPA is a risk factor of poor survival in patients undergoing neoadjuvant chemotherapy for borderline resectable pancreatic cancer. TPA evaluation could potentially suggest the treatment strategy in this disease.

Early Prediction of a Serious Postoperative Course in Perihilar Cholangiocarcinoma: Trajectory Analysis of the Comprehensive Complication Index

OBJECTIVE

The aim of this study was to visualize the postoperative clinical course using the comprehensive complication index (CCI) and to propose an early alarming sign for subsequent serious outcomes in perihilar cholangiocarcinoma.

BACKGROUND

Surgery for this disease carries a high risk of morbidity and mortality. The developmental course of the overall morbidity burden and its clinical utility are unknown.

METHODS

Patients who underwent major hepatectomy for perihilar cholan-giocarcinoma between 2010 and 2019 were reviewed retrospectively. All postoperative complications were evaluated according to the Clavien-Dindo classification (CDC), and the CCI was calculated on a daily basis until postoperative day 14 to construct an accumulating graph as a trajectory. Group-based trajectory modeling was conducted to categorize the trajectory into clinically distinct patterns and the predictive power of early CCI for a subsequent serious course was assessed.

RESULTS

A total of 4230 complications occurred in the 484 study patients (CDC grade I, n = 27; II, n = 132; IlIa, n = 290; IIIb, n = 4; IVa, n = 21; IVb, n = 1; and V, n = 9). The trajectory was categorized into 3 patterns: mild (n = 209), moderate (n = 235), and severe (n = 40) morbidity courses. The 90-day mortality rate significantly differed among the courses: 0%, 0.9%, and 17.5%, respectively (P<0.001). The cutoff values of the CCI on postoperative days 1, 4, and 7 for predicting a severe morbidity course were 15.0, 28.5, and 40.6 with areas under the curves of 0.780, 0.924, and 0.984, respectively.

CONCLUSIONS

The CCI could depict the chronological increase in the overall morbidity burden, categorized into 3 patterns. Early CCI potentially predicted sequential progression to serious outcomes.

Cyclodextrin Conjugated α-Bisabolol Suppresses FAK Phosphorylation and Induces Apoptosis in Pancreatic Cancer

BACKGROUND/AIM

α-Bisabolol is an essential oil component extracted from plants, such as chamomile. We have previously reported that α-bisabolol suppressed proliferation, invasion, and motility of pancreas cancer. Cyclodextrin improved the solubility of α-bisabolol, therefore it enabled to administer intravenously. The aim of this study was to clarify the effect of cyclodextrin conjugated α-bisabolol (CD-BSB) and the signals pathways associated with α-bisabolol for pancreatic cancer.

MATERIALS AND METHODS

Human pancreatic cancer cell lines were treated with or without CD-BSB. Cytomorphology and apoptosis were assessed in these treated groups. In addition, several phosphorylated proteins were analyzed to clarify the signal pathway concerning CD-BSB. In subcutaneous xenograft model, tumor volume and Ki-67 expression were evaluated among Control (untreated), CD-BSB, or Gemcitabine (GEM).

RESULTS

CD-BSB significantly changed cytomorphology and induced apoptosis in pancreatic cancer cells. CD-BSB suppressed phosphorylation of focal adhesion kinase (FAK). In addition, pFAK 397 was inhibited by CD-BSB in a concentration-dependent manner in cancer cells. In the subcutaneous xenograft models, the tumor volume in the CD-BSB groups was lower than Control groups. Ki67-positive cells in CD-BSB treated group were lower than the GEM-treated groups.

CONCLUSION

We clarified the efficiency of CD-BSB in xenograft tumor using intravenous administration. α-Bisabolol suppresses phosphorylation of FAK 397 and impairs cytoskeletal polymerization in a pancreatic cancer cell line. Further investigations are required to reveal the precise mechanisms of the antitumor effects of solubilized α-bisabolol to facilitate its clinical application. Our data indicate that solubilized α-bisabolol has therapeutic potential and could improve the prognosis of cancer patients.

Antitumor Effects of Deep Ultraviolet Irradiation for Pancreatic Cancer

BACKGROUND/AIM

Deep ultraviolet (DUV) light spans within the 250 nm to 350 nm invisible wavelength range. Although it strongly damages various cells, the efficacy of DUV irradiation on pancreatic cancer cells has never been clarified. The purpose of this study was to reveal the antitumor effects of DUV irradiation on pancreatic cancer cells.

MATERIALS AND METHODS

Human pancreatic cancer cell lines were eradicated with DUV or ultraviolet A (UVA) for 5 s. Several angiogenesis-related proteins were studied in cancer cells after DUV irradiation using a protein antibody array. A subcutaneous xenograft model was established by inoculation of pancreatic cancer cells into mice. Tumors in this model were irradiated with DUV or UVA once or twice for two weeks. Tumor volumes in these groups (DUV×1: one irradiation, DUV×2: two irradiations, and untreated) were analyzed one week after the second irradiation.

RESULTS

DUV irradiation significantly changed the cytomorphology of pancreatic cancer cells. In addition, DUV irradiation induced apoptosis on pancreatic cancer cells more strongly than UVA irradiation and no irradiation. Interestingly, lower expression of thrombospondin 1 (TSP1) and tissue inhibitor of metalloproteinase 1 (TIMP1) was identified after DUV treatment. The tumor volume in the DUV-treated groups (DUV×1 and DUV×2) was smaller than that in the untreated group.

CONCLUSION

Further investigations are required to reveal the precise mechanisms of the antitumor effects of DUV irradiation and to facilitate its clinical application as a new therapy for pancreatic cancer. Overall, DUV irradiation can be potentially used as a therapeutic option of pancreatic malignancy.

Impact of preoperative muscle mass and quality on surgical outcomes in patients undergoing major hepatectomy for perihilar cholangiocarcinoma

PURPOSES

This study sought to define the impact of skeletal muscle mass and quality on postoperative outcomes in patients with perihilar cholangiocarcinoma.

METHODS

Patients who underwent major hepatectomy for perihilar cholangiocarcinoma were included. The normalized total psoas area (TPA) (psoas muscle index [PMI]) and average Hounsfield units of the TPA (psoas muscle density [PMD]) were measured using preoperative computed tomography images. The cohort was dichotomized using the following indices: sex-specific lowest tertile (low PMI and low PMD) and other (normal PMI and normal PMD). Intraoperative and postoperative outcomes were compared, focusing on PMI and PMD.

RESULTS

A total of 456 patients were analyzed. The intraoperative blood loss (IBL) was 21.3 ml/kg in the low PMI group and 17.2 ml/kg in the normal PMI group (P = .008). Patients in the low PMI or PMD group experienced postoperative infectious complications more frequently than those in the other groups. The median survival time was 37.8 months in the low PMI group and 54.2 months in the normal PMI group (P = .027).

CONCLUSIONS

PMI and PMD were closely associated with IBL and postoperative infectious complications. Additionally, PMI impacted long-term survival. These results suggest an importance of improving muscle mass and quality before surgery.

Early volume loss of skeletal muscle after esophagectomy: a risk for late-onset postoperative pneumonia

Late-onset postoperative pneumonia (LOPP) after esophagectomy is poorly understood. This study was designed to clarify the features and risk factors for this event. Patients who underwent esophagectomy for esophageal cancer between 2006 and 2016 were included. LOPP was defined as radiologically proven pneumonia that occurred over 3 months after surgery, and clinically relevant late-onset postoperative pneumonia (CR-LOPP) was defined as LOPP that required administration of oxygen and antibiotics in the hospital and/or more intensive treatment. The total psoas muscle area (TPA) was measured using preoperative and postoperative (at 3 months after surgery) computed tomography scan images. Potential risk factors for CR-LOPP were investigated. Among 175 study patients, 46 (26.3%) had LOPP, 29 (16.6%) of whom exhibited CR-LOPP with a cumulative incidence of 15.6% at 3 years and 22.4% at 5 years. Four (13.8%) of these patients died of LOPP. Univariable analysis showed that clinical stage ≥III (P = 0.005), preoperative prognostic nutritional index (PNI) <45 (P = 0.035), arrhythmia (P = 0.014), postoperative hospital stay ≥40 days (P = 0.003), and percent decrease of TPA more than 5% (P < 0.001) were associated with CR-LOPP but not early onset postoperative pneumonia. Multivariable analysis revealed that clinical stage ≥III (hazard ratio [HR] 3.01, P = 0.004), postoperative hospital stay ≥40 days (HR 2.51, P = 0.015), and percent decrease of TPA >5% (HR 9.93, P < 0.001) were independent risk factors for CR-LOPP. CR-LOPP occurred in over 20% of patients at 5 years, and early postoperative loss of TPA was a potential trigger for this delayed complication.

A proposal of drain removal criteria in hepatobiliary resection

BACKGROUND

Standardized criteria for the drain removal in hepatobiliary resection are lacking. We evaluated the outcomes of delayed removal policy in this extended surgery.

METHODS

Patients undergoing hepatectomy with biliary reconstruction between 2012 and 2018 were retrospectively reviewed. The drains were removed on postoperative day (POD) 7 when the drainage fluid was grossly serous, biochemically normal, and negative for bacterial contamination as assessed by Gram staining; additionally, no abnormal fluid collection was confirmed by computed tomography. Clinically relevant abdominal complications (CRACs), including biliary leakage, pancreatic fistula or intra-abdominal abscess, served as the primary outcome measure.

RESULTS

Among 374 study patients, surgical drains were removed in 166 (44.3%) patients who met the criteria. Of these patients, 16 (9.6%) patients required additional drainage afterwards due to CRAC. Drains were retained and exchanged in 208 (55.6%) patients who did not meet the criteria. Of them, exchanged drains were soon removed in 34 patients due to no signs of CRAC. The diagnostic ability of the criteria revealed 0.916 sensitivity, 0.815 specificity, and 0.866 accuracy.

CONCLUSION

The four findings on POD 7 worked well as criteria for drain removal, and these criteria may be helpful in drain management after hepatobiliary resection.

A long-term survivor of advanced retroperitoneal dedifferentiated liposarcoma: a successful multimodal approach with extended resection and chemotherapy

Surgical resection is the mainstay of treatment for retroperitoneal liposarcoma (RPLS). Herein, we describe a case of dedifferentiated RPLS successfully treated with an extended surgical approach with adjuvant chemotherapy. A 61-year-old male was referred to our hospital with a chief complaint of chest tightness. Abdominal computed tomography revealed a large retroperitoneal tumor, 11 cm in diameter, extensively invading the surrounding organs: the celiac axis, the splenic artery, the pancreatic body and tail, the lesser curvature of the stomach and the left adrenal gland. Endoscopic ultrasound-guided fine-needle aspiration biopsy confirmed dedifferentiated liposarcoma, suggesting aggressive tumor biology. We performed total gastrectomy combined with distal pancreatectomy with celiac axis and left adrenal gland resection with a curative intent. The postoperative course was almost uneventful. As the pathological findings indicated a positive margin with a well-differentiated liposarcoma component, we added adjuvant chemotherapy with four cycles of doxorubicin and ifosfamide (AI). Five years after primary surgery, regular follow-up CT demonstrated a pulmonary hilar lymph node enlargement and a tumor at paraesophageal locations. After downsizing chemotherapy with eribulin followed by pazopanib, he underwent partial esophagectomy with dissection of the paraesophageal tumor. The pathological findings indicated recurrence of dedifferentiated liposarcoma with a tumor-free surgical margin. He is currently alive without any evidence of recurrence almost 7 years after the first surgery and 15 months after the second surgery. The long-term survival gained in this patient indicates that extended resections and adjuvant chemotherapy could prolong survival in patients even with RPLS with dedifferentiated tumor histology.

Fish bone migration after pancreaticoduodenectomy: Incidence and treatment options

OBJECTIVE

Migration of a fish bone to the bile duct or pancreatic duct is a possible complication after pancreaticoduodenectomy (PD). The aim of this study was to clarify the incidence and indications for intervention in such cases.

METHODS

We reviewed the cases with fish bone migration after PD detected on computed tomography (CT) scan between October 2000 and October 2020 were reviewed and the incidence of fish bone migration, presence of symptoms and signs, therapeutic modalities and patient outcomes were analyzed.

RESULTS

Among the 1475 PD procedures performed at our institution during the study period, 14 cases of fish bone migration were noted on CT, the incidence of which was 0.95% (14/1475). The time duration from surgery to the detection of fish bone ranged from 88 to 5902 days (median 917 d). Ten patients remained asymptomatic without therapeutic intervention for up to 2919 days (median 509 d). Four patients were treated by endoscopy, either at the patient's request (n = 1) or because of their symptoms (n = 3), and removal was successful in three cases but failed in one case in which the fish bone migrated to the right intrahepatic bile duct. No surgical treatment was required in any case.

CONCLUSIONS

The incidence of fish bone migration on CT after PD was about 1%. Some cases resolved spontaneously, and most of the asymptomatic cases required no intervention. For symptomatic cases, endoscopic treatment should be considered first. It is important to confirm the location of the fish bone by CT and determine whether it can be removed.

Superiority of clinical American Joint Committee on Cancer T classification for perihilar cholangiocarcinoma

BACKGROUND

Clinical tumor staging is essential information for making a therapeutic decision in cancer. This study aimed to identify the optimal tumor classification system for predicting resectability and survival probability in perihilar cholangiocarcinoma.

METHODS

Patients who were treated for perihilar cholangiocarcinoma between 2009 and 2018 were enrolled. Local tumor extension was staged radiologically according to a diameter-based classification system in addition to the AJCC, Blumgart, and Bismuth systems. Survival and resectability were compared between T subgroups, and the discriminability of the four systems was assessed with Harrell's concordance index (C-index).

RESULTS

Among 702 study patients, 559 (80.0%) underwent laparotomy, 489 (70.0%) of whom underwent resection. The resectability significantly decreased for more advanced tumors in all systems (P < .001); the AJCC system had the greatest discriminability for resectability (area under the curve 0.721). Overall survival at 5 years was 69.9% for AJCC cT1, 45.8% for cT2, 31.8% for cT3, and 15.3% for cT4 tumors (cT1 vs cT2; P = .002, cT2 vs cT3; P = .008 and cT3 vs cT4; P < .001). The AJCC system had the largest C-index of 0.627.

CONCLUSIONS

The AJCC T system was the optimal classification system for predicting resectability and survival in perihilar cholangiocarcinoma.

A clinicopathological reappraisal of intraductal papillary neoplasm of the bile duct (IPNB): a continuous spectrum with papillary cholangiocarcinoma in 181 curatively resected cases

BACKGROUND

Intraductal papillary neoplasm of the bile-duct (IPNB) has recently been further subclassified into "so-called IPNBs" (Type-1) and "narrow-sense papillary cholangiocarcinomas" (Type-2), but their differential diagnosis is challenging. This study aimed to reevaluate Type-1 and Type-2 IPNBs.

METHODS

Consecutive patients who underwent papillary bile-duct tumor resection were included. Using six pathological features (location, mucin secretion, histological architecture, histological type, presence of a low/intermediate-dysplasia component, and proportion of the invasive component), all papillary tumors were scored. Tumors scoring 5-6 were classified as Type-1, 0-1 as Type-2, and 2-4 as Type-Unclassifiable.

RESULTS

The 181 papillary bile-duct tumor patients were divided into three groups, consisting of 12 Type-1, 46 Type-2, and 123 Type-Unclassifiable-gray-zone lesions between Type-1 and Type-2 that constituted the largest proportion of papillary tumors. Type-1 tumors were pathologically the least advanced, while the other types showed gradual advancement. The 5-year survival rate was better for patients with Type-1 tumors than for those with Type-Unclassifiable or Type-2 tumors.

CONCLUSION

The scoring system worked well to delineate a continuous spectrum of pathologic features ranging from Type-1, through Type-Unclassifiable, to Type-2, the latter two being challenging to differentially diagnose. Type-1 is regarded as an early neoplasm of Type-Unclassifiable and Type-2.

Adjuvant S-1 vs gemcitabine for node-positive perihilar cholangiocarcinoma: A propensity score-adjusted analysis

BACKGROUND

The efficacy of adjuvant chemotherapy for biliary cancers remains controversial because of conflicting results from previous phase 3 studies that used different key drugs and enrolled patients with heterogeneous tumor sites and disease stages. Fluoropyrimidine seems more beneficial than gemcitabine (GEM) combination regimens in the adjuvant setting; however, data comparing the survival benefit between GEM- and fluoropyrimidine-based regimens are lacking.

METHODS

Patients who underwent resection for node-positive perihilar cholangiocarcinoma were included. The patients who underwent adjuvant chemotherapy were divided into the S-1 and GEM groups according to the regimen. The recurrence-free survival (RFS) and the overall survival (OS) were compared between the groups and adjusted with propensity scores generated from 14 potentially confounding clinicopathological factors.

RESULTS

In total, 186 patients (Surgery alone, n = 71; S-1, n = 60; GEM, n = 55) were included. The S-1 and GEM completion rates were 75% and 65%, respectively. Among the patients who underwent adjuvant therapy, the RFS was longer in the S-1 group patients than the GEM group patients (median, 24.4 months vs 14.9 months; P = .044) whereas the OS was not significantly different between the groups (median, 48.5 months vs 35.0 months; P = .324). After propensity score adjustment, the differences in RFS and OS between the groups were more evident (HR: 2.696, 95% CI: 1.739-4.180 P < .001; HR: 1.988, 95% CI: 1.221-3.238, P < .001, respectively).

CONCLUSIONS

Compared with adjuvant GEM monotherapy, adjuvant S-1 monotherapy may improve survival in node-positive perihilar cholangiocarcinoma patients.

A presurgical prognostic stratification based on nutritional assessment and carbohydrate antigen 19-9 in pancreatic carcinoma: An approach with nonanatomic biomarkers

BACKGROUND

Nutritional status and tumor markers are important prognostic indicators for surgical decisions in pancreatic carcinoma. This study aimed to stratify the probability of surviving pancreatic carcinoma based on systematically chosen nonanatomic biomarkers.

METHODS

We included 187 consecutive patients that underwent surgical resections for pancreatic carcinoma. We performed multivariable analyses to evaluate prognostic indicators, including 4 blood-test indexes: the neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, prognostic nutritional index, and the modified Glasgow prognostic score; and 4 body-composition indexes: the normalized total psoas muscle area, the normalized total elector spine muscle area, the psoas muscle computed tomography value, and the elector spine muscle computed tomography value.

RESULTS

Poor survival was associated with 2 independent risk factors: neutrophil-to-lymphocyte ratio ≥3.0 (hazard ratio, 1.54) and prognostic nutritional index <36 (hazard ratio, 1.60), and with high carbohydrate antigen 19-9 levels (≥37 IU/mL). The 2 indexes were not significantly associated with clinicopathological factors, including carbohydrate antigen 19-9. Patients with no risk factors had significantly better survival than those with 1 (P = .007) or 2 risk factors (P = .001), and survival was similar in the latter 2 groups (P = .253). A presurgical nonanatomic scoring system (range, 0-2) was constructed: 0 points for no risk factors, 1 point for 1 or 2 nutritional risk factors, and 1 point for carbohydrate antigen 19-9 ≥37 IU/mL. Survival rate at 3 years decreased with increasing scores (76% for score 0, 42% for score 1, and 21% for score 2; all P < .05).

CONCLUSION

Neutrophil-to-lymphocyte ratio and prognostic nutritional index were independent prognostic risk factors in pancreatic carcinoma and integrating these indexes with carbohydrate antigen 19-9 levels could successfully stratify survival.

Hepatopancreatoduodenectomy with simultaneous resection of the portal vein and hepatic artery for locally advanced cholangiocarcinoma: Short- and long-term outcomes of superextended surgery

BACKGROUND

Only a few authors have reported negative results for hepatopancreatoduodenectomy (HPD) with simultaneous resection of the portal vein and hepatic artery in a limited number of patients. The aim of the current study was to outline our experience with this superextended surgery and to discuss its clinical value.

METHODS

Medical records of consecutive patients who underwent resection of perihilar cholangiocarcinoma between 2007 and 2020 were retrospectively reviewed.

RESULTS

During the study interval, 650 patients with perihilar cholangiocarcinoma underwent resection. The superextended surgery was performed in only nine (1.4%) patients. Left or right trisectionectomy was primarily performed. For portal vein reconstruction, external iliac vein graft was required in seven patients. For hepatic artery reconstruction, rotating left gastric artery was often used. The median operative time was 870 minutes and blood loss was 2,598 mL. Postoperatively, pancreatic fistula and liver failure occurred in all patients, followed by intraabdominal abscess (n = 8), and bacteremia (n = 4). One patient died on day 86 due to multiple organ failure. Two patients survived for more than 7 years.

CONCLUSIONS

HPD with simultaneous resection of the portal vein and hepatic artery is demanding but worth performing as the last option, with careful patient selection in experienced centers.

The influence of the preoperative thickness of the abdominal cavity on the gastrojejunal anatomic position and delayed gastric emptying after pancreatoduodenectomy

BACKGROUND

We aimed to investigate the hypothesis that preoperative thickness of the abdominal cavity influenced on the gastrojejunostomy position and the incidence of delayed gastric emptying (DGE) after pancreatoduodenectomy.

METHODS

Between January 2009 and December 2018, consecutive patients who underwent subtotal stomach-preserving pancreatoduodenectomy were retrospectively reviewed. Thickness of the abdominal cavity at the level of the celiac axis (TACC) and umbilicus (TACU) were measured using computed tomography before surgery. The ventral deviation of the gastrojejunostomy was evaluated as the sagittal fundus anastomotic angle (SFAA) using sagittal computed tomography images taken after surgery.

RESULTS

A total of 281 patients were included. Of these, clinically relevant DGE (CR-DGE) was observed in 47 patients. TACC was significantly correlated with SFAA (R = 0.53, P < 0.001). Both TACC and SFAA were significantly greater in patients with CR-DGE compared to those without CR-DGE. In contrast, TACU was not associated with SFAA and the incidence of CR-DGE. Multivariate analysis revealed that TACC >110 mm (odds ratio, 3.07; p = 0.002) and pancreatic fistula (odds ratio, 2.71; p = 0.013) were identified as independent risk factors for CR-DGE.

CONCLUSION

Thickness of the upper abdominal cavity had a significant influence on gastrojejunal anatomic position and the development of CR-DGE after pancreatoduodenectomy.

Combined Vascular Resection for Locally Advanced Perihilar Cholangiocarcinoma

OBJECTIVE

To evaluate the efficacy and safety of combined vascular resection (VR) in advanced perihilar cholangiocarcinoma (PHC).

SUMMARY OF BACKGROUND DATA

Hepatectomy combined with portal vein resection (PVR) and/or hepatic artery resection (HAR) is technically demanding but an option only for tumor eradication against PHC involving the hilar hepatic inflow vessels; however, its efficacy and safety have not been well evaluated.

METHODS

Patients diagnosed with PHC during 2001-2018 were included. Patients who underwent resection were divided according to combined VR. Patients undergoing VR were subdivided according to type of VR. Postoperative outcomes and OS were compared between patient groups.

RESULTS

Among the 1055 consecutive patients, 787 (75%) underwent resection (without VR: n = 484, PVR: n = 157, HAR: n = 146). The incidences of postoperative complications and mortality were 49% (without VR vs with VR, 48% vs 50%; P= 0.715) and 2.1% (without VR vs with VR, 1.2% vs 3.6%; P= 0.040), respectively. The OS of patients who underwent resection with VR (median, 30 months) was shorter than that of those who underwent resection without VR (median, 61 months; P < 0.0001); however, it was longer than that of those who did not undergo resection (median, 10 months; P < 0.0001). OS was not significantly different between those who underwent PVR and those who underwent HAR (median, 29 months vs 34 months; P = 0.517).

CONCLUSION

VR salvages a large number of patients from having locally advanced PHC that is otherwise unresectable and is recommended if the hilar hepatic inflow vessels are reconstructable, providing acceptable surgical outcomes and substantial survival benefits.

Tumor marker recovery rather than major pathological response is a preferable prognostic factor in patients with pancreatic ductal adenocarcinoma with preoperative therapy

BACKGROUND/PURPOSE

A pathological response of the primary tumor by preoperative therapy is a prognostic factor in various malignancies, and several histologic grading systems have been proposed for pancreatic ductal adenocarcinoma (PDAC). However, the prognostic value remains unclear. We explored the clinical implication of a major pathological response following preoperative therapy in patients with PDAC.

METHODS

Of 415 patients with resected PDAC, 137 who had undergone preoperative therapy were examined. Cox proportional hazards models were used to determine the predictors of a major pathological response, and survival analyses were performed.

RESULTS

Twenty patients exhibited a major pathological response (≥90% tumor reduction). Significant associations were observed between a major pathological response and resectability (P = .001), the period of preoperative therapy (P < .001), RECIST best response (P < .001), the tumor size after preoperative therapy (P = .02), and tumor marker recovery (P < .001). Multivariate analysis of progression-free survival (PFS) revealed that both body mass index (≥20 kg/m2 ) (P = .035) and tumor marker recovery (P = .046) were independent prognostic factors. The median survival time (MST) of PFS for a ≥90% pathological response was better than that of a <90% response (P = .25); however, the MST for tumor marker recovery was significantly better than that without tumor marker recovery (P = .0054).

CONCLUSIONS

In our study, a major pathological response was not extracted as a prognostic factor. Rather, tumor marker recovery was a preferable prognostic factor in patients with PDAC who had undergone preoperative therapy.

How long should follow-up be continued after R0 resection of perihilar cholangiocarcinoma?

BACKGROUND

Although several studies have been conducted on the patterns of recurrence in resected perihilar cholangiocarcinoma, the appropriate follow-up period after resection is still controversial.

METHODS

Consecutive patients who underwent an R0 resection of perihilar cholangiocarcinoma between 2001 and 2014 were reviewed retrospectively, focusing on the time and site of initial recurrence. A Cox proportional hazards model was used for multivariate analysis.

RESULTS

During the study period, 404 patients underwent R0 resection, of whom 242 patients (59.9%) developed a recurrence. The most common site of recurrence was locoregional, followed by peritoneum and liver. Approximately 70% of patients were asymptomatic when recurrence was detected. The median survival time in all cohorts was 4.8 years, and the estimated cumulative probability of recurrence was 54.3% at 5 years and 65.7% at 10 years. Multivariate analyses revealed that lymph node metastasis (hazard ratio 2.80, P < .001) and microscopic venous invasion (hazard ratio, 1.70, P < .001) were independent risk factors for recurrence-free survival. The cumulative probability of recurrence in 84 patients with 2 risk factors was nearly 90% at 5 years; even in the 178 patients without risk factors, the probability at 5 years was 30%, and thereafter, the probability of recurrence gradually increased, reaching nearly 50% at 10 years. No trends in the time and site of recurrence were detected.

CONCLUSION

Approximately 60% of patients with perihilar cholangiocarcinoma experience recurrence after R0 resection. Even in patients without an independent risk for recurrence, the recurrence probability is high, reaching nearly 50% at 10 years. Thus, close surveillance for 10 years is necessary even after R0 resection of perihilar cholangiocarcinoma.

Impact of Perioperative Steroid Administration in Patients Undergoing Major Hepatectomy with Extrahepatic Bile Duct Resection: A Randomized Controlled Trial

BACKGROUND

To date, five randomized controlled trials have assessed the clinical benefit of perioperative steroid administration in hepatectomy; however, all of these studies involved a substantial number of 'minor' hepatectomies. The benefit of steroid administration for patients undergoing 'complex' hepatectomy, such as major hepatectomy with extrahepatic bile duct resection, is still unclear. This study aimed to evaluate the clinical benefit of perioperative steroid administration for complex major hepatectomy.

METHODS

Patients with suspected hilar malignancy scheduled to undergo major hepatectomy with extrahepatic bile duct resection were randomized into either the control or steroid groups. The steroid group received hydrocortisone 500 mg immediately before hepatic pedicle clamping, followed by hydrocortisone 300 mg on postoperative day (POD) 1, 200 mg on POD 2, and 100 mg on POD 3. The control group received only physiologic saline. The primary endpoint was the incidence of postoperative liver failure.

RESULTS

A total of 94 patients were randomized to either the control (n = 46) or steroid (n = 48) groups. The two groups had similar baseline characteristics; however, there were no significant differences between the groups in the incidence of grade B/C postoperative liver failure (control group, n = 8, 17%; steroid group, n = 4, 8%; p = 0.188) and other complications. Serum bilirubin levels on PODs 2 and 3 were significantly lower in the steroid group than those in the control group; however, these median values were within normal limits in both groups.

CONCLUSION

Perioperative steroid administration did not reduce the risk of postoperative complications, including liver failure following major hepatectomy with extrahepatic bile duct resection.

Impact of the preoperative body composition indexes on intraoperative blood loss in patients undergoing pancreatoduodenectomy

PURPOSES

This study sought to identify any significant predictors of blood loss during pancreatoduodenectomy (PD) among preoperative variables, including the body composition indexes.

METHODS

The preoperative data of patients undergoing PD were retrospectively reviewed. The objective variable was the percentage of blood loss during PD to the estimated circulating blood volume (proportional blood loss: PBL). The circulating blood volume was estimated using Nadler's formula. The total psoas area, average Hounsfield units of psoas area (psoas muscle density: PMD), and visceral to subcutaneous adipose tissue area ratio (VSR) were measured at the third vertebra using preoperative plain computed tomography images. A univariate analysis and multiple linear regression analysis for PBL were conducted using the preoperative variables.

RESULTS

A total of 415 patients were analyzed. The median PBL was 24.5%. The PMD (coefficient - 0.267; 95% CI - 0.518, - 0.015), VSR (coefficient 2.719; 95% CI 0.238, 5.201), serum albumin level (coefficient - 8.458; 95% CI - 13.02, - 3.898), neoadjuvant therapy (coefficient 9.605; 95% CI 1.722, 17.49), and prothrombin time-international normalized ratio (PT-INR, coefficient 38.63; 95% CI 10.94, 66.31) were independently associated with PBL.

CONCLUSIONS

The preoperative PMD, VSR, serum albumin level, neoadjuvant therapy, and PT-INR independently affected PBL. These factors could therefore be potential targets to reduce blood loss during PD.

Postoperative infectious complications caused by multidrug-resistant pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection

BACKGROUND

Few reports have addressed postoperative infectious complications caused by multidrug-resistant pathogens. The aim of this study was to review the surgical outcomes of patients undergoing major hepatectomy with extrahepatic bile duct resection and to clarify the incidence of and the risk factors for postoperative infectious complications caused by multidrug-resistant pathogens.

METHODS

Medical records of consecutive patients who underwent major hepatectomy with extrahepatic bile duct resection between 2006 and 2017 were retrospectively reviewed.

RESULTS

Among 620 study patients, 219 had postoperative infectious complications, including 62 (10.0%) with postoperative infectious complications caused by multidrug-resistant pathogens. The mortality of the 62 patients with postoperative infectious complications caused by multidrug-resistant pathogens was higher (n = 8, 12.9%) than that in the 157 patients with postoperative infectious complications caused by non-multidrug-resistant pathogens(n = 2, 1.3%) (P < .001). With multivariate analysis, the presence of preoperative cholangitis, the extent of liver resection more than 50%, operative time longer than 600 minutes, the amount of blood loss more than 1500 mL, and the presence of postoperative infectious complications caused by multidrug-resistant pathogens were identified as independent risk factors for postoperative death. The presence of multidrug-resistant pathogens in preoperative bile culture, the amount of blood loss greater than 1500 mL, the presence of bile leakage, and pancreatic fistula were identified as independent risk factors for postoperative infectious complications caused by multidrug-resistant pathogens.

CONCLUSION

The incidence of postoperative infectious complications caused by multidrug-resistant pathogens in patients undergoing major hepatectomy with extrahepatic bile duct resection is high, approximately 10%. This troublesome complication is closely associated with postoperative death. Thus, preventing postoperative infectious complications caused by multidrug-resistant pathogens is an urgent task to improve surgical outcome after major hepatectomy with extrahepatic bile duct resection.

A case of small in situ perihilar cholangiocarcinoma incidentally accompanied by benign bile duct stricture after open cholecystectomy

Background

In situ cholangiocarcinoma is difficult to detect by imaging studies. Thus, cholangiocarcinoma is rarely resected with a preoperative definitive diagnosis, especially nonpapillary flat type in situ carcinoma, which is extremely rare.

Case presentation

A 70-year old man was diagnosed with gallbladder cancer and received open cholecystectomy with lymphadenectomy at a local hospital. Histologically, the tumor was localized in the mucosal layer, and no lymph node metastases were found. Three months later, hilar bile duct stricture due to delayed bile duct ischemia was found. Then, biliary drainage was performed with endoscopic biliary stenting. Three months later, the patient experienced cholangitis with septic shock, and percutaneous transhepatic biliary drainage (PTBD) into the left intrahepatic bile duct was performed. Unexpectedly, the aspiration bile cytology of the PTBD catheter showed malignant cells, and the patient was referred to our clinic for possible surgical treatment. According to additional studies, the hilar bile duct stricture was 3 cm in length. None of the imaging studies detected malignant cells in the bile duct around the hilar stricture. The left portal vein was obstructed due to inadvertent puncture of the PTBD. No findings indicated cholangiocarcinoma. We performed left hepatectomy with caudate lobectomy and extrahepatic bile duct resection. The postoperative course was uneventful. In the final pathology, flat type in situ carcinoma was found at the confluence of the right and left hepatic ducts, which was distant from the biliary stricture.

Conclusions

When a tumor is undetectable but cytology is positive, in situ cholangiocarcinoma may exist; thus, surgery should be carefully considered.

Predictive performance of Blumgart T staging for perihilar cholangiocarcinoma in a Japanese center

BACKGROUND

The Blumgart system has been used for local tumor assessment in perihilar cholangiocarcinoma to predict resectability and survival, and T3 tumors are considered unresectable disease. The aim was to validate the predictive performance of this system using a Japanese cohort.

METHODS

Medical records of consecutive patients with perihilar cholangiocarcinoma between 2006 and 2016 were retrospectively reviewed. Resectability, surgical procedure, R0 resection rate, and survival were compared among T stages.

RESULTS

Among 729 study patients, 191 patients had T1 tumors, 94 patients had T2 tumors, and 444 (60.9%) patients had T3 tumors according to the Blumgart T stage. Resection was performed in 513 (70.4%) patients; resectability rate decreased with the progression of T stage: 89.0% in T1, 79.8% in T2, and 60.4% in T3 tumors (P < 0.001). The incidences of left hepatic trisectionectomy and portal vein resection were 44.0% and 54.1%, respectively, in patients with T3 tumors, which were significantly greater than those of T1/2 tumors (P = 0.001 and P < 0.001). R0 resection reduced with advanced T stage: 92.4% in T1, 81.3% in T2, and 70.9% in T3 tumors (P < 0.001). The 5-year survival rate was 53.4%, 38.4%, and 19.7% in T1, T2, and T3 tumors, respectively (P < 0.001); that was 59.6%, 48.6%, and 30.7%, respectively, in the resected cohort (P < 0.001).

CONCLUSION

Blumgart T stage was closely associated with the resectability rate, surgical procedures, R0 resection rate, and survival time, suggesting that the T stage works as well as a presurgical staging system. However, the unresectable classification of T3 tumors should be revised.

Discrepancy between volume and functional recovery in early phase liver regeneration following extended hepatectomy with extrahepatic bile duct resection

AIM

To elucidate the clinical factors having an impact on liver regeneration rate following preoperative portal vein embolization (PVE) and subsequent extended hepatectomy. The correlation between liver volume and functional recovery after extended hepatectomy was also investigated.

METHODS

Records of patients who underwent extended hepatectomy with extrahepatic bile duct resection following PVE for perihilar cholangiocarcinoma were reviewed retrospectively with attention to liver regeneration. All patients underwent computed tomography before PVE, after PVE (immediately before surgery), and on postoperative day (POD) 7. The kinetic growth rate (KGR) was calculated as the percent increase in liver volume relative to the future liver remnant volume per day after PVE (KGR_PVE ) and after POD 7 (KGR_POD7 ) using the computed tomography images before PVE, after PVE, and on POD 7.

RESULTS

In the 289 study patients, the median of KGR_PVE was 1.35%/day whereas that of KGR_POD7 was 5.56%/day. The extent of liver resection had the greatest impact on both KGR_PVE and KGR_POD7 and the impacts of other factors were less. There was a significant negative correlation between KGR_PVE and KGR_POD7 (P = 0.002). No correlations were observed between KGR_PVE or KGR_POD7 and serum total bilirubin and prothrombin time - international normalized ratio on POD 7, nor in the incidence of liver failure after surgery.

CONCLUSIONS

Early phase liver regeneration after extended hepatectomy was largely influenced by the extent of liver resection and showed no correlation with the indices of liver failure. There was a discrepancy between volume and functional recovery in early phase liver regeneration.

Postoperative Pancreatic Fistula in Surgery for Perihilar Cholangiocarcinoma

BACKGROUND

There are numerous studies on postoperative pancreatic fistula (POPF) in pancreatic surgery but few studies on POPF in extrahepatic bile duct resection with or without hepatectomy for perihilar cholangiocarcinoma (PHCC). The aim of this study is to investigate the incidence of and risk factors for POPF in this challenging surgery.

METHODS

All consecutive patients who underwent surgical resection for presumed PHCC between January 2008 and December 2017 were retrospectively reviewed, with special attention paid to POPF.

RESULTS

Among 416 patients, 90 patients showed a drain amylase level of > 3 times the normal limit on day 3 or after. The severity of POPF was biochemical leakage in 46 patients and grade B in 44 patients. No patient had grade C POPF; thus, the incidence of clinically relevant POPF was 10.6% (44/416). The resection line of the common bile duct was closely associated with POPF; 23 (27.7%) of the 83 patients who underwent intrapancreatic resection of the common bile duct developed POPF. The occurrence of intra-abdominal abscess and liver failure was significantly higher in patients with POPF, but the 90-day mortality was similar. The multivariate analysis identified a body mass index of ≥ 22 and intrapancreatic bile duct resection as independent risk factors for POPF.

CONCLUSIONS

POPF occurs in approximately 10% of patients undergoing resection for PHCC. Careful postoperative management with attention to POPF is required, especially in patients who undergo intrapancreatic resection of the common bile duct and in those with a high body mass index.

Benign hilar bile duct strictures resected as perihilar cholangiocarcinoma

BACKGROUND

Differentiation between perihilar cholangiocarcinoma (PHCC) and benign strictures is frequently difficult. The aim of this study was to investigate the incidence and long-term outcome of patients with tumours resected because of suspicion of PHCC, which ultimately turned out to be benign (malignancy masquerade).

METHODS

Patients who underwent surgical resection with a diagnosis of PHCC between 2001 and 2016 were reviewed retrospectively.

RESULTS

Among 707 consecutive patients, 685 had PHCC and the remaining 22 (3·1 per cent) had benign biliary stricture. All patients with benign disease underwent major hepatectomy, with no deaths. Preoperative histological assessment using bile duct biopsy or aspiration cytology had a high specificity (90 per cent), low sensitivity (62 per cent) and unsatisfactory accuracy (63 per cent). Despite the increasing use of histological assessment, the incidence of benign strictures resected did not decrease over time, being 0·9 per cent in 2001-2004, 4·0 per cent in 2005-2008, 3·8 per cent in 2009-2012 and 2·9 per cent in 2013-2016. The final pathology of benign strictures included IgG4-related sclerosing cholangitis (9 patients), hepatolithiasis (4), granulomatous cholangitis (3), non-specific chronic cholangitis (3), benign strictures after cholecystectomy (2), and a benign stricture possibly caused by parasitic infection (1). The 10-year overall survival rate for the 22 patients with benign stricture was 87 per cent, without recurrence of biliary stricture.

CONCLUSION

The incidence of benign strictures resected as PHCC as a proportion of all resections was relatively low, at 3·1 per cent. Currently, unnecessary surgery for suspected PHCC is unavoidable.

Preoperative course of patients undergoing endoscopic nasobiliary drainage during the management of resectable perihilar cholangiocarcinoma

BACKGROUND

Although there are many studies on technical outcomes of endoscopic nasobiliary drainage (ENBD), no authors reported on preoperative course of patients undergoing ENBD. The aim of this study was to investigate the course of patients with ENBD during the waiting period.

METHODS

Patients who underwent resection of perihilar cholangiocarcinoma (PHCC) between January 2013 and September 2017 were retrospectively reviewed.

RESULTS

During the study period, 191 consecutive patients underwent surgical resection of PHCC after ENBD. Of the study patients, 154 (80.6%) patients were discharged, returned to their home, then re-admitted for surgery. The remaining 37 patients were continuously hospitalized. The number of cholangitis events during the waiting period was 0 in 120 patients, 1 in 59 patients, 2 ≤ in 12 patients. Endoscopic re-intervention was needed in 52 patients. The median length between the first admission and surgery was 37 days (range 12-197 days) in the entire cohort; it was longer in patients with portal vein embolization than in those without (43 vs. 27 days, P < 0.001).

CONCLUSIONS

In patients undergoing resection of PHCC, ENBD is widely tolerable with relatively low incidence of cholangitis and thus recommended for preoperative biliary drainage.

Occult synchronous liver metastasis from perihilar cholangiocarcinoma

BACKGROUND

No authors have reported occult liver metastases from perihilar cholangiocarcinoma (PHCC), which are defined as intrahepatic metastases that are overlooked by preoperative workup and intraoperative inspection but are detected by final pathology. The aim of this study was to clarify the features of such unappreciated metastases.

METHODS

We reviewed retrospectively the medical records of patients with PHCC treated between 2001 and 2016 with attention to liver metastases.

RESULTS

During the study interval, 945 consecutive patients with PHCC were treated, including 260 unresected and 685 resected patients (672 with hepatectomy and 13 without). Of these, 36 patients had overt liver metastases. Of the 672 hepatectomized patients, 21 (3.1%) patients had occult liver metastases with a median number of 1 (range 1-6). When compared between occult and overt metastases, the diameter was smaller in the former (5 mm vs 12 mm, P < .001). When compared between the 21 patients with occult metastases and the 645 hepatectomized patients without liver metastases, microscopic venous invasion and lymph node metastases were observed frequently in the patients with occult metastases. Survival for these 21 patients with occult metastases was better than that for the 36 patients with overt metastases (median survival time; 17.1 vs 7.4 months, P < .01).

CONCLUSION

Occult liver metastases from PHCC are not extremely rare. Meticulous handling of the resected specimens is crucial to detect such metastases. Although patients with occult metastases had advanced stages of the disease, their survival was better than that for patients with overt metastases.

Left trisectionectomy combined with resection of the right hepatic vein and inferior vena cava after right hepatic vein embolization for advanced intrahepatic cholangiocarcinoma

Background

When the inferior right hepatic vein (IRHV) is present, left hepatic trisectionectomy with resection of the right hepatic vein (RHV) is theoretically possible without reconstruction of the RHV. We here report a successful case of this extended hepatectomy after RHV embolization for advanced intrahepatic cholangiocarcinoma.

Case presentation

A 71-year-old man was admitted to our clinic with abdominal pain. Computed tomography showed a cholangiocarcinoma located at the caudate lobe that involved the inferior vena cava (IVC) and the roots of the three major hepatic veins. Portal vein embolization of the left and right anterior portal veins was performed. As the IRHV was present but thin, RHV was also embolized. Left hepatic trisectionectomy with resection of the involved IVC and RHV, preserving the IRHV, was done. The IVC was reconstructed with artificial graft. The patient was discharged on postoperative day 36.

Conclusion

RHV embolization is useful in extended left trisectionectomy with resection of the RHV when the IRHV is present but thin.

The Prognostic Impact of the Lymphocyte-to-Monocyte Ratio in Resected Pancreatic Head Adenocarcinoma

OBJECTIVE

Although the prognostic significance of systematic inflammation-based scores, such as the neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), and the prognostic nutritional index (PNI), has been explored in pancreatic cancers, few reports have investigated the lymphocyte-to-monocyte ratio (LMR). We aimed to retrospectively investigate the prognostic value of the preoperative LMR in patients with resectable pancreatic head cancer (PHC).

METHODS

From 2005 to 2016, 165 patients underwent pancreatoduodenectomy for PHC. All samples of peripheral blood were collected within 2 weeks prior to surgery. The best cutoff values of the LMR for predicting survival were determined by using a minimum p value approach (cut-off value: 2.8). The clinicopathological features of LMR <2.8 (n = 25) and ≥2.8 (n = 140) were compared.

RESULTS

Patients with LMR ≥2.8 showed significantly lower NLR and PLR, and significantly higher PNI. Levels of CEA and CA19-9 were similar, and the pathological findings were comparable between the groups. The overall survival of patients with LMR ≥2.8 (66.2% at 1 year) was superior to that of patients with LMR <2.8 (36.1% at 1 year, p = 0.015). Multivariate analysis identified LMR <2.8 (hazard ratio 1.72, 95% CI 1.02-2.89, p = 0.042), lymphatic and venous invasion and positive surgical margin as independent prognostic factors.

CONCLUSIONS

LMR may carry important prognostic information for patients with resectable PHC. Preoperative LMR may be considered for use in risk stratification for individual patients with PHC.

Cholangiographic Tumor Classification for Simple Patient Selection Prior to Hepatopancreatoduodenectomy for Cholangiocarcinoma

BACKGROUND

Hepatopancreatoduodenectomy (HPD) is employed for patients with laterally advanced cholangiocarcinoma. However, the survival benefit of this extended approach remains controversial. The aim of this study is to identify a tumor feature benefiting from HPD from the standpoint of long-term survival.

PATIENTS AND METHODS

Patients with cholangiocarcinoma who underwent HPD with curative intent between 2001 and 2017 were retrospectively analyzed. Tumors were radiologically classified by preoperative cholangiogram. Diffuse type was defined as significant tumor/stricture located from the hilar to intrapancreatic duct; localized type was defined as tumor otherwise. Univariable and multivariable analyses were performed to identify prognostic indicators.

RESULTS

Of 100 study patients, 28 (28%) patients had diffuse tumor type, while the remaining 72 (72%) patients had localized tumors. The former group showed significantly longer lateral length (43 versus 22 mm, P < 0.001) and more frequent pancreatic invasion (50% versus 32%, P = 0.110), advanced T classification (64% versus 49%, P = 0.185), and nodal metastasis (57% versus 47%, P = 0.504), compared with the latter group. The survival for patients with diffuse tumor type was significantly worse than that for patients with localized tumor type, with 5-year survival rates of 59.0% versus 26.3%, respectively (P = 0.003). Multivariable analysis identified four independent factors deteriorating long-term survival: cholangiographic diffuse tumor (P = 0.021), higher age (P = 0.020), percutaneous biliary drainage (P = 0.007), and portal vein resection (P = 0.007).

CONCLUSIONS

Presurgical cholangiographic classification, diffuse or localized type, is a tumor-related factor closely associated with survival probability; therefore, it may be a useful feature for patient selection prior to HPD for cholangiocarcinoma.

Major hepatectomy with or without pancreatoduodenectomy for advanced gallbladder cancer

BACKGROUND

The indications for major hepatectomy for gallbladder cancer either with or without pancreatoduodenectomy remain controversial. The clinical value of these extended procedures was evaluated in this study.

METHODS

Patients who underwent major hepatectomy for gallbladder cancer between 1996 and 2016 were identified from a prospectively compiled database. Postoperative outcomes and overall survival were compared between patients undergoing major hepatectomy alone or combined with pancreatoduodenectomy (HPD).

RESULTS

Seventy-nine patients underwent major hepatectomy alone and 38 patients had HPD. The patients who underwent HPD were more likely to have T4 disease (P < 0·001), nodal metastasis (P = 0·015) and periaortic nodal metastasis (P = 0·006), but were less likely to receive adjuvant therapy (P = 0·006). HPD was associated with a high incidence of grade III or higher complications (P = 0·002) and death (P = 0·037). Overall survival was longer in patients who underwent major hepatectomy alone than in patients who underwent HPD (median survival time 32 versus 10 months; P < 0·001). In multivariable analysis, surgery in the early period (1996-2006) (P = 0·002), pathological T4 disease (P = 0·005) and distant metastasis (P < 0·001) were associated with shorter overall survival, and cystic duct tumour (P = 0·002) with longer overall survival.

CONCLUSION

Major hepatectomy alone for gallbladder cancer contributes to favourable overall survival with low morbidity and mortality, whereas HPD is associated with poor overall survival and high morbidity and mortality rates. HPD may eradicate locally spreading gallbladder cancer; however, the indication for the procedure is questioned from an oncological viewpoint.

Comparison between autologous and homologous blood transfusions in liver resection for biliary tract cancer: a propensity score matching analysis

BACKGROUND

It remains unclear whether preoperative blood donation is truly beneficial in liver surgery. The aim of this study was to compare surgical outcomes between patients receiving autologous and homologous transfusions during liver resection for biliary tract cancer (BTC).

METHODS

Patients who underwent hepatectomy for BTC were retrospectively reviewed (2006-2017). Patients who deposited autologous blood and underwent resection without homologous blood transfusion intraoperatively (Autologous group) were compared with non-depositing patients who required homologous transfusion during hepatectomy (Homologous group). Propensity score matching analyses were performed to adjust the data for the baseline characteristics of both groups.

RESULTS

During the study period, 359 patients were included in the Autologous group, and 105 patients were in the Homologous group. The postoperative maximum total bilirubin (T-Bil) levels and the incidence of postoperative liver failure were significantly higher in the Homologous group than in the Autologous group. After propensity score matching, postoperative maximum T-Bil levels were significantly higher in the Homologous group, whereas the incidence of postoperative liver failure was comparable between the two groups; between-group differences were not observed for the remaining major complications, hospital stays and mortality.

CONCLUSION

Although autologous blood transfusion may minimize postoperative hyperbilirubinemia, it may not decrease the risk for mortality or morbidities following hepatectomy for BTC.

Pleural dissemination of cholangiocarcinoma caused by percutaneous transhepatic biliary drainage during the management of resectable cholangiocarcinoma

BACKGROUND

Only 3 case reports have addressed pleural dissemination in association with percutaneous transhepatic biliary drainage. The aim of this study was to investigate recurrence after resection of cholangiocarcinoma after percutaneous transhepatic biliary drainage and to clarify the incidence of and the factors responsible for pleural dissemination.

METHODS

Between 2001 and 2015, we reviewed retrospectively all consecutive patients who underwent resection for perihilar or distal cholangiocarcinoma after percutaneous transhepatic biliary drainage for recurrence, including pleural dissemination.

RESULTS

During the study period, all consecutive patients underwent resection of cholangiocarcinoma after management with percutaneous transhepatic biliary drainage. Of these, 100 patients (32.1%) underwent left-sided percutaneous transhepatic biliary drainage alone, and 212 (67.9%) underwent right-sided percutaneous transhepatic biliary drainage with or without left-sided percutaneous transhepatic biliary drainage. Pleural dissemination, which developed exclusively on the right side of the thoracic cavity after resection, was found in 12 patients (3.8%); these patients underwent right-sided percutaneous transhepatic biliary drainage; computed tomography demonstrated that the percutaneous transhepatic biliary drainage catheter passed through the thoracic cavity in all 12 patients. The diagnosis of pleural dissemination was made at a median of 381 days (range, 44 to 2,944 days) after operation. Survival was poor, with a median survival time of 516 days. Statistically, right-sided percutaneous transhepatic biliary drainage was identified as a risk factor for pleural dissemination.

CONCLUSION

Pleural dissemination after right-sided percutaneous transhepatic biliary drainage is likely a procedure-related iatrogenic complication because of the "special route" by which the percutaneous transhepatic biliary drainage catheter must be passed through the right thoracic cavity.

Comparison of outcomes of laparoscopy-assisted and open proximal gastrectomy with jejunal interposition for early gastric cancer in the upper third of the stomach: A retrospective observational study

INTRODUCTION

Laparoscopy-assisted proximal gastrectomy with jejunal interposition (LAPG-JI) is not yet widely used because the three anastomotic procedures involved in this operation are technically complicated. This study aimed to describe our surgical procedure for LAPG-JI and assess its feasibility and safety.

METHODS

This was a retrospective study of 70 patients who had undergone proximal gastrectomy with jejunal interposition for gastric cancer in the upper third of the stomach between July 2007 and October 2016. Of these patients, 32 underwent LAPG-JI, and 38 underwent open proximal gastrectomy with jejunal interposition. Clinical characteristics and both surgical and postoperative outcomes were compared between LAPG-JI and open proximal gastrectomy with jejunal interposition.

RESULTS

The operation time was longer in the LAPG-JI group (189 vs 154 min, P < 0.001) and estimated blood loss was lower (30 vs 180 mL, P < 0.001). There were no differences in the rates of early (9.4% vs 13.2%) or late postoperative complications (12.5% vs 10.5%). No anastomotic leakage was observed in either group. In the LAPG-JI group, the time to first eating was shorter, and the white blood cell counts on postoperative days 1 and 7 and body temperature on postoperative day 3 were lower. The number of additional doses of postoperative analgesia was lower in the LAPG-JI group. Reflux esophagitis graded C according to the Los Angeles classification was observed in only one patient (3.1%) in the LAPG-JI group.

CONCLUSION

Although the operation time was longer in the LAPG-JI group, the procedure seemed to be feasible and safe. Also, it offered the advantages of laparoscopic surgery, including less invasiveness and quicker recovery.

Surgery for perihilar cholangiocarcinoma from a viewpoint of age: Is it beneficial to octogenarians in an aging society?

BACKGROUND

Whether operative treatment provides benefits for elderly patients with perihilar cholangiocarcinoma is unknown. The aim of this study was to review resection of perihilar cholangiocarcinoma according to age and to clarify its value for octogenarians.

METHODS

Between April 1977 and December 2015, we reviewed consecutive patients who underwent resection for perihilar cholangiocarcinoma with a special focus on patient age.

RESULTS

During the study interval, 831 patients underwent resection for perihilar cholangiocarcinoma. The median age of the resected patients increased by 11 years over approximately 40 years. Before 2001, no octogenarians underwent operative intervention; however, the proportion of operations for octogenarians increased to 9% after 2010. Further analyses were performed on 643 resected patients between 2001 and 2015. The resectability rate was not different between the octogenarians and the other age groups (71% vs 72.4%). The Charlson Comorbidity Index and preoperative laboratory data were similar between the 2 groups. A less advanced tumor was a predominant feature in the octogenarians compared to the other age groups. Consequently, the procedure used in the octogenarians were less extensive, but the proportion of R₀ resection was greater in the octogenarians than in the other age groups (95.% vs 78.3%, P = .008). The ratio of patients who died of other diseases was also greater among octogenarians (29% vs 6.0%, P < .001). Overall survival was similar between the 2 groups (41% vs 38.9% at 5 years).

CONCLUSION

Resection of perihilar cholangiocarcinoma can be performed with low mortality irrespective of age with careful patient selection and offers long-term survival even in octogenarians.