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BackgroundLaparoscopic anatomic liver resection is considered highly challenging, especially in segment 8 (S8), owing to the limited angle of the laparoscope and limited manipulation of the surgical instrument1,2. Additionally, resection is technically difficult when approaching the more peripheral branches since the Glissonean pedicle of S8 has several variations3 and is far from the hepatic hilum. The hepatic vein (HV)-guided approach involves entering from the cranial side of the liver while overcoming these difficulties with the unique view and techniques of laparoscopy4,5. We describe laparoscopic anatomic resection of the dorsal part of S8 using the HV-guided approach for hepatocellular carcinoma.Methods The drainage vein of segment 8 (V8), which often runs between the ventral and dorsal parts of S86,7, was exposed from the confluence of the middle HV to the periphery. The dorsal Glissonean branch of S8 (G8dor) was identified by deep dissection of the parenchyma on the right side of the V8. The right HV (RHV) was exposed toward the periphery after dissecting the G8dor. Liver parenchymal dissection was completed by connecting the demarcation line and the RHV.ResultsThe total operation time was 319 min, estimated blood loss was 5 mL, and the patient was discharged on postoperative day 6 with no complications.ConclusionLaparoscopic anatomic resection of the dorsal parts of S8 could be safely performed by exposing the HVs from their roots and using the HVs as a landmark to identify the intrahepatic Glissonean pedicles.

BackgroundLaparoscopic anatomic liver resections of the posterosuperior segments are technically demanding procedures.1–5 The segments are located in a deep-seated area of the liver surrounded by the ribs and the diaphragm, making forceps manipulation difficult. To overcome this limitation, an intrahepatic Glissonean approach and exposure of the hepatic veins from the root side was applied.6–10 The authors describe the technical aspects of performing a bisegmentectomy 7–8.MethodsLiver parenchymal transection was initiated from the ventral aspect of the root of the middle hepatic vein, which often runs in the intersegmental plane, identifying the Glissonean pedicle of segment 8 (G8). After dissection of the G8, segmentectomy 8 was performed through identification of the ischemic area. After complete mobilization of the right lobe, the Glissonean pedicle of segment 7 (G7), which runs relatively near the liver surface,9, 10 was marked using ultrasonography. After division of the G7, a wide dissection between the caudate lobe and segment 7 was performed and connected to the previously dissected plane from the dorsal side of the right hepatic vein (RHV). Finally, bisegmentectomy 7–8 was performed with RHV resection because of tumor invasion.ResultsThe operation time was 510 min, and the estimated blood loss was 150 ml. The patient was discharged on postoperative day 10 without any complications.ConclusionsApplication of the intrahepatic Glissonean approach and exposure of the major hepatic veins from their roots using unique laparoscopic principles allows a safe performance of bisegmentectomy 7–8.

Several therapeutic regimens, including neoadjuvant chemoradiation therapy (NACRT), have been reported to serve as anticancer immune effectors. However, there remain insufficient data regarding the immune response after NACRT in pancreatic ductal adenocarcinoma (PDAC) patients. Data from 40 PDAC patients that underwent surgical resection after NACRT (NACRT group) and 30 PDAC patients that underwent upfront surgery (US group) were analyzed to examine alterations in immune cell counts/distribution using a multiplexed fluorescent immunohistochemistry system. All immune cells were more abundant in the cancer stroma than in the cancer cell nest regardless of preoperative therapy. Although the stromal counts of CD4+ T cells, CD20+ B cells, and Foxp3+ T cells in the NACRT group were drastically decreased in comparison with those of the US group, counts of these cell types in the cancer cell nest were not significantly different between the two groups. In contrast, CD204+ macrophage counts in the cancer stroma were similar between the NACRT and US groups, while those in the cancer cell nests were significantly reduced in the NACRT group. Following multivariate analysis, only a high CD204+ macrophage count in the cancer cell nest remained an independent predictor of shorter relapse‐free survival (odds ratio = 2.37; P = .033). NACRT for PDAC decreased overall immune cell counts, but these changes were heterogeneous within the cancer cell nests and cancer stroma. The CD204+ macrophage count in the cancer cell nest is an independent predictor of early disease recurrence in PDAC patients after NACRT. This study sought to investigate any potential alterations in the distribution and clinical impact of immune cells in patients with pancreatic ductal adenocarcinoma (PDAC) treated with neoadjuvant chemoradiation therapy (NACRT). The present analysis revealed that NACRT for PDAC decreased overall immune cell counts, but these changes were heterogeneous within the cancer cell nests and cancer stroma. The CD204+ macrophage count in the cancer cell nest is an independent predictor of early disease recurrence in PDAC patients after NACRT.

Background The incidence of hepatocellular carcinoma (HCC) requiring surgical treatment in older patients has been continuously increasing. This study aimed to examine the safety and feasibility of performing laparoscopic liver resection (LLR) versus open liver resection (OLR) for HCC in older patients at a Japanese institution. Methods Between January 2010 and June 2021, 133 and 145 older patients (aged ≥ 70 years) who were diagnosed with HCC underwent LLR and OLR, respectively. Propensity score matching (PSM) analysis with covariates of baseline characteristics was performed. The intraoperative and postoperative data were evaluated in both groups. Results After PSM, 75 patients each for LLR and OLR were selected and the data compared. No significant differences in demographic characteristics, clinical data, and operative times were observed between the groups, although less than 10% of cases in each group underwent a major resection. Blood loss (OLR: 370 mL, LLR: 50 mL; P  < 0.001) was lower, and the length of postoperative hospital stay (OLR: 12 days, LLR: 7 days; P  < 0.001) and time to start of oral intake (OLR: 2 days, LLR: 1 day; P  < 0.001) were shorter in the LLR group than in the OLR group. The incidence of complications ≥ Clavien–Dindo class IIIa was similar between the two groups. Conclusions LLR, especially minor resections, is safely performed and feasible for selected older patients with HCC.

Background In the surgical treatment of intrahepatic cholangiocarcinoma (ICC), postoperative complications may be predictive of long-term survival. This study aimed to identify an immune-nutritional index (INI) that can be used for preoperative prediction of complications. Patients and methods Multi-institutional data from 316 patients with ICC who had undergone surgical resection were retrospectively analysed, with a focus on various preoperative INIs. Results Severe complications (Clavien-Dindo grade III–V) were identified in 66 patients (20.8%), including Grade V complications in 7 patients (2.2%). Comparison of areas under the receiver operating characteristic curve (AUCs) among various INIs identified the prognostic nutritional index (PNI) as offering the highest predictive value for severe complications (AUC = 0.609, cut-off = 50, P  = 0.008). Multivariate analysis revealed PNI <  50 (odds ratio [OR] = 2.22, P  = 0.013), hilar lesion (OR = 2.46, P  = 0.026), and long operation time (OR = 1.003, P  = 0.029) as independent risk factors for severe complications. In comparing a high-PNI group (PNI ≥ 50, n  = 142) and a low-PNI group (PNI <  50, n  = 174), the low-PNI group showed higher rates of both major complications (27% vs. 13.4%; P  = 0.003) and infectious complications (14.9% vs. 3.5%; P  = 0.0021). Furthermore, median survival time and 1- and 5-year overall survival rates were 34.2 months and 77.4 and 33.8% in the low-PNI group, respectively, and 52.4 months and 89.3 and 47.5% in the high-PNI group, respectively ( P  = 0.0017). Conclusion Preoperative PNI appears useful as an INI correlating with postoperative severe complications and as a prognostic indicator for ICC.

The Tokyo Guidelines 2018 (TG18) recommend emergent cholecystectomy (EC) for acute cholecystitis. However, the number of patients on antithrombotic therapy (AT) has increased significantly, and no evidence has yet suggested that EC should be performed for acute cholecystitis in such patients. The aim of this study was to evaluate whether EC is as safe for patients on AT as for patients not on AT. We retrospectively analyzed patients who underwent EC from 2007 to 2018 at a single center. First, patients were divided into two groups according to the use of antithrombotic agents: AT; and no-AT. Second, the AT group was divided into three sub-groups according to the use of single antiplatelet therapy (SAPT), double antiplatelet therapy (DAPT), or anticoagulant with or without antiplatelet therapy (AC ± APT). We then evaluated outcomes of EC among all four groups. The primary outcome was 30- and 90- day mortality rate, and secondary outcomes were morbidity rate and surgical outcomes. A total of 478 patients were enrolled (AT, n = 123, no-AT, n = 355) patients. No differences in morbidity rate (6.5% vs. 3.7%, respectively; P  = 0.203), 30-day mortality rate (1.6% vs. 1.4%, respectively; P  = 1.0) or 90-day mortality rate (1.6% vs. 1.4%, respectively; P  = 1.0) were evident between AT and no-AT groups. Between the no-AT and AC ± APT groups, a significant difference was seen in blood loss (10 mL vs. 114 mL, respectively; P  = 0.017). Among the three AT sub-groups and the no-AT group, no differences were evident in morbidity rate (3.7% vs. 8.9% vs. 0% vs. 6.5%, respectively; P  = 0.201) or 30-day mortality (1.4% vs. 0% vs. 0% vs. 4.3%, respectively; P  = 0.351). No hemorrhagic or thrombotic morbidities were identified after EC in any group. In conclusion, EC for acute cholecystitis is as safe for patients on AT as for patients not on AT.

Background The treatment of delayed complications after liver trauma such as bile leakage (BL) and hepatic artery pseudoaneurysms (HAPs) is difficult. The purpose of this study is to investigate the outcomes and management of post-traumatic BL and HAPs. Methods We retrospectively evaluated patients diagnosed with blunt liver injury, graded by the American Association for the Surgery of Trauma Liver Injury Scale, who were admitted to our hospital between April 2010 and December 2019. Patient characteristics and treatments were analyzed. Results A total of 176 patients with blunt liver injury were evaluated. Patients were diagnosed with grade I–II liver injury (n = 127) and with grade III-V injury (n = 49). BL was not observed in patients with grade I–II injury. Eight patients with grade III-V injury developed BL: surgical intervention was not needed for six patients with peripheral bile duct injury, but hepaticojejunostomy was needed for two patients with central bile duct injury. Out of 10 patients with HAPs, only three with grade I–II injury and one with grade III–V were treated conservatively; the rest six with grade III-V injury required transcatheter arterial embolization (TAE). All pseudoaneurysms disappeared. Conclusions Severe blunt liver injury causing peripheral bile duct injury can be treated conservatively. In contrast, the central bile duct injury requires surgical treatment. HAPs with grade I–II injury might disappear spontaneously. HAPs with grade III–V injury should be considered TAE.

Undifferentiated carcinoma with osteoclast-like giant cells (UC-OGC) is a rare pancreatic tumor and typically presents as a giant hypervascular tumor with rapid growth and intratumoral hemorrhage. UC-OGC localized in the main pancreatic duct (MPD) without extraductal invasion is extremely rare and difficult to diagnose preoperatively. Although the tumor rapidly increases in size and often becomes too large for resection, patients with UC-OGC who undergo curative resection show a better prognosis than those with other types of undifferentiated carcinomas and pancreatic ductal adenocarcinoma (PDAC). We must recognize that UC-OGC could present as an MPD-localized tumor and, therefore, should not miss the chance for resection. In this study, we present an unusual case of UC-OGC that was completely localized in the MPD without extraductal invasion. A 77-year-old Japanese man presented to our hospital with excessive thirst. Blood tests showed elevated glycosylated hemoglobin levels (11.9%). Carcinoembryonic antigen, carbohydrate antigen 19-9, Duke pancreatic monoclonal antigen type 2, Span-1, and neuron-specific enolase levels were within normal ranges. Contrast-enhanced computed tomography (CT) showed a 22-mm indistinct nodule with prolonged enhancement in the pancreatic body and dilatation of the distal MPD. Fluorine-18-fluorodeoxyglucose positron-emission tomography with CT showed uptake at the nodule but no evidence of metastasis. Endoscopic ultrasonography showed that the tumor was a heterogeneous hypoechoic nodule localized in the MPD. Pancreatic juice cytology indicated atypical cells but no evidence of malignancy. We suspected PDAC, acinar cell carcinoma, or an intraductal tubulopapillary neoplasm. We performed laparoscopic distal pancreatectomy and splenectomy, along with lymph node dissection. Histopathological examination revealed a 30-mm intraductal tumor with intratumoral hemorrhage, fibrosis, and angiogenesis. The tumor was composed of atypical spindle cells that were partly positive for cytokeratin AE1/3, CAM5.2, and vimentin and scattered osteoclast-like multinucleated giant cells that were positive for CD68. The tumor was completely localized to the MPD without extraductal invasion or lymph node metastasis. The patient received tegafur, gimeracil, and oteracil potassium as postoperative adjuvant chemotherapy for six months and has been recurrence-free for more than five years. UC-OGC demonstrates rapid growth; however, a good prognosis can be expected with curative resection.

Background Open pancreaticoduodenectomy (OPD) is an essential surgical procedure for expert hepato-biliary-pancreatic (HBP) surgeons. However, there is no standard for how many surgeries must be performed by a surgeon in training before they are considered to have enough experience to ensure surgical safety. Methods Cumulative Sum (CUSUM) analysis was performed using the surgical data of OPDs performed during the training period of board-certified expert surgeons of the Japanese Society of Hepato-Biliary-Pancreatic Surgery. Results Fourteen HBP surgeons participated in this study and performed 334 OPDs during their training period. The median (interquartile range) values for operative time, blood loss, and length of hospital stay were 455 (397–519) minutes, 450 (234–-716) ml, and 28 (21–38) days, respectively. CUSUM analysis showed inflection points at 20 surgeries performed for operative time. After 20 procedures, operative time was significantly shorter (461 min vs. 425 min, p  = 0.021) and blood loss was significantly lower (470 ml vs. 340 ml, p  = 0.038). No significant differences between within 20 and after 21 procedures were found in the complication rate (53% vs. 48%, p  = 0.424) and rate of in-hospital deaths (1.5% vs.1.4%. p  = 0.945). Up to 20 surgeries, PDAC and another malignant tumor had longer operative time than benign/low malignant diseases (486 min vs. 472 min vs. 429 min, p  < 0.001), and higher blood loss (500 ml vs. 502 ml vs. 355 ml, p  < 0.001). Mortality rate was higher at PDAC cases (5% vs. 0% vs. 0%, p  = 0.01). After the 21 procedures, these outcomes were improved and no differences in by primary disease were observed. Multivariable analysis showed that within 20 surgeries were independent risk factors of longer operative time (HR2.6, p  = 0.013) and higher blood loss (HR2.0, p  = 0.049). Conclusions To stabilize the surgical outcome of OPD for malignant disease, at least 20 surgeries should be performed at a certified institution during surgeon training. Trial registration Clinical trial number: Not applicable.

Background/Objectives: Postoperative recurrence is a critical issue in the treatment of resectable pancreatic ductal adenocarcinoma (rPDAC). Moreover, the prognosis after early recurrence is extremely poor. This study aimed to develop a recurrence prediction model and to define early recurrence after upfront surgery (UFS) for rPDAC. Methods: This multicenter retrospective study included patients who underwent UFS for anatomically rPDAC between January 2013 and December 2017. Multivariate analyses were conducted to identify the risk factors for recurrence-free survival and to construct a recurrence prediction model. Subsequently, a minimum p value approach was used to determine the optimal cutoff values for early and late recurrence. Results: The cohort included 603 patients (325 men and 278 women). During the median follow-up period of 25 months (interquartile range, 15–38 months), 381 patients (63.2%) experienced a recurrence. Multivariate analyses revealed carbohydrate antigen 19-9 ≥37 U/mL (hazard ratio [HR], 1.58; p < 0.001), tumor size ≥ 2.2 cm (HR, 1.59; p < 0.001), lymph node metastasis (HR, 1.86; p < 0.001), R1 resection (HR, 1.56; p = 0.002), and no adjuvant chemotherapy (HR, 1.54; p < 0.001) as independent predictors. The recurrence prediction model demonstrated an area under the curve of 0.72–0.75. The optimal threshold for early and late recurrences was a recurrence-free interval of five months. Carbohydrate antigen 19-9 ≥ 156 U/mL was a significant predictor of early recurrence (OR, 3.28; p < 0.001). Conclusions: This study identified the prognostic risk factors for recurrence and developed a recurrence prediction model for patients undergoing UFS for rPDAC. Moreover, a recurrence-free interval of five months was identified as the optimal threshold for distinguishing between early and late recurrences.