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BackgroundLimited studies have reported the actual learning process of laparoscopic liver resection (LLR). This study aimed to chronologically evaluate our 15 years’ experience of LLR.MethodsAll consecutive LLRs between 2006 to 2020 were retrospectively analyzed. The time period was divided into three groups; first (2006–2010), second (2011–2015), and third (2016–2020) period. The primary endpoint of this study was a composite of overall (Clavien–Dindo grade ≥ II) or major (grade ≥ IIIa) postoperative complications within 30 days. Using the IWATE criteria (four difficulty levels based on six indices), LLR was categorized as basic (< 7 points) and advanced (≥ 7 points) one. All analyses were performed based on the intention-to-treat principles.ResultsDuring the study period, a total of 382 LLRs were gradually performed (first period, n = 54; second period, n = 114, and third period, n = 214). Low incidences of overall and major complications were maintained (9.3, 10.5, and 7.0%, p = 0.514, and 1.9, 2.6, and 2.3%, p = 1.000). Meanwhile, pure LLRs (i.e., LLRs without hand-assisted or hybrid approach) and advanced LLRs were increasingly performed in 25 (46.3%), 71 (62.3%), and 205 (95.8%) patients (p < 0.001) and 3 (5.6%), 18 (15.8%), and 58 (27.1%) patients (p < 0.001), respectively.ConclusionsThis study suggests that stepwise approach from basic to advanced procedures and use of hand-assisted or hybrid approach during the early phases for starting LLR practice may allow for maintaining low morbidity in specialized center.

BackgroundOligometastatic recurrence involves relapsed tumors for which locoregional treatment (LT) may yield a survival benefit. However, there are no clear criteria for selecting patients for LT or determining the effects of LT in recurrent biliary tract cancer (BTC). The aim of this retrospective study is to assess the effects of LT on survival outcomes and to identify potential criteria for selecting LT in recurrent BTC.Patients and MethodsIn the present work, 232 consecutive patients with recurrent BTC who initially underwent curative surgery between 1996 and 2015 were evaluated. The primary outcome was length of survival after recurrence (SAR). Propensity score stratification with various tumor-related factors was used to identify patients who would likely benefit from LT.ResultsAmong the cohort, 60 (25.9%) patients underwent LT, whereas 172 (74.1%) patients did not. The multivariate Cox model identified carbohydrate antigen 19-9 levels of > 50 U/mL, multiorgan recurrence, tumor number > 3, tumor size > 30 mm, and early recurrence (≤ 1 year) as independent predictors of poor SAR (P < 0.001 for each factor). In the propensity-score-stratified analysis, LT was associated with survival benefits for patients representing single-organ recurrence with at most three tumors and late-onset recurrence (> 1 year) (median SAR: 48.6 vs. 14.2 months, n = 33 vs. n = 34, hazard ratio: 0.10, 95% confidence interval: 0.04–0.20, P < 0.001).ConclusionsPatients with recurrent BTC may benefit from LT if they have single-organ recurrence with at most three tumors and late-onset recurrence. We propose that these patients may have clinically relevant “oligometastatic recurrence” of BTC.

Background Intermittent Pringle maneuver (PM) is widely performed to reduce blood loss during hepatectomy; however, its impact on clinically relevant post-hepatectomy liver failure (PHLF) remains controversial. This study aimed to assess the impact of PM on PHLF and explore whether PM provides additional value for predicting PHLF. Methods Consecutive patients, who underwent hepatectomy without biliary and/or vascular reconstruction between 2011 and 2018 in a single institution, were retrospectively analyzed. The main outcome was PHLF grades B/C as defined by the International Study Group of Liver Surgery. A multivariable logistic regression model of variables significantly associated with PHLF was established. The model’s predictive ability was assessed by the area under the receiver operating characteristic curve (AUROC). Results Among 597 patients, PHLF occurred in 42 (7.0%). PM was applied in 421 patients (70.5%) and was associated with the development of PHLF (PM vs. no-PM: 9.7 vs. 0.6%, P  < 0.001). After the propensity score matching, patients with PM experienced significantly increased rates of PHLF ( P  = 0.010). Rem-ALPlat index (including future liver remnant, preoperative albumin level, and platelet count; P  < 0.001), the number of PMs ( P  = 0.032), and blood loss ( P  = 0.007) were identified as significant predictors of PHLF. The model’s AUROC combined with the intraoperative variables was higher than that of the preoperative model alone (0.877 vs. 0.789, P  = 0.004). Conclusions PM was involved in the occurrence of clinically relevant PHLF. Further, intraoperative factors including PM may provide additional value to predict PHLF and may facilitate early post-hepatectomy intervention.

Chylous ascites, a rare but severe complication of abdominal surgery, often results from lymphatic vessel damage during procedures, such as extended resection and lymphadenectomy. Although conservative management through dietary modifications and medications is the primary approach, refractory cases may lead to severe complications including nutritional deficiencies and even death. Herein, we report a case of refractory chylous ascites that progressed to chylothorax after extended right hepatectomy with lymph node dissection for intrahepatic cholangiocarcinoma. A 73-year-old woman developed chylous ascites one month postoperatively, which subsequently perforated the diaphragm and led to a massive chylothorax. Despite conservative management including fasting and drainage, surgical intervention was required to resolve the condition. This case highlights the importance of timely recognition and treatment of refractory chylous ascites after extensive liver resection.

Immune checkpoint inhibitors (ICIs) have been approved for treating various advanced malignancies. Immune-related adverse events (irAEs) can manifest diversely and at varying times. However, postoperative diarrhea is a common complication in pancreaticoduodenectomy (PD). This case report presents a unique instance of delayed-onset irAE colitis occurring one year after PD in a patient with gastric cancer who received neoadjuvant nivolumab, a monoclonal antibody targeting human programmed death 1. A 54-year-old male developed severe diarrhea and weight loss, ultimately diagnosed with irAE colitis, which responded to steroid therapy. This report underscores the importance of extended monitoring, recognizing the potential for late-onset toxicities associated with ICIs, and differentiating from PD-related diarrhea.

Background We previously reported that tumor standardized uptake value (SUVmax) by 18 F-fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) was a potential predictor in patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC). However, the prognostic value of SUVmax in the era of multidisciplinary strategy has remained unclear. The aim of this study was to reappraise the prognostic value of tumor SUVmax in patients undergoing surgery for ICC. Methods Data from 82 consecutive ICC patients, who underwent 18 F-FDG-PET/CT and subsequent surgery between 2006 and 2017, were retrieved from a prospectively maintained institutional database. Adjuvant strategy was administrated during this study period in our center. Results Tumor SUVmax was associated with tumor size ( p  = 0.002) and tumor number ( p  = 0.005), but not associated with T and N stage classified by American Joint Committee on Cancer-classification system, and other tumor factors. According to the tumor SUVmax cut-off values of 8.0 based on the minimum p value approach, actuarial 5-year overall survival (OS) rates in patients undergoing upfront surgery for ICC were significantly stratified at 54.7% versus 26.0% (low vs. high tumor SUVmax group, p  = 0.008). The actuarial 3-year disease-free survival (DFS) rates were also significantly stratified at 41.0% versus 18.3% ( p  < 0.001). Multivariate Cox regression analyses revealed that tumor SUVmax retained its significance on OS ( p  = 0.039) as well as DFS ( p  < 0.001). Conclusion Even in the era of multidisciplinary strategy, high tumor SUVmax still represents poor prognosis in patients undergoing surgery for ICC. These patients, therefore, would probably be required more effective strategies.

Background/Aim: This study evaluated the prognostic relationship between tumor 18F-fluorodeoxyglucose (FDG) uptake on positron-emission tomography (PET)/computed tomography (CT) imaging and markers of systemic inflammatory response (SIR) in patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC). Patients and Methods: Between 2002 and 2016, 94 patients with ICC who underwent 18F-FDG-PET scans before surgery were analyzed. 18F-FDG uptake was quantified as a maximum standardized uptake value (SUVmax). The neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and C-reactive protein (CRP) were selected as SIR markers. Results: There was no strong correlation between SUVmax and, NLR, PLR and CRP (all Pearson's |r| <0.40). Multivariate Cox regression analyses identified high tumor SUVmax (≥8) and high NLR (≥5) as independent predictors of poor overall survival (p=0.013 and p=0.002) and disease-free survival (p<0.001 and p=0.004). Conclusion: Prognostic information provided by tumor SUVmax and SIR markers may be independent prognostic factors in patients undergoing surgery for ICC.