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Background Biliary tract cancer (BTC) is a type of malignancy that is challenging to manage. Further, advanced-stage BTC has poor prognosis. Based on the recent TOPAZ-1 trial, adding durvalumab to gemcitabine and cisplatin significantly improves survival in unresectable BTC, thereby making it the new standard first-line treatment. However, real-world data are essential to validate its efficacy and safety in routine clinical settings, which often involve older patients and those with comorbidities or previous therapies. This study aimed to evaluate the outcomes of combination chemotherapy with gemcitabine, cisplatin, and durvalumab (GCD) in a real-world cohort with BTC. Methods This retrospective analysis included patients with unresectable advanced-stage BTC treated with GCD between December 2022 and April 2024 at three institutions. GCD was administered for up to eight cycles, followed by durvalumab monotherapy. Clinical data, including the characteristics of the patients, adverse events, and treatment responses, were collected. The Kaplan–Meier method and the Cox proportional hazards model were used to assess progression-free survival (PFS), overall survival (OS), and other factors affecting outcomes. Results The current study included 54 patients with a median age of 72 years. Half of the patients had recurrence post-surgery, and many of them had previously received chemotherapy. The median PFS and OS rates were 4.1 and 8.0 months, respectively. Adverse events (AEs) were frequently observed, with 42.1% of patients presenting with grade 3 or higher AEs. However, immune-related AEs were rare and mild. Dose adjustments, which are often caused by renal impairment or fatigue, were common (66.7%). Multivariate analysis revealed that older age, a lower performance status score, and a high neutrophil-to-lymphocyte ratio (NLR) were significant predictors of a shorter PFS. Further, a lower performance status score, and a high NLR were associated with a low OS. Conclusions GCD combination chemotherapy is a viable treatment option for advanced-stage BTC in a real-world setting where dose modifications can improve tolerability among elderly patients. Neutrophil-to-lymphocyte ratio can be a prognostic biomarker of OS in patients with BTC receiving immune checkpoint inhibitors. This finding highlights the potential of individualized treatment strategies. Nevertheless, further research should be performed to validate these results in larger cohorts.

INTRODUCTION: Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare, low-grade malignant tumor. Although SPNs generally exhibit indolent behavior, spontaneous regression detected on CT imaging is exceedingly rare, and to the best of our knowledge, regrowth following regression has not been previously reported.CASE PRESENTATION: A 33-year-old woman was referred to Kansai Medical University following the detection of liver dysfunction during a routine medical checkup. Imaging revealed a well-demarcated 20-mm mass in the pancreatic body, and an endoscopic US-guided biopsy confirmed SPN. Surgical resection was initially planned but postponed because of a COVID-19 infection in a fellow inpatient. During follow-up, the tumor showed spontaneous regression and became undetectable on imaging at 4 months. However, MRI at 16 months revealed tumor regrowth, which became clearly visible on T2-weighted imaging by 23 months, measuring 15 mm. At 24 months, a laparoscopic spleen-preserving distal pancreatectomy was performed. Histopathology confirmed SPN with intratumoral hemorrhage and characteristic pseudopapillary architecture. Complete resection was achieved, and the patient’s postoperative course was uneventful.CONCLUSIONS: This case illustrates that SPN can regress spontaneously, yet subsequently regrow, underscoring the need for careful long-term imaging surveillance even after apparent tumor shrinkage.

Background Posthepatectomy liver failure (PHLF) remains a severe complication after liver resection. This retrospective study investigated the correlation of three hepatic functional tests and whether 99mTc-galactosyl human serum albumin (99mTc-GSA) scintigraphy and modified albumin–bilirubin (ALBI) score are useful for predicting PHLF. Methods This retrospective cohort study included 413 consecutive patients undergoing hepatectomies between January 2017 and December 2020. To evaluate preoperative hepatic functional reserve, modified ALBI grade, indocyanine green clearance (ICG-R15), and 99mTc-GSA scintigraphy (LHL15) were examined before scheduled hepatectomy. Based on a retrospective chart review, multivariable logistic regression analysis adjusted for confounding factors was performed to confirm that mALBI, ICG-R15, and LHL15 are independent risk factors for PHLF. Results ICG-R15 and LHL15 were moderately correlated ( r  =  − 0.61) but this correlation weakened when ICG-R15 was about ≥ 20. Weak correlations were observed between LHL15 and ALBI score ( r  =  − 0.269) and ALBI score and ICG-R15 ( r  = 0.339). Of 413 patients, 66 (19%) developed PHLF (20 grade A, 44 grade B, 2 grade C). Multivariable logistic regression analyses, major hepatectomy ( P  < 0.001), mALBI grade ( P  = 0.01), ICG-R15 ( P  < 0.001), and Esophagogastric varices ( P  = 0.007) were significant independent risk factors for PHLF. Subgroup analysis showed that ICG-R15 < 19, major hepatectomy, and mALBI grade and ICG-R15 ≥ 19, major hepatectomy, LHL15, and Esophagogastric varices were significant independent risk factors for PHLF ( P  = 0.033, 0.017, 0.02, 0.02, and 0.001, respectively). Conclusion LHL15, the assessment of Esophagogastric varices, and mALBI grade are complementary to ICG-R15 for predicting PHLF risk.

Aim Emergency cholecystectomy for acute cholecystitis remains controversial in patients classified as high risk by the Tokyo Guidelines 2018 (TG18), although surgery is often unavoidable in real‐world emergency settings. The perioperative risk profile of this TG18 non‐recommended population remains insufficiently defined. The objective of this study was to examine perioperative outcomes in patients undergoing emergency cholecystectomy against TG18 recommendations, while also exploring clinical factors associated with actual operative risk. Methods This retrospective cohort study included 252 consecutive patients who underwent emergency cholecystectomy for acute cholecystitis between 2018 and 2025. Patients were stratified into TG18 emergency‐surgery‐recommended and non‐recommended groups. Perioperative outcomes were compared, and independent risk factors of major postoperative complications, defined as Clavien‐Dindo grade≥III events, were evaluated. Results Major postoperative complications occurred in 11.9% of patients and were significantly more frequent in the TG18 non‐recommended group than in the recommended group (18.0% vs. 2.9%, p < 0.001). In multivariable analysis, American Society of Anesthesiologists physical status classification ≥ 3 and preoperative shock status were independent predictors of major postoperative complications, whereas age and Charlson Comorbidity Index were not. Exploratory stratification of the non‐recommended cohort demonstrated substantial heterogeneity in risk, with comparatively low complication rates observed in patients without physiological instability. Conclusion Emergency cholecystectomy may be feasible in carefully selected TG18 non‐recommended patients. Perioperative risk appears to be driven by physiological instability rather than chronological age or comorbidity burden, supporting a more individualized approach to surgical decision‐making. Emergency cholecystectomy was evaluated in patients with acute cholecystitis classified as non‐recommended for surgery by the Tokyo Guidelines 2018. Major postoperative complications, rather than mortality, better reflected operative risk. Physiological instability, particularly ASA‐PS ≥ 3 and shock status, identified high‐risk patients, suggesting that surgical decision‐making should prioritize real‐time physiological status over age or comorbidity burden.

BackgroundThe optimal approach for the safe implementation and education of robotic pancreaticoduodenectomy (RPD) remains unclear. Prolonged operation time may cause surgeon fatigue and result in perioperative complications. To solve this issue, our department adopted task division by the console surgeon turnover between resection and reconstruction in 2022.MethodsThis study retrospectively investigated consecutive patients who underwent RPD from November 2009 (initial introduction of RPD) to December 2023. The analysis excluded patients who underwent concomitant resection of other organs. The cases performed by a single console surgeon (single approach) were compared with those performed by two or more console surgeons (multiple approach).ResultsThis study analyzed 85 consecutive RPD cases, including 51 with the single approach and 34 with the multiple approach. The operation time was significantly shorter (832 vs. 618 min, p < 0.001), and the postoperative major complication was less frequent (45% vs. 12%, p = 0.003) in the multiple approach group, although less experienced surgeons performed the multiple approach (number of RPD experiences: 19 cases vs. 5 cases, p < 0.001). The console surgeon turnover between the resection and reconstruction resulted in a safe pancreatojejunostomy performed by the less experienced surgeon (number of pancreatic reconstruction experiences: 6.5 vs. 14 cases, p = 0.010). Surgeons who started RPD with a multiple approach observed a reduction in surgical time and a lower incidence of complications earlier than those who started with a single approach.ConclusionTask division during the early introduction phase of RPD using the multiple approach demonstrated potential contributions to improved surgical outcomes and enhanced educational benefits.

BackgroundRobotic pancreaticoduodenectomy (RPD) is technically demanding, and 20–50 cases are required to surpass the learning curve. This study aimed to show our experience of 76 cases from the introduction of RPD and report the changes in surgical results owing to the accumulation of cases and optimization of surgical techniques.MethodsA total of 76 patients who underwent RPD between November 2009 and May 2023 at the Fujita Health University Hospital were divided into three groups: competency (n = 23, Nov 2009–Mar 2020), proficiency (n = 31, Apr 2020–Jun 2022), and mastery (n = 22, Jul 2022–May 2023) phases. In the mastery phase, for the education of new surgeons and maintenance of surgical quality, optimization of the procedure, including hanging maneuver with or without stapling transection of the retropancreatic tissue was implemented. The surgical outcomes were compared between the groups.ResultsThe mean operation time decreased over time despite of the participation of newly started operators in mastery phase [competency: 921.5 min (IQR 775–996 min) vs. proficiency: 802.8 min (IQR 715–887 min) vs. mastery: 609.2 min (IQR 514–699 min), p < 0.001]. Additionally, Clavien–Dindo ≥ grade IIIa complications decreased from 52.2% in competency phase to 35.5% and 9.1% in proficiency and mastery phases, respectively (p = 0.005).ConclusionOperation time and major complications decreased along the learning curve from the introduction of RPD. In addition, optimization of the procedure, including hanging maneuver of the retropancreatic tissue seemed to be effective in reducing operation time and educating new RPD surgeons.

Surgical techniques and outcomes of minimally invasive anatomic liver resection (AR) using the extrahepatic Glissonian approach for hepatocellular carcinoma (HCC) are undefined. In 327 HCC cases undergoing 185 open (OAR) and 142 minimally invasive (MIAR; 102 laparoscopic and 40 robotic) ARs, perioperative and long-term outcomes were compared between the approaches, using propensity score matching. After matching (91:91), compared to OAR, MIAR was significantly associated with longer operative time (643 vs. 579 min, p = 0.028); less blood loss (274 vs. 955 g, p < 0.0001); a lower transfusion rate (17.6% vs. 47.3%, p < 0.0001); lower rates of major 90-day morbidity (4.4% vs. 20.9%, p = 0.0008), bile leak or collection (1.1% vs. 11.0%, p = 0.005), and 90-day mortality (0% vs. 4.4%, p = 0.043); and shorter hospital stay (15 vs. 29 days, p < 0.0001). On the other hand, laparoscopic and robotic AR cohorts after matching (31:31) had comparable perioperative outcomes. Overall and recurrence-free survivals after AR for newly developed HCC were comparable between OAR and MIAR, with potentially improved survivals in MIAR. The survivals were comparable between laparoscopic and robotic AR. MIAR was technically standardized using the extrahepatic Glissonian approach. MIAR was safe, feasible, and oncologically acceptable and would be the first choice of AR in selected HCC patients.

Robotic distal pancreatectomy (RDP) has emerged as a minimally invasive approach to left-sided pancreatic tumors. This study aimed to evaluate the efficacy of the robot-assisted approach (RAA) using a laparoscopic articulating vessel-sealing device (LAVSD) during RDP by comparing it with the pure-robotic approach (PRA). Among 62 patients who underwent RDP between April 2020 and December 2023 at Fujita Health University, 22 underwent RAA (the RAA group). In RAA, console surgeons mainly prepared the surgical fields, and assistant surgeons actively dissected the adipose and connective tissues using LAVSD. The surgical outcomes of these patients were compared with those of 40 consecutive patients who underwent RDP with PRA. In total, 28 males and 34 females with a median age of 71 years were analyzed. The console surgeon’s prior experience of performing RDP was similar between the groups (RAA; median, 6 [range, 0–36], PRA; median, 5.5 [range, 0–34] cases). The operation time was significantly shorter in the TST group (median, 300.5 [range, 202–557] vs. 363.5 [range, 230–556] min, p  = 0.015). Major complications (Clavien–Dindo ≥ grade 3a) occurred less frequently in the RAA group (4.6% vs. 25.0%, p  = 0.028). Although the median postoperative hospital stay was slightly shorter in the RAA group (median, 12 [range, 8–38] vs. 14.5 [8–44] days, p  = 0.095), no statistically significant difference was observed. Compared with PRA, RAA using LAVSD is found to be safe and feasible in introducing RDP for operators with little experience.