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Background Extending the clinical indications for laparoscopic liver resection (LLR) should be carefully considered based on a surgeon’s experience and skill. However, objective indexes to help surgeons assess the estimated difficulty of LLR are scarce. The aim of our study was to develop the first objective numerical rating scale to predict the surgical difficulty of various LLR procedures. Methods We performed a retrospective review of the operative outcomes of 187 patients who underwent a pure LLR. First, the value of preoperative factors for predicting surgical time was evaluated by multivariate linear regression analyses, and a scoring system was constructed. Next, the integrity of our predictive linear model was evaluated against the documented operative outcomes for patients forming our study group. Results Four predictive factors were identified and scored based on the weighted contribution of each factor predicting surgical time: extent of resection (scored 0, 2, or 3); location of tumor (scored 0, 1, or 2); obesity (scored 0 or 1); and platelet count (scored 0 or 1). The scores were summed to classify surgical difficulty into three levels: low (total score ≤1); medium (total score 2–3); and high (total score ≥4). Operative outcomes, including surgical time, volume of blood loss, length of hospital stay, and rate of morbidity, were significantly different between the three surgical difficulty levels. Conclusion Our novel model will be useful for surgeons to predict the difficulty of an LLR procedure relative to their own experience and skill.

Background Laparoscopic major hepatectomy (LMH) is an innovative procedure that is still in the exploration phase. Although new surgical techniques have learning curves, safety should be maintained from the onset. This retrospective study was conducted to evaluate the safe introduction of LMH. Methods We retrospectively reviewed data from 245 consecutive patients who underwent pure laparoscopic liver resection. Patients were divided into three groups: Phase I, the first 64 cases, all minor hepatectomies; Phase II, cases from the first LMH case to the midmost of the LMH cases ( n  = 69, including 22 LMHs); Phase III, the most recent 112 cases, including 22 LMHs. Patient characteristics and surgical results were evaluated, and the learning curve was analysed with the cumulative sum (CUSUM) method. Results The first LMH was adopted after sufficient preparatory experience was gained from performing 64 minor hepatectomies. In cases of LMH, there were no significant differences in the surgical time between Phases II and III (356 vs. 309 min; P  = 0.318), morbidity rate (22.7 vs. 31.8 %; P  = 0.736), or major morbidity rate (18.2 vs. 9.1 %; P  = 0.664); however, estimated blood loss was significantly reduced from Phase II to Phase III (236 vs. 68 mL; P  = 0.018). The CUSUM for morbidity also showed similar outcomes through Phases II and III. Conclusion There is a learning curve associated with laparoscopic liver resection. To maintain a low morbidity rate, 60 laparoscopic minor hepatectomies could provide adequate experience before the adoption of LMH.

BackgroundThe use of pure laparoscopic donor hepatectomy has been increasing, with various advantages reported. However, the Glissonean approach has not been adopted despite its usefulness. The aim of this study was to introduce the Glissonean pedicle approach for laparoscopic living donor hepatectomy.MethodsWe retrospectively reviewed data from 11 patients who underwent pure laparoscopic donor hepatectomy for adult living donor liver transplantation. In this novel operative procedure, after mobilization of the liver, the right or left Glissonean pedicle was encircled, and then the liver parenchymal transection was completed. Next, the right or left hepatic artery, portal vein, and hepatic duct were dissected out. The right or left hepatic duct was divided under intraoperative cholangiography guidance using indocyanine green fluorescence, and the hepatic artery and the portal vein were cut. Finally, the hepatic vein was divided using the laparoscopic stapler, and the graft liver was procured via a suprapubic incision.ResultsThe overall median surgical time was 387 min (range 280–563 min), and the volume of blood loss was 75 mL (21–1228 mL). The warm ischemic time was 5 min (2–10 min). A conversion to open procedure was occurred in 1 patient. A complication, a grade IIIa bile leakage according to the Clavien–Dindo classification, was noted in 1 patient.ConclusionThis is the first report of the Glissonean pedicle approach for pure laparoscopic donor hepatectomy; our results demonstrate the safety and feasibility of this technique.

Background The use of laparoscopic liver resection (LLR) is widespread owing to its several advantages, especially smaller incision (Kaneko et al., Ann Gastroenterol Surg 1:33–43, 1 ; Ciria et al., Surg Endosc 34:349–360, 2 ). However, both posterior sectionectomy and donor hepatectomy are extremely difficult procedures to perform in LLR (Hasegawa et al., Ann Gastroenterol Surg 2:376–382, 3 ; Soubrane and Kwon, J Hepatobiliary Pancreat Sci 24:E1–E5, 4 ; Takahara et al., Transplantation 101:1628–1636, 5 ; Lee et al., Clin Transplant 33:e13683, 6 ; Hong et al., Surg Endosc 33:3741–3748, 7 ; Rhu et al., J Hepatobiliary Pancreat Sci 27:16–25, 8 ). Moreover, the right posterior section graft procurement is also difficult even in open laparotomy procedure (Sugawara et al., Transplantation 73:111–114, 9 ; Hwang et al., Liver Transpl 10:1150–1155, 10 ; Hori, Kirino, and Uemoto, Hepatol Res 45:1076–1082, 11 ; Kusakabe et al., Liver Transpl 26:299–303, 12 ). The pure laparoscopic donor posterior sectionectomy has not been reported yet. Therefore, we aimed to introduce a novel procedure through a video clip. Methods The donor was placed in the semi-left lateral decubitus position with the reverse Trendelenburg position using a bean bag device. The right liver was mobilized, and the right hepatic vein was exposed. To adopt the liver hanging maneuver, a tape was inserted between the middle and right hepatic veins along the inferior vena cava. The posterior Glissonean pedicle was encircled and controlled, and the liver parenchyma was completely transected using the liver hanging maneuver. The vessels to the posterior section were respectively isolated. The posterior branches of the hepatic duct, hepatic artery, and portal vein were cut. The right hepatic vein was divided, and the graft liver was retrieved via a suprapubic incision. This study was approved by institutional ethics board (No. MH2019-119), and informed consent was taken from the patient. Results The overall surgical time was 503 min, and the blood loss was 400 mL. No complications were observed, and the donor was discharged from the hospital on postoperative day 11. Conclusion This is the first report of pure laparoscopic donor hepatectomy of the posterior section graft. This procedure is more difficult than other laparoscopic donor hepatectomies because it involves parenchymal transection in the right intersectional plane and dissection of the posterior branches of hilar vessels.

BackgroundPure laparoscopic donor hepatectomy (PLDH) is being increasingly performed at centers with experienced surgeons [1–6]. This procedure is still developing and is associated with several challenges owing to its technical difficulty [7–9]. Conversely, the anterior approach is sometimes applied to both laparoscopic and open right hepatectomy for management of tumors in the liver [10, 11]. However, there are no reports regarding the use of the anterior approach for PLDH. We found this method to be useful; therefore, we aimed to introduce the novel procedure using a video clip.MethodsThe donor was placed in the supine position. First, the right side of the inferior vena cava was dissected instead of performing the liver hanging maneuver. The right Glissonean pedicle was encircled and controlled, and the liver parenchyma was completely transected. Thereafter, the ligaments around the liver were dissected, and the graft was mobilized. The hilar vessels were respectively separated. Finally, the right hepatic duct, right hepatic artery, right portal vein, and right hepatic vein were divided, and the graft liver was retrieved. This study was approved by institutional ethics board (MH2019-119), and informed consent was taken from the patient.ResultsThe overall surgical time was 400 min, the volume of blood loss was 31 mL, the warm ischemic time was 7 min, and no complications were seen.ConclusionThe advantages of the anterior approach for right-sided PLDH might be attribute to reduction of compression injury and incidence of subcapsular hematoma, as liver mobilization is easily performed because of increased liver mobility. However, PLDH is a highly-skilled procedure, and indications for PLDH should be extended in a step-wise manner. Further, the procedure should be performed only by highly proficient surgeons having extensive experience in both laparoscopic liver resection and living donor liver transplantation.

Background Robotic liver resection has emerged as a new modality in the field of minimally invasive surgery. However, the effectiveness of this approach for liver resection is not yet known. Methods A literature survey was performed using specific search phrases in PubMed. Case series that focused on biliary reconstruction were excluded. Characteristics, such as patient demographics, perioperative outcomes, and oncological results for colorectal liver metastasis and hepatocellular carcinoma were analyzed. Results Nineteen series that described the cases of 217 eligible patients were reviewed. The most commonly performed procedures were wedge resection and segmentectomy. Right hepatectomy was performed in a few specialized centers. The conversion and complication rates were 4.6 and 20.3 %, respectively. The most common reason for conversion was unclear tumor margin. Intra-abdominal fluid collection was the most frequently occurring morbidity. Mean operation time was 200–507 min. Mean intraoperative blood loss was 50–660 mL, with a tendency toward increased blood loss observed in series that included major hepatectomies. Mean postoperative hospital stay was 5.5–11.7 days. The longest mean follow-up time was 36 months for colorectal liver metastasis and 25.1 months in hepatocellular carcinoma. Disease-free survival for mixed malignancies was comparable to that after laparoscopic procedures. Overall survival was not reported. Conclusions Robotic liver resection is safe and feasible for experienced surgeons with advanced laparoscopic skills. Long-term oncologic outcomes are unclear, but short-term perioperative results seem comparable to those of conventional laparoscopic liver resection.

PurposeTo evaluate the early remission rate of type 2 diabetes mellitus (T2DM) after laparoscopic sleeve gastrectomy (LSG) and establish a preliminary scoring system that predicts T2DM remission.MethodsWe assessed the outcomes of 49 morbidly obese patients with T2DM who underwent LSG between 2008 and 2018. The prognostic factors for T2DM remission 1 year post-LSG were identified and an original scoring system was established. We validated our scoring system by comparing it with the individualized metabolic surgery score and the ABCD score.ResultsThe patients’ mean body weight loss and percentage of excess weight loss were 34.4 kg and 59.4%, respectively, while the T2DM remission rate was 77.5%. The serum insulin level and the T2DM duration were independent predictive factors, the receiver-operating characteristic (ROC) curves for which revealed cutoff values of 12.7 ng/mL and 72 months, respectively. We set our system’s score range at 0–2, whereby patients with higher scores have a good T2DM remission prognosis, as higher insulin levels, and/or shorter T2DM duration. Our scoring system had accuracy levels similar to those of the ABCD score with a simple stratification.ConclusionOur preliminary scoring system attains a good level of accuracy for predicting T2DM remission.

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.

Purpose As a safe and reliable alternative to central venous catheters (CVCs), peripherally inserted central catheters (PICCs) are commonly used in clinical practice. However, the insertion of PICCs by nurse practitioners (NPs), especially in Japan, has not been reported extensively. Thus, we investigated the safety and efficiency of PICC insertions by NPs. Methods The participants were 1322 patients who underwent PICC insertion by NPs at Fujita Health University Hospital (FNPs). The basilic vein in the brachium was the preferred vein for insertion; the brachial vein was the alternative. Patients were monitored from the time of PICC insertion until its removal. Ultrasonography-guided puncture was used for all catheter insertions, and the catheter tip was replaced into the superior vena cava under fluoroscopic imaging with maximal sterile barrier precautions. The outcomes of the PICC insertions by the FNPs were evaluated retrospectively. Results Overall, 23 FNPs inserted a collective total of 1322 PICCs, which remained in place for a collective total of 23,619 catheter days. The rate of successful PICC insertion was 99% (1310 patients). The median time taken for PICC insertion was 12 min (interquartile range, 10–15 min). Intraoperative complications occurred in two patients (0.2%). The confirmed incidence of central line–associated bloodstream infection was 3.4% (45 patients), and these infections occurred on 1.9 per 1000 catheter days. The median duration of PICC placement was 15 days (range, 10–23 days). Conclusion PICC insertion by NPs is safe and a potential alternative to CVC insertion by surgeons.

Background/Objectives: Due to the increasing incidence of pancreatic and periampullary cancers with advancing age, coupled with the growing evidence supporting minimally invasive pancreatectomy, the demand for such procedures is rising. However, data on the feasibility of robotic pancreatectomy in octogenarian patients remain scant. This study aimed to investigate overall outcomes of robotic pancreatectomy and evaluate its safety and feasibility in octogenarian patients. Methods: A multicenter, retrospective study was conducted, including 380 patients who underwent robotic pancreatectomy at two high-volume centers in Japan from April 2020 to December 2024. Using prospectively collected data, we compared outcomes between younger patients (<80 years) and octogenarian patients (≥80 years). Multivariable logistic regression analyses were performed to assess the impact of age on postoperative outcomes. Results: Among the 380 patients, with a median age of 72 (interquartile range: 61–77) years, 213 underwent robotic pancreatoduodenectomy (RPD), and 167 underwent robotic distal pancreatectomy (RDP). Octogenarian patients were found to have more comorbidities and a higher incidence of malignant diseases. Octogenarians experienced significantly longer hospital stays post-RPD (22 [octogenarian; n = 36] vs. 14 [younger; n = 177] days, p < 0.001) and post-RDP (14 [n = 23] vs. 10.5 [n = 144] days, p = 0.02), yet their perioperative outcomes were comparable. Multivariable analyses indicated that age (≥80 years) was not a significant risk factor for major complications following robotic pancreatectomy (odds ratio, 1.33; 95% confidence interval, 0.59–2.84; p = 0.479). Conclusions: This multicenter study conducted at high-volume centers suggests that robotic pancreatectomy can be safely performed in carefully selected octogenarian patients.