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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.

Portal annular pancreas (PAP) is an uncommon anomaly in which the pancreatic parenchyma surrounds the portal or superior mesenteric vein. An adequate operative approach is necessary to prevent clinically relevant postoperative pancreatic fistula after pancreaticoduodenectomy for PAP. We herein report a case of robotic pancreaticoduodenectomy for PAP. In PAP, dissection of the retroportal parenchyma is the most important aspect of surgery. Adequate retraction of the portal system using vessel loops allows for a safe dissection and transection of the retroportal parenchyma. The robotic approach has some advantages for dissecting the retroportal parenchyma. The magnified three-dimensional view helps the surgeon distinguish the nerve plexus from the pancreatic parenchyma. The caudal view allows for direct dissection of the retroportal parenchyma from the superior mesenteric artery. Dissection can easily be performed using articulated forceps. Owing to these advantages, robotic pancreaticoduodenectomy can be safely performed for PAP.

INTRODUCTION: Portal vein (PV) and splenic vein (SV) stenosis are known complications of pancreatoduodenectomy (PD) and often lead to portal hypertension. PV stenosis extending to the SV confluence can result in sinistral portal hypertension (SPH), characterized by gastrointestinal varices and splenomegaly in the presence of normal liver function. There is no standardized treatment strategy for SPH following PD.CASE PRESENTATION: A 42-year-old female underwent robot-assisted PD for a pancreatic neuroendocrine tumor without immediate PV complications. Postoperatively, the patient experienced fluid retention; however, this did not pose a problem, and no therapeutic intervention was necessary. Two months later, imaging revealed PV stenosis and SV obstruction. Eleven months after surgery, the patient presented with melena, and imaging confirmed the presence of gastroesophageal varices with severe PV stenosis and complete SV obstruction. Endoscopic variceal ligation was performed, and the hemodynamic status of the portal system was assessed using computed tomography during arterial portography (CTAP). CTAP showed communication between the superior mesenteric vein and the SV via the middle colic vein. Therefore, we decided to perform PV stenting. The stent was successfully placed, resulting in a significant improvement in the esophageal varices. The patient was discharged on postoperative day 4, receiving anticoagulant therapy, with no further complications.CONCLUSIONS: This case demonstrates the efficacy of PV stenting after careful hemodynamic assessment in a patient who developed SPH due to PV stenosis and SV obstruction following PD.

Aim Regarding the resectability of pancreatic adenocarcinoma (PDAC), not only anatomical factors but also biological and conditional factors have come to be considered. This study examined the impact of the Global Leadership Initiative on Malnutrition (GLIM) criteria on prognosis after resection of anatomically resectable PDAC. Methods The medical records of consecutive patients who underwent resection for resectable PDAC between January 1, 2014, and December 31, 2022, were retrospectively reviewed. Patients were classified as normal, moderately, or severely malnourished according to the GLIM criteria. Results In total, 194 patients were included in the analysis. According to the GLIM criteria, 61 (31.4%), 49 (25.2%), and 84 (42.3%) patients were normal, moderately, and severely malnourished, respectively. Patients with malnutrition had shorter overall, recurrence‐free, and disease‐specific survival (OS, RFS, and DSS) than normal patients (OS, normal vs. moderate, p = 0.015; normal vs. severe, p < 0.001; RFS, normal vs. moderate p = 0.012, normal vs. severe, p < 0.001; DSS, normal vs. moderate, p = 0.023; normal vs. severe, p < 0.001). In multivariate analysis regarding OS using all factors, moderate or severe malnutrition according to the GLIM criteria (p = 0.007), performance status (p = 0.086), preoperative diabetes (p = 0.017), tumor diameter ≥ 3 cm (p = 0.002), lymph node metastasis (p < 0.001), and postoperative adjuvant therapy (p = 0.027) were independent prognostic factors. In multivariate analysis using preoperative factors, malnutrition according to the GLIM criteria remained a significant prognostic factor (p = 0.003). Conclusion The GLIM criteria are effective prognostic predictors in patients with resectable PDAC undergoing upfront surgery. Preoperative nutritional assessment using these criteria may contribute to determining treatment plans for resectable PDAC. The GLIM criteria are effective prognostic predictors in patients with resectable PDAC undergoing upfront surgery. Preoperative nutritional assessment using these criteria may contribute to determining treatment plans for resectable PDAC.

Background The optimal treatment for isolated local recurrence (ILR) of pancreatic adenocarcinoma (PDAC) after surgical resection remains unclear. This study aimed to evaluate the safety and efficacy of proton radiotherapy (PRT) for ILR of PDAC after surgery. Methods The medical records of patients with ILR of PDAC after surgery who underwent proton beam therapy between 2011 and 2015 at Hyogo Ion Beam Medical Center were retrospectively studied. Results The study analyzed 30 patients (14 women and 16 men) with a median age of 65 years (range 38–81 years) who had initially undergone pancreatoduodenectomy ( n  = 23) or distal pancreatectomy ( n  = 7) for their primary tumors. Upon ILR, PRT was administered with a median total cumulative dose of 67.5 gray equivalent (GyE) (range 50–67.5 GyE) using 19 to 25 fractions. For 25 patients, concurrent chemotherapy was administered using gemcitabine ( n  = 18) or S-1 ( n  = 7). Four patients (13.3%) experienced acute grade ≥ 3 gastrointestinal toxicities. After a median follow-up period of 17.6 months (range 2.1–50.4 months), 23 patients had experienced tumor progression and 10 had died. Nine patients (30%) experienced local tumor progression. The median overall, progression-free, and local progression-free survival rates were 26.1, 12.3, and 41.2 months, respectively. Pre-PRT serum levels of cancer antigen 19-9 higher than 100 U/mL and duke pancreatic monoclonal antigen type 2 higher than 150 U/mL were significantly associated with shorter progression-free survival rates. Conclusions Proton radiotherapy for ILR of PDAC after surgery is well tolerated and produces good locoregional control and should be considered for eligible patients.

Stapling is the standard method for pancreatic transection during laparoscopic distal pancreatectomy. Although most surgeons use a 60 mm cartridge stapler, space limitations created by laparoscopic surgery make the instrument difficult to handle, especially during pancreatic transection at the neck. Therefore, we currently use a 45 mm cartridge stapler for laparoscopic pancreatic transection at the neck. Between October 2019 and December 2020, we performed pancreatic transection using a 45 mm cartridge stapler in 27 patients. Fifteen patients experienced biochemical leakage, but no patients developed clinically relevant pancreatic fistula. The compactness of the 45 mm cartridge has several benefits: (1) less space is required for flexing, opening, and closing the device; (2) it enables easy insertion of the lower jaw behind the pancreas, even if the dissected space behind the pancreas is narrow; (3) less obstruction of the surgeons’ view prevents accidental injury to the surrounding tissues and vessels. These benefits may enable safe pancreatic transection.

Background Pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) with arterial abutment is a complex, high‐risk surgery. We aimed to investigate the clinicopathological features, risk factors, and learning curve for local recurrence after pancreatectomy for PDAC with arterial abutment. Methods Sixty consecutive patients who underwent pancreatectomy for borderline resectable and locally advanced PDAC with arterial abutment at Kobe University Hospital between 2010 and 2020 were enrolled in this retrospective study. Logistic regression analysis was performed to investigate the risk factors for local recurrence. The local recurrence rate was examined for every 10 cases over time. Results Eighteen (30.0%) patients developed local recurrence; 12 (20.0%) developed local‐only recurrence, and six (10.0%) developed local and other recurrences. The median survival time after surgery was similar between patients with local‐only (n = 12) and other recurrences (n = 31) (18.9 vs. 17.3 months, p = 0.650). The local recurrence rate was significantly lower during the late period than during the early period (13.3% vs. 46.7%, respectively). In the multivariate analyses, the operative period (odds ratio, 7.01; 95% CI: 1.09–45.2; p = 0.041) was the independent factor associated with local recurrence. The local recurrence rate in the first 10 patients was 70%, but it gradually decreased to 10% in the last 10 patients. Conclusions Local recurrence has a significant impact on survival, as do other recurrences after pancreatectomy for PDAC with arterial abutment. A learning curve may exist for the local recurrence rate, suggesting that it should be performed by experienced surgical teams at high‐volume centers. In a retrospective series of 60 consecutive resections for borderline‐resectable/locally advanced PDAC with arterial abutment, local recurrence rate decreased from 70% in the first 10 cases to 10% in the most recent 10. A learning curve may exist for the local recurrence rate after such surgery, suggesting that it should be performed at high‐volume centers.

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.