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Importance: In distal pancreatectomy (DP), the splenic vein is isolated from the pancreatic parenchyma prior to being ligated and divided to prevent intra-abdominal hemorrhage from the splenic vein stump with pancreatic fistula (PF). Conversely, dissecting the splenic vein with the pancreatic parenchyma is easy and time-saving., Objective: To establish the safety of combined division of the splenic vein compared with separate division of the splenic vein., Design, Setting, and Participants: This study was designed as a multicenter prospective randomized phase 3 trial. All results were analyzed using the modified intent-to-treat set. Patients undergoing DP for pancreatic body and tail tumors were eligible for inclusion. Patients were randomly assigned between August 10, 2016, and July 30, 2019., Interventions: Patients were centrally randomized (1:1) to either separate division of the splenic vein or combined division of the splenic vein., Main Outcomes and Measures: The primary end point was the incidence of grade B/C PF, and the incidence of intra-abdominal hemorrhage was included as one of the secondary end points., Results: A total of 318 patients were randomly assigned, and 2 patients were excluded as ineligible. Of the 316 remaining patients, 150 (50.3%) were male. The modified intent-to-treat population constituted 159 patients (50.3%) in the separate division group and 157 patients (49.7%) in the combined division group. In the modified intent-to-treat set, the proportion of grade B/C PF in the separate division group was 27.1% (42 of 155) vs 28.6% (44 of 154) in the combined division group (adjusted odds ratio, 1.108; 95% CI, 0.847-1.225; P = .047), demonstrating noninferiority of the combined division of the splenic vein against separate division. The incidence of postoperative intra-abdominal hemorrhage in the 2 groups was identical at 1.3%., Conclusions and Relevance: This study demonstrated noninferiority of the combined division of the splenic vein compared with separate division of the splenic vein regarding safety. Thus, isolating the splenic vein from the pancreatic parenchyma is deemed unnecessary., Trial Registration: ClinicalTrials.gov Identifier: NCT02871804.

Background/aim: To evaluate complications and risk factors associated with transumbilical incision as an organ removal site in laparoscopic pancreatectomy (LP)., Patients and Methods: In total, 52 patients who underwent LP between 2009 and 2017 were included in this study. The development of superficial surgical site infection (SSI) and transumbilical port-site incisional hernia was recorded., Results: None of the patients had SSI. However, three (5.77%) presented with transumbilical incisional hernia. No variables were significantly associated with the risk of transumbilical incisional hernia., Conclusion: No evident risk factors correlated with hernia formation. Hence, incisional hernia might have occurred at a certain probability. In some cases, it was caused by technical problems. However, the use of transumbilical incision as an organ removal site was feasible, and a new incision for organ removal alone was not required., (Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Objectives: The relationship between eosinophils and cancer prognosis is unknown. Therefore, we analyzed the relationship between circulating eosinophils and the survival of stage IIA and IIB pancreatic cancer patients who underwent surgical resection., Methods: This study included a retrospective cohort of 67 consecutive patients. Patients were categorized into two different groups based on the optimal cutoff for pretreatment levels of each biomarker, according to the receiver operating characteristic curves., Results: The Kaplan-Meier method showed that low eosinophil (P = 0.0403), high neutrophil (P = 0.0066), and high monocyte (P = 0.0003) counts were associated with short overall survival (OS). Low lymphocyte-to-monocyte ratio (P = 0.0194) and eosinophil-to-lymphocyte ratio (ELR) (P = 0.0413) were associated with reduced OS. In multivariate analysis, histological differentiation (P = 0.0014), high neutrophils (P = 0.047), high monocytes (P = 0.029), and low eosinophils (P < 0.0001) were correlated with poorer OS. Histological differentiation (P = 0.033), low lymphocyte-to-monocyte ratio (P = 0.029), and low ELR (P = 0.005) were correlated with poor OS and were significant independent prognostic factors of poor outcomes., Conclusions: Low eosinophils and low ELR were significant independent prognostic factors of poor outcomes., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pancreatic fistula is one of the serious complications for patients undergoing distal pancreatectomy, which leads to significant morbidity. The aim of our study is to compare linear stapling closure plus continuous suture with linear stapling closure alone during laparoscopic distal pancreatectomy (LDP) in terms of clinically relevant postoperative pancreatic fistula (POPF) rate., Methods: Twenty-two patients underwent LDP at our institution between 2011 and 2013. Twelve patients had linear stapling closure with peri-firing compression (LSC) alone compared with ten patients who had linear stapling closure, peri-firing compression plus continuous suture (LSC/CS) for stump closure of remnant pancreas in LDP. Biochemical leak and clinically relevant POPF were compared between both groups., Results: POPF occurred in 4 of 12 (33.3%) patients with linear stapling closure while no patient developed a clinically relevant POPF in the triple combination of linear stapling, peri-firing compression plus continuous suture group (p = 0.043).1 patient (8.3%) in the LSC group and 5 patients (50%) in the LSC/CS group had evidence of a biochemical leak. There were no significant differences in operative time (188.3 vs 187.0 min) and blood loss (135 vs. 240 g) between both groups but there was a significantly of shorter length of hospital stay (11.9 vs. 19.9 days) in LSC/CS group (p = 0.037). There was no mortality in either group., Conclusions: The triple combination of linear stapling, peri-firing compression plus continuous suture in LDP has effectively prevented occurrence of clinically relevant ISGPF POPF., Trial Registration: The study was retrospectively registered September 30, 2019 at Showa University Ethics Committee as IRB protocol numbers 2943.

Purpose: Three-dimensional virtual endoscopy (3DVE) has the potential advantage of enhanced anatomic delineation and spatial orientation during laparoscopic procedures. In the present study, we aimed to evaluate the impact of 3DVE guidance in laparoscopic distal pancreatectomy (LDP)., Methods: Thirty-eight patients presenting to our hospital with a variety of pancreatic tumors underwent preoperative computed tomography scanning to clearly define the major peripancreatic vasculature and correlate it with a 3DVE system (SYNAPSE VINCENT: Fujifilm Medical, Tokyo, Japan). This map served as the guide during preoperative planning, surgical education, and simulation and as intraoperative navigation reference for LDP. Operative records and pathological findings were analyzed for each procedure. Operative parameters were compared between the 38 patients in this study and 8 patients performed without 3DVE guidance at our institution., Results: The 3DVE navigation system successfully created a preoperative resection map in all patients. Relevant peripancreatic vasculature displayed on the system was identified and compared during the intervention. The mean blood loss in LDP performed under 3DVE guidance versus LDP without 3DVE was 168.5 +/- 347.6 g versus 330.0 +/- 211.4 g, p = 0.008 while and the operative time was 171.9 +/- 51.7 min versus 240.6 +/- 24.8 min, p = 0.001., Conclusions: 3DVE in conjunction with a "laparoscopic eye" creates a preoperative and intraoperative three-dimensional data platform that potentially enhances the accuracy and safety of LDP.

Background: There are no established standard criteria for choosing the most appropriate procedure of splenic artery dissection during laparoscopic distal pancreatectomy (LDP). The aim of this study was to evaluate the clinical benefits of individualized procedures for splenic artery dissection during LDP based on the variations in arterial structure visualized on preoperative three-dimensional computed tomography (3D-CT)., Methods: Patients who underwent LDP following 3D-CT at a single center were retrospectively evaluated. 3D-CT images were used to construct virtual 3D laparoscopic images for surgical planning. The splenic artery was classified into two major anatomic types: type S that curves and runs suprapancreatic and type D that runs straight and dorsal to the pancreas. Splenic artery dissection was planned according to these two variations, with type S dissected using an suprapancreatic approach and type D using a dorsal approach., Results: Type-specific dissection was applied for 30 patients: 25 (83%) with type S and 5 (17%) with type D splenic artery anatomies. In 25 (83%) patients, the splenic artery was successfully dissected using the planned surgical procedure, whereas the surgical plan had to be altered in 5 cases (17%) due to difficulty in dissecting the splenic artery., Conclusion: The individualized procedures for splenic artery dissection according to anatomic variations visualized on 3D-CT images can help improve the success and safety of LDP.

Purpose: The Frey procedure is an effective surgery for chronic pancreatitis (CP) patients who have pancreatic head lesions with dilation of the main pancreatic duct. However, pancreatic tail lesions can cause relapsing pancreatitis after the procedure. Therefore, additional distal pancreatectomy (DP) might complement the therapeutic effect of the Frey procedure in controlling inflammation of the pancreatic tail. The Frey procedure with DP (Frey + DP) is indicated for inflammatory lesions in the pancreatic head and tail. In this study, we assessed the usefulness of Frey + DP using the retrospective clinical data of our cases., Methods: The clinical outcomes were compared between CP patients who underwent the Frey procedure (N = 44) and Frey + DP (N = 13) from January 2005 to April 2016., Results: Frey + DP showed similarly good therapeutic effects to the Frey procedure with regard to the postoperative stay, morbidity, mortality, pain relief and nutrition, although the Frey + DP had a longer operative time, more bleeding and higher incidence of diabetes mellitus than the Frey procedure because of the additional DP. One patient in the Frey group received additional DP because of recurrent pain due to the tail lesion., Conclusion: Frey + DP can be a promising treatment for CP patients with pancreatic head and tail lesions.

Purpose: The aim of surgical intervention for chronic pancreatitis (CP) is to relieve symptoms and improve quality of life. However, the precise effect of surgery on the nutritional status of CP patients, which is often impaired by exocrine and endocrine pancreatic dysfunction, has not been elucidated. We conducted this study to evaluate whether Frey's procedure improves the nutritional status of CP patients., Methods: The nutritional status of 35 patients who underwent Frey's procedure for CP at our institute between April 2005 and December 2014, was assessed by the controlling nutritional status (CONUT) scoring before and 1 year after the surgery, and compared with that of seven CP patients who underwent pancreatoduodenectomy. The occurrence of postoperative hepatic steatosis was also monitored., Results: The nutritional status improved after Frey's procedure, but not after pancreatoduodenectomy. The median postoperative CONUT score after Frey's procedure was significantly lower than the preoperative score (1.0 ± 0.5 vs. 4.0 ± 2.5; p < 0.001)., Conclusion: Frey's procedure is superior to pancreatoduodenectomy for improving the nutritional status of CP patients.

Background/purpose: This study was designed to establish institutional indications for pancreatic islet transplantation by examining patients with total pancreatectomy as candidates for islet allotransplantation., Methods: In 12 patients who underwent total pancreatectomy, we compared pre-and postoperative plasma glucose level, body mass index, HbA1c, and daily insulin use; we examined candidacy for islet allotransplantation based on the guidelines of Japan's islet transplantation registry., Results: Eight of the 12 patients with total pancreatectomy were operated for intraductal papillary mucinous neoplasm. At our institution, the 5-year survival of patients with intraductal papillary mucinous neoplasm was far better (76.3%) than that of patients with pancreatic cancer. Postoperatively, plasma glucose level, HbA1c, and daily insulin use were increased in all patients with total pancreatectomy. Of the 12 patients treated with total pancreatectomy, 4 (intraductal papillary mucinous neoplasm, n = 2; islet cell tumor, n = 1; and acute pancreatitis due to arteriovenous malformation, n = 1) showed deteriorated diabetic control and therefore were considered to be candidates for islet allotransplantation according to the guidelines., Conclusions: Islet allotransplantation could be indicated for patients with favorable postoperative survival who have had a total pancreatectomy for either benign or neoplastic disease.