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Purpose: Locally advanced pancreatic ductal adenocarcinoma (PDAC) with an unreconstructible superior mesenteric vein (SMV) invasion is one of the criteria of unresectability in the National Comprehensive Cancer Network guidelines. Advances in chemotherapy have improved downstaging and conversion surgery outcomes, thereby broadening surgical options for locally advanced PDAC. However, operations for PDAC with an unreconstructible SMV is less well-documented. If the collateral route is well-developed and can be preserved or reconstructed, SMV resection can be performed without reconstruction. In this paper, we detail our surgical technique and the outcomes for patients undergoing pancreatoduodenectomy with SMV resection and non-reconstruction (PD-SMVR-NR). Methods: All consecutive patients with pancreatic head cancer who underwent PD at Juntendo University Hospital, Japan, between January 2019 and December 2022 were evaluated from a prospectively maintained preoperative database. Demographic data, clinical history, operative record, morbidity, mortality, and pathologic data were reviewed. Results: Over four years at our Institute, 161 patients with pancreatic head cancer underwent PD, and 86 of these patients underwent PD with portal vein (PV) or SMV resection. There were three patients who underwent PD-SMVR-NR. Each patient had well-developed collateral vessels bypassing the obstructed segment of the SMV. All three patients had no hospital mortality with acceptable complications (Clavien-Dindo grade 2). Two patients achieved R0 resection. Conclusion: By understanding the hemodynamics of venous flow and preserving collateral vessels, especially the superior right colic vein arcade and porto-mesenterico-splenic confluence, pancreatoduodenectomy with superior mesenteric vein resection and non-reconstruction can be performed safely. [ABSTRACT FROM AUTHOR]

Background: The size and function of the future liver remnant (FLR) is an essential consideration for both eligibility for treatment and postoperative prognosis when planning surgical hepatectomy. Over time, a variety of preoperative FLR augmentation techniques have been investigated, from the earliest portal vein embolization (PVE) to the more recent Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) and liver venous deprivation (LVD) procedures. Despite numerous publications on this topic, no bibliometric analysis has yet been conducted. Methods: Web of Science Core Collection (WoSCC) database was searched to identify studies related to preoperative FLR augmentation techniques published from 1997 to 2022. The analysis was performed using the CiteSpace [version 6.1.R6 (64-bit)] and VOSviewer [version 1.6.19]. Results: A total of 973 academic studies were published by 4431 authors from 920 institutions in 51 countries/regions. The University of Zurich was the most published institution while Japan was the most productive country. Eduardo de Santibanes had the most published articles, and Masato Nagino was the most frequently co-cited author. The most frequently published journal was HPB, and the most cited journal was Ann Surg, with 8088 citations. The main aspects of preoperative FLR augmentation technique is to enhance surgical technology, expand clinical indications, prevent and treat postoperative complications, ensure long-term survival, and evaluate the growth rate of FLR. Recently, hot keywords in this field include ALPPS, LVD, and Hepatobiliary Scintigraphy. Conclusion: This bibliometric analysis provides a comprehensive overview of preoperative FLR augmentation techniques, offering valuable insights and ideas for scholars in this field. [ABSTRACT FROM AUTHOR]

Background: Although curative resection with vascular reconstruction improves the prognosis of blood-invading locally advanced hepatobiliary tumors, the mortality and morbidity of the procedure remains unclear. This study aimed to clarify the risk factors associated with mortality and morbidity in patients undergoing liver resection with vascular reconstruction., Methods: This retrospective observational study included 1215 patients undergoing hepatectomy of more than one section with vascular reconstruction, except for left lateral sectionectomy registered in the National Clinical Database (NCD) between 2015 and 2019. The rates of surgical mortality and relevant clinical factors were evaluated., Results: Among the four types of vascular reconstruction, portal venous reconstruction was frequently performed in 724 patients (59.6% of the enrolled patients). Surgical mortality was 8.1%. Patients with hepatic artery reconstruction had the highest surgical mortality rate of 15.8%. In other types of reconstruction, surgical mortality was 9.1% in the portal vein, 5.2% in inferior vena cava, and 4.9% in hepatic vein. Factors significantly associated with surgical mortality include age, sex (male), preoperative comorbidity (American Society of Anesthesiologists grade >3, respiratory distress, diabetes, preoperative pneumonia, weight loss, and obstructive jaundice), poorer liver functional reserve (indocyanine green retention rate at 15 min and prothrombin time/international normalized ratio >1.1) and accompanying biliary reconstruction., Conclusions: The NCD revealed the detailed status of liver resection combined with vascular reconstruction in Japan. Based on the results of this analysis, understanding the factors that influence the outcome and postoperative course of each procedure will provide patients with accurate information and opportunities to improve future outcomes., (© 2024 Japanese Society of Hepato‐Biliary‐Pancreatic Surgery.)

Background: Whether the portal/superior mesenteric vein (PV) should be resected during pancreatoduodenectomy for pancreatic ductal adenocarcinoma (PDAC) based on preoperative CT or intraoperative findings is controversial., Methods: This was a retrospective study with data of patients who had undergone pancreatoduodenectomy for PDAC between 2002 and 2016 in a tertiary referral centre. Based on the extent of contact between the PV and tumour on CT, patients were categorized into: group 1, no contact; group 2, contact 180° or less; group 3, contact greater than 180°. Extent of pathological PV invasion (pPV) (no invasion, pv0; invasion to tunica adventitia, pv1; invasion to media, pv2; invasion to intima, pv3) was compared with patient survival. To assess the feasibility of performing PV resection (PVR) based on intraoperative findings, the prognosis of patients in groups 1 and 2 with pv0 and no PVR (PVR(-)pv0) was compared with that of patients who had PVR (PVR(+)pv0), selected using propensity score matching., Results: Groups 1, 2 and 3 comprised 230, 232 and 38 patients respectively, and PVR was performed in 10·9, 73·3 and 95 per cent of them ( P  < 0·001). Extent of pPV differed significantly ( P  < 0·001). The positive predictive value of radiological tumour contact with PV in predicting positive pPV was 42·6 per cent. In 64 patients with PVR(-)pv0 and 64 matched patients with PVR(+)pv0, the R0 resection rate (66 versus 73 per cent respectively; P  = 0·337) and survival (median 32·4 versus 32·1 months; P  = 0·780) were not significantly different., Conclusion: PVR is needed only when the tumour is in clear contact with the PV and cannot be detached during surgery.

Background: The aim of this study was to determine the added value of portal or superior mesenteric vein (PV/SMV) resection during pancreatoduodenectomy for pancreatic head carcinoma., Methods: A multicentre observational study was conducted in patients with pancreatic head carcinoma who underwent pancreatoduodenectomy in seven Japanese hospitals between 2001 and 2012. Clinicopathological factors were compared between patients who did and did not undergo PV/SMV resection. Those with an impact on survival were identified by univariable and multivariable analysis., Results: Of the 937 patients who underwent pancreatoduodenectomy, 435 (46·4 per cent) had PV/SMV resection, whereas the remaining 502 (53·6 per cent) did not. Some 71·5 and 63·9 per cent of patients with and without PV/SMV resection respectively had lymph node-positive disease. Patients who underwent PV/SMV resection had more advanced tumours. Perioperative mortality and morbidity rates did not differ between the two groups. Multivariable analysis revealed that PV/SMV resection was not an independent prognostic factor for overall survival (P = 0·268). Among the 435 patients in whom the PV/SMV was resected, borderline resectable tumours with arterial abutment (P = 0·021) and absence of adjuvant chemotherapy (P < 0·001) were independent predictors of poor survival in multivariable analysis. Patients with resectable or borderline resectable tumours with PV/SMV involvement had a median survival time with additional adjuvant chemotherapy of 43·7 and 29·7 months respectively. Median survival time in patients with borderline resectable tumours with arterial abutment was 18·6 months despite adjuvant chemotherapy., Conclusion: Pancreatoduodenectomy with PV/SMV resection and adjuvant chemotherapy in patients with pancreatic head carcinoma may provide good survival without increased mortality and morbidity., (© 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Aim: To analyze hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) using the tumor-node-metastasis (TNM) staging system., Methods: We retrospectively analyzed 372 patients with HCC who underwent hepatectomy between 1980 and 2009. We studied the outcomes of HCC patients with PVTT to evaluate the American Joint Committee on Cancer TNM staging system (7(th) edition) for stratifying and predicting the prognosis of a large cohort of HCC patients after hepatectomy in a single-center. Portal vein invasion (vp) 1 was defined as an invasion or tumor thrombus distal to the second branch of the portal vein, vp2 as an invasion or tumor thrombus in the second branch of the portal vein, vp3 as an invasion or tumor thrombus in the first branch of the portal vein, and vp4 as an invasion or tumor thrombus in the portal trunk or extending to a branch on the contralateral side., Results: The cumulative 5-year overall survival (5yrOS) and 5-year disease-free survival (5yrDFS) rates of the 372 patients were 58.3% and 31.3%, respectively. The 5yrDFS and 5yrOS of vp3-4 patients (n = 10) were 20.0%, and 30.0%, respectively, which was comparable with the corresponding survival rates of vp1-2 patients (P = 0.466 and 0.586, respectively). In the subgroup analysis of patients with macroscopic PVTT (vp2-4), the OS of the patients who underwent preoperative transarterial chemoembolization was comparable to that of patients who did not (P = 0.747). There was a significant difference in the DFS between patients with stage I HCC and those with stage II HCC (5yrDFS 39.2% vs 23.1%, P < 0.001); however, the DFS for stage II was similar to that for stage III (5yrDFS 23.1% vs 13.8%, P = 0.330). In the subgroup analysis of stage II-III HCC (n = 148), only alpha-fetoprotein (AFP) > 100 mg/dL was independently associated with DFS., Conclusion: Hepatectomy for vp3-4 HCC results in a survival rate similar to hepatectomy for vp1-2. AFP stratified the stage II-III HCC patients according to prognosis.

Background: Indications for distal pancreatectomy with en-bloc celiac axis resection (DP-CAR) in pancreatic carcinoma remain controversial., Methods: Fifty-two consecutive patients with pancreatic cancer who underwent distal pancreatectomy, including 36 standard distal pancreatectomies (standard DP) and 16 DP-CAR were reviewed retrospectively., Results: After standard DP, microscopically positive margins were identified at the dissection sites around the transection margins of the splenic arteries and were detected more frequently in the patients with tumors within 10 mm from the root of the splenic artery (14%). After DP-CAR, the estimated overall survival rate in patients who were pathologically negative for portal venous and artery invasion (n = 7) was greater than that of the other patients (n = 9; P = .023, log-rank test). The estimated overall 1- and 2-year survival rates after standard DP/DP-CAR were 81/81% and 52/53%, and the median survival times were 32/25 months, respectively, with no differences noted between the groups. There were no differences in the mortality rates and the incidence of each complication between the 2 groups except for delayed gastric emptying., Conclusion: DP-CAR was a feasible and safe procedure, similar to standard DP. DP-CAR should be reserved for patients without tumor infiltrating either the portal venous or arterial systems., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objectives: The prognosis in patients with hepatocellular carcinoma (HCC) accompanied by main portal vein tumour thrombus (MPVTT) is poor. The aim of this study was to clarify the factors linked to survival of >5 years after hepatectomy in HCC patients with MPVTT., Methods: Twenty-nine HCC patients with MPVTT were divided into two groups comprising, respectively, patients who survived >5 years after hepatectomy (survivors, n= 5) and those who did not (non-survivors, n= 24). The two groups were compared., Results: Overall survival rates at 1, 3 and 5 years were 62.1%, 24.1% and 17.2%, respectively. Four (80.0%) 5-year survivors had recurrences of HCC in which the number of recurrent nodules was under four. Three (21.4%) of the 14 non-survivors who underwent curative resection experienced recurrences of HCC and all of them demonstrated fewer than four recurrent nodules (P= 0.0114). Local therapy, such as radiofrequency ablation and resection of recurrence, had more often been used in survivors than in non-survivors (P= 0.0364)., Conclusions: Although surgical outcomes in patients with HCC accompanied by MPVTT are unsatisfactory, some patients do enjoy longterm survival. When the number of recurrent nodules is less than four, local therapy should be selected with the aim of achieving 5-year survival., (© 2012 International Hepato-Pancreato-Biliary Association.)

Background/purpose: Advanced gallbladder carcinoma with paraaortic lymph node metastasis or distant metastasis is normally considered a contraindication for surgery. Our latest analyses suggest otherwise., Methods: Records of 166 patients who underwent surgery for stage IV gallbladder carcinoma were reviewed retrospectively. Predictors of hospital mortality and long-term survival were analyzed. Long-term survival in patients with paraaortic lymph node metastasis and/or distant metastasis was also determined., Results: Fifteen patients were 5-year survivors, with a 5-year survival rate of 12% among the 166 patients investigated. Overall hospital mortality was 14%. Male sex and portal vein resection were independent predictors of hospital mortality. Multivariate analysis of long-term survival failed to identify independent predictors. Patients with distant metastasis were divided into two groups based on whether or not the metastases were distant from the liver. Patients with paraaortic lymph node metastasis who underwent curative resection or who had isolated liver metastasis survived longer than those with other distant metastasis or those with unresectable advanced cancer., Conclusions: Patients with advanced gallbladder carcinoma can benefit from surgical resection even when paraaortic lymph node metastasis and/or liver metastasis are present. However, surgical indications in advanced disease should be determined on an individual basis, based on clinical status.

Pancreatic adenocarcinoma remains to have poor prognosis. Most of all patients have locally advanced disease with or without distant disease when diagnosed. Current rationale for the treatment of pancreatic adenocarcinoma in the US and European countries consists of the following formula: (1) accurate staging by improved imaging. (2) a balanced-resection which means not too extensive not too limited. (3) centralized treatment in high-volume center with minimal surgical mortality. (4) surgery alone is not enough for cure and need more radical adjuvant or neoadjuvant therapy. On the other hands, Japanese surgeons had challenged to improve outcome by radical resections but did not show their advantages in terms of survival benefit as shown in recent randomized controlled trials. Now we should look back to surgical role and think 'who can benefit by surgical resection'. The efficacy of "Japanese" radical resection including vascular resection or pancreatic nerve plexus resection should be evaluated, although the devise of novel diagnostic modalities and more effective adjuvant or neoadjuvant therapy are crucial to improve prognosis of this disease.

Aggressive surgery has been used in bilio-pancreatic cancers in many institutions in Japan. Approaches in pancreatic cancer include extended lymph node and soft tissue dissection in patients with ductal carcinoma of the pancreatic head. In biliary tract disease, approaches have included hepatectomies with or without vascular resection, reconstruction designed according to the extent of disease in individual patients, and combined liver and pancreas resection (hepatopancreatoduodenectomy) in locally advanced disease. Based on current experience, portal vein resection can be recommended in both pancreatic cancer and hilar cholangiocarcinoma and in select patients with gallbladder disease. Extended dissection of para-aortic lymph nodes is recommended in hilar cholangiocarcinoma but not in gallbladder disease; extended lymph node dissection in pancreatic cancer currently is being evaluated in a randomized controlled trial. Hepatopancreatoduodenectomy is recommended for select patients with gallbladder cancer., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Through the technical evolution and excellent results in living related liver transplantation in children, living related/unrelated liver transplantation in adults has come into reality. Disadvantages of small-for-size liver grafts are now significantly mitigated by the repertoire of left lobe, right lobe, and whole left liver grafts. Evolution of living donor liver transplantation in adults, however, has disclosed significant controversies about anatomical aspects and physiology of the liver. This article summarizes our experiences in the past 5 years and discusses still unresolved problems and perspective in the future.

Since the tumor thrombus in the main portal vein appears in the terminal stage of hepatocellular carcinoma (HCC), any attempt to remove it surgically is thought to be impractical as the malignancy itself cannot be entirely removed. During the past 5 years, we have performed tumor thrombectomy combined with hepatectomy in 29 of 298 patients with HCC. This combined therapy was initially decided upon as an emergency measure to prevent impending rupture of esophageal varices, rather than to improve patient survival. Since portal flow was obtained after removal of thrombi, this condition enabled transcatheter arterial embolization (TAE) and/or percutaneous ethanol injection therapy (PEIT). Although improved patient survival was not the primary goal of the emergency operation and there was an operative mortality of 11%, half of the other patients in the present series had unexpectedly high survival rates of 1 year (52.2%), 2 years (23.2%), and 3 years (11.6%), which were significantly higher than in patients not undergoing operation (n = 22).

The Gore-Tex prostheses, made of pure polytetrafluoroethylene (PTFE) by W. L. Gore and Associates (USA), were first described in 1972. The first published report included results of experimental studies and description of two clinical cases. In the following years (1973-1981) many varieties of the PTFE prostheses were made. Each time the prostheses were tested on laboratory animals (dogs, rabbits, rats). The prostheses were used in the arterial and the venous systems. Observations were carried out as long as to 6 months after operation. The degree of patency was in the range from 56 to 100%. All research were important in the evaluation of the new models of PTFE prostheses. However, studies on prostheses of the diameter more than 5 mm are lacking. The present article outlines and criticizes basic experimental studies, which added to the knowledge on PTFE prostheses of the Gore-Tex type, depending on their structure. Due to experimental studies the Gore-Tex prostheses are now widely applied in clinical treatment.

Fourteen patients with "noncorrectable" biliary atresia are living without jaundice for more than 2 yr after hepatic portoenterostomy or its modification. Retardation of physical growth was observed in one of them, and mental retardation in another, both of which seemed irrelevant to biliary atresia. Serial tests for liver function after operation revealed early recovery of serum bilirubin, transminase, and turbidity, and delayed improvement of alkaline phosphatase. Postoperative needle biopsy of the liver disclosed that changes in hepatic parenchyma and ductular proliferation were rapidly improved after successful operation. Improvement of fibrosis of the liver was delayed, and it was not satisfactory in patients whose preoperative changes in the liver were severe or in whom ascending cholangitis had been a frequent complication. Histologic features of hepatic cirrhosis were observed in the liver in three cases, in two of which there had been frequent episodes of cholangitis. Only one of these showed clinical signs of portal hypertension. Functional and morphologic cure can be achieved in "noncorrectable" biliary atresia by hepatic portoenterostomy or its modifications, although varying degree of hepatic fibrosis may remain according to severity of preoperative changes of the liver and postoperative complication of ascending cholangitis.