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Background Patients with advanced-stage breast cancer often demonstrate pancreatic metastases. However, pancreatic metastases resection from breast cancer has been rarely performed, with only 20 cases having been reported to date. Case presentation A 49-year-old woman presented to our hospital in September 2003 with complaints of uncontrollable oozing from her left breast tumor. Computed tomography revealed a left breast tumor approximately 9.3 cm in diameter as well as heterogeneously enhanced solid mass lesions with necrotic foci in the pancreatic tail and body, up to 6.2 cm, which were radiologically diagnosed as pancreatic metastases from breast cancer. An emergent left simple mastectomy was performed to control bleeding. After epirubicin and cyclophosphamide hydrate treatment failed to improve her condition, the pancreatic metastases responded to weekly paclitaxel treatment, but eventually regrew. The patient underwent distal pancreatectomy with splenectomy, left adrenalectomy, partial stomach resection, and paraaortic lymph nodes excision in December 2004 after no other metastasis was confirmed. Furthermore, she received radiation therapy for left parasternal lymph node metastasis 6 months later. The patient recovered well. Consequently, she has no evidence of disease > 15 years after pancreatectomy. Conclusions This is the first reported case of pancreatectomy for pancreatic metastases from breast cancer, which was simultaneously diagnosed. Patients with no metastasis other than resectable pancreatic metastases and breast cancer and who possess some sensitivity for chemotherapy may benefit from pancreatectomy.

Background Sickle cell disease (SCD) is a monogenic disease characterized by sickle hemoglobin (HbS). Patients homozygous for HbS experience symptoms resulting from sickled erythrocytes no later than adolescence. However, heterozygous HbS carriers, or those with the so-called sickle cell trait (SCT), may undergo surgery without their hemoglobinopathy being known. Case presentation A 53-year-old Nigerian male with hepatitis C infection underwent radiofrequency ablation therapy for multiple hepatocellular carcinomas (HCCs) 17 months prior. Follow-up computed tomography (CT) revealed a solitary tumor (3.2 cm) in the medial section of the cirrhotic liver. The Child–Pugh score was five, and the indocyanine green retention rate at 15 min was 17.4%. The nontumorous liver of the medial section accounted for 10% of the total liver volume according to CT volumetry. With the diagnosis of recurrent HCC, left medial sectionectomy was performed under intermittent blood flow occlusion by Pringle’s maneuver. Intraoperative ultrasonography confirmed that hepatic blood flow had been preserved after hepatectomy. However, laboratory tests on postoperative day (POD) 1 revealed severe liver damage: aspartate aminotransferase 9250 IU/L, alanine aminotransferase 6120 IU/L, total bilirubin 2.8 mg/dL, and prothrombin time% 20.9%. The patient’s renal and respiratory functions also deteriorated; therefore, continuous hemodiafiltration and plasma exchange were initiated under mechanical ventilation. Whole-body contrast-enhanced CT showed no apparent ischemia of the remnant liver, but diffuse cerebral infarction was detected. Despite intensive treatments, he died of multiple organ failure on POD 20. The pathological examination of the resected specimen revealed that the intrahepatic peripheral vessels were occluded by sickled erythrocytes. Additionally, chromatographic analysis of hemoglobin detected the presence of abnormal hemoglobin, although microscopic examination of the peripheral blood erythrocytes did not show morphological abnormalities. Based on these findings, we determined that he had SCT and developed vaso-occlusive crisis involving multiple organs just after hepatectomy. Conclusion SCD is a rare disease in eastern Asia, but its prevalence is increasing globally. Surgeons should pay increased attention to this disease, especially when performing hepatectomy under blood flow occlusion.

Background: To assess medical procedures, particularly damage control resuscitation, at the time of transfer between hospitals for the purpose of treating massive hemorrhage.Methods: This study used a single-center retrospective observational design, enrolling patients referred to Teine Keijinkai Hospital from another hospital between April 2012 and March 2019 for the treatment of massive hemorrhage. We excluded patients who entered cardiac arrest before arriving at our center. Qualitative or categorical variables were compared using the χ2 or Fisher’s exact test, as appropriate. Quantitative continuous variables were compared using Mann-Whitney nonparametric tests, as appropriate. Risk factors associated with coagulopathy from univariate analyses (fibrinogen level £150 mg/dl; prothrombin time-international normalized ratio ³1.5) were entered into stepwise logistic regression analysis. Significance was defined for values of p < 0.05.Results: Multiple logistic regression analysis revealed trauma (odds ratio (OR) 4.800; 95% confidence interval (CI) 2.016–11.433; p < 0.001) and volume of crystalloid solution (OR 1.001; 95%CI 1.000–1.001; p = 0.008) as independent factors associated with coagulopathy. Patients with coagulopathy showed higher 24-h mortality rates (10.9%) than patients without coagulopathy (1.2%; p = 0.021), and cause of death was hemorrhagic shock for all cases of death within 24 h.Conclusion: In our area, withholding intravenous fluid to achieve permissive hypotension, early administration of fresh frozen plasma, and use of fibrinogen concentrate may improve the prognosis of patients with massive hemorrhage undergoing transfer between hospitals.Trial registration: UMIN, UMIN000041201. Registered 24 July 2020 – Retrospectively registered, https://upload.umin.ac.jp/cgi-open-bin/icdr_e/ctr_view.cgi?recptno=R000047048

Simple Summary Pancreatic cancer (PC) is among the most lethal malignancies due to an often delayed and difficult initial diagnosis. Therefore, the development of a novel, early stage, diagnostic PC marker in liquid biopsies is of great significance. In this study, we analyzed the differential glycomic profiling of extracellular vesicles (EVs) derived from serum using lectin microarray. The glyco-candidates of PC-specific EVs were quantified using a high-sensitive exosome-counting system, ExoCounter. An absolute quantification system for altered glycan-containing EVs elevated in PC serum was established. EVs recognized by O-glycan-binding lectins ABA or ACA were identified as candidate markers by lectin microarray. Quantitative analyses using ExoCounter revealed that the ABA- or ACA-positive EVs were significantly increased in the serum of PC patients. These specific EVs with O-glycans can act as potential biomarkers in a liquid biopsy for PC patients screening. Abstract Pancreatic cancer (PC) is among the most lethal malignancies due to an often delayed and difficult initial diagnosis. Therefore, the development of a novel, early stage, diagnostic PC marker in liquid biopsies is of great significance. In this study, we analyzed the differential glycomic profiling of extracellular vesicles (EVs) derived from serum (two cohorts including 117 PC patients and 98 normal controls) using lectin microarray. The glyco-candidates of PC-specific EVs were quantified using a high-sensitive exosome-counting system, ExoCounter. An absolute quantification system for altered glycan-containing EVs elevated in PC serum was established. EVs recognized by O-glycan-binding lectins ABA or ACA were identified as candidate markers by lectin microarray. Quantitative analyses using ExoCounter revealed that the ABA- or ACA-positive EVs were significantly increased in the culture of PC cell lines or in the serum of PC patients including carbohydrate antigen 19-9 negative patients with high area under curve values. The elevated numbers of EVs in PC serum returned to normal levels after pancreatectomy. Histological examination confirmed that the tumors stained with ABA/ACA. These specific EVs with O-glycans recognized by ABA/ACA are elevated in PC sera and can act as potential biomarkers in a liquid biopsy for PC patients screening.

Cancer originating in the biliary tract can be classified as bile duct cancer (cholangiocarcinoma), gallbladder cancer, or ampullary cancer. Bile duct cancer is further divided to intrahepatic, perihilar and distal bile duct subtypes according to the anatomical location of the tumor. The biological characteristics of each tumor are heterogeneous. However, because of the rarity of each disease, the efficacy of new drugs has been tested in groups of patients with different biliary tract cancers. In patients with metastatic or recurrent biliary tract cancer, recent randomized clinical trials revealed the non-inferiority of gemcitabine + S-1 and the superiority of gemcitabine + cisplatin + S-1 compared with gemcitabine + cisplatin in terms of overall survival, thereby establishing a new standard treatment. In the field of adjuvant therapy for biliary tract cancer, the British BILCAP (capecitabine compared with observation in resected biliary tract cancer) study revealed longer median overall survival in the capecitabine group than in the observation group in the per-protocol analysis (but not in the intention-to-treat analysis), bringing a shift toward postoperative management. Several other studies of adjuvant therapy are ongoing, and they may lead to reforms in treatment strategy for resectable biliary tract cancer in the future. The use of neoadjuvant therapy for biliary tract cancer is in its infancy, but it is expected to overcome the limitations of adjuvant therapy for this malignancy. In this review, we summarized the evidence available from clinical trials of adjuvant and neoadjuvant therapy for biliary tract cancer and described ongoing clinical trials.

Lung is the most common target organ for distant metastasis of phyllodes tumor (PT), where the metastatic tumors are mostly seen as nodules or masses. We report here a rare case in which pure ground-glass opacity (GGO) was observed on chest CT about 3 years after the initial treatment of breast PT. After the lung lobectomy, we histologically confirmed that it should be diagnosed as a metastasis of PT. GGO rarely shows on metastatic tumors, and no reports have been made on GGO thus far in connection with metastasis of PT. Thus, in case GGO was found on the CT of patients having a history of PT, we suggest to take possible distant-metastasis into consideration.

There is an increasing unmet need for successful immunotherapeutic interventions. Lymphocyte extravasation via tumor tissue endothelial cells (TECs) is required for lymphocyte infiltration into tumor sites. This study aimed to investigate the clinical significance of dysfunctional TECs in pancreatic ductal adenocarcinoma (PDAC) and identify chemical compounds that boost tumor-infiltrating lymphocyte (TIL) numbers. We performed immunohistochemical detection and clinicopathological analysis of VCAM-1 on TECs, which is essential for lymphocyte trafficking. We characterized the gene expression profiles of TECs from fresh PDAC tissues. We isolated compounds that upregulated VCAM-1 and E-selectin expression in TECs and examined their biological activities. Compared to endothelial cells from chronic pancreatitis tissue, TECs showed significantly lower VCAM-1 and E-selectin expression and significant weaknesses in lymphocyte adhesion and transmigration, resulting in decreased T cell infiltration around vessels. Patients with a relatively high percentage of VCAM-1+ vessels among all vessels in PDAC tissue had an improved prognosis. A bioinformatics survey demonstrated that TNFR1 signaling was involved in abnormal VCAM-1 and E-selectin expression in TECs. We screened compounds affecting TNFR1 signaling, and the IAP inhibitor, Embelin, induced these molecules on TECs and enhanced T cell adhesion to TECs and transmigration. Furthermore, in vivo, Embelin enhanced tumor-infiltrating T cell numbers, leading to an antitumor immune response. Embelin accelerates TIL infiltration and the antitumor immune response by recovering VCAM-1 expression in TECs. Our strategy may be a therapeutic approach for accelerating the immunotherapeutic response in immune-quiescent tumors, leading to clinical trials’ success.

Background Definitions of regional lymph nodes for gallbladder cancer differ according to staging system. Hence, the appropriate extent of lymph node dissection has not yet been standardized. Methods Pathological stages and disease-specific survival (DSS) of patients who had undergone surgical resection of gallbladder cancer between 1990 and 2016 were reviewed. Patients with nodal metastases limited to the hepatoduodenal ligament or common hepatic artery, extending to the posterosuperior pancreatic head lymph nodes (PSPLNs), or in nodes along the coeliac axis or superior mesenteric vessels were grouped as having Na, Nb and Nc disease respectively. Metastases beyond these regions were defined as distant metastases (M1). Absence of distant metastasis was expressed as M0. Results A total of 259 patients were evaluated. There were 74, 31 and nine patients respectively in the Na, Nb and Nc groups. Twenty-five, nine and four patients in the respective groups had M1 disease (P = 0·682). The 5-year DSS rate was comparable between patients with Na M0 and those with Nb M0 disease (36 versus 34 per cent respectively; P = 0·950), whereas the rate in patients with Nc M0 status (0 per cent) was worse than that of patients with Nb M0 (P = 0·017) and comparable to that of patients with M1 disease (14 per cent; P = 0·590). Among 22 patients with Nb M0 disease, the 5-year DSS rate did not differ between those who had undergone pancreatoduodenectomy and those who had had dissection of PSPLNs without pancreatoduodenectomy (50 versus 30 per cent respectively; P = 0·499). Conclusion PSPLNs and nodes along the hepatoduodenal ligament and hepatic artery should be considered regional nodes for gallbladder cancer, and should be resected.

Background: Whether repeat hepatectomy for colorectal liver metastases should be performed after chemotherapy or observation is unclear. Methods: We selected patients with resectable hepatic recurrence after their first hepatectomies performed between 2000 and 2015. They were classified according to the further treatment: Group A, prompt repeat hepatectomy; Group B, observation; and Group C, ≤6 months of chemotherapy. In Group B/C, patients who later underwent hepatectomy and those who did not due to disease progression were classified as B1/C1 and B2/C2, respectively. Predictors of B2/C2 were evaluated. Results: Groups A, B, and C consisted of 81, 36, and 17 patients, respectively. Recurrence-free interval was longer in Group A (median months; Group A, 10.3; Group B, 5.7; Group C, 3.5; p < 0.01). Group B1/C1 and B2/C2 included 34 and 19 patients, respectively. Five-year survival after recurrence of Group B1/C1 was 56%, which was comparable with Group A (56%, p = 0.77) and better than Group B2/C2 (0%, p < 0.01). Multivariate analysis showed synchronous colorectal liver metastases (OR 7.23) and recurrent hepatic tumor number (OR 4.04) were predictors of tumor progression. Conclusion: Selecting patients optimally either for prompt or delayed repeat hepatectomy following chemotherapy or observation is a feasible strategy.

Background The feasibility of salvage hepatectomy for locally recurrent hepatocellular carcinomas (HCCs) is unclear, especially for patients with viable parts of previously multinodular tumors. Methods We reviewed charts of patients who underwent initial hepatectomies between 2000 and 2014 to select those with local recurrences (LR) after non-surgical treatments. Their postoperative outcomes, including morbidity, recurrence-free survival (RFS), and overall survival (OS) were compared with matched patients who underwent initial hepatectomies for primary HCCs (PR). Their local recurrence patterns were divided into recurrent solitary tumors (Subgroup A); and recurrent parts of multinodular tumors (Subgroup B). Results Among 664 patients, hepatectomy for LR was performed in 62 patients. Matched 59 patients were selected as PR. Clinicopathologic profiles at initial surgery were comparable between the LR and PR groups. Incidence of major morbidity (LR vs. PR, 7% vs. 5%, P = 1.00), 5-year RFS (21% vs. 37%, P = 0.28), and 5-year OS (69% vs. 69%, P = 0.62) were comparable. In the LR group, Subgroup B showed worse 5-year RFS (A vs. B, 29% vs. 0%, P P = 0.01). Postoperative recurrence occurred in 46 patients, but local and extrahepatic recurrence was seen only in 2 patients and 2 patients, respectively. Conclusion Salvage hepatectomy for locally recurrent HCCs is feasible, and results in prognosis comparable with hepatectomy for primary HCCs. Although the risk of postoperative recurrence was high in Subgroup B, rare local recurrence suggests the usefulness of salvaging uncontrolled tumor by nonsurgical treatment.

The treatment of choice for duodenal neuroendocrine tumors (NETs) ranges from endoscopic resection and local excision to pancreaticoduodenectomy. The aim of this study was to investigate the optimal treatment for this tumor. We retrospectively analyzed the clinicopathological data of 14 patients with NETs in the second portion of the duodenum who underwent surgery in our hospital from 2000 to 2015. The duodenal NETs were classified as either ampullary or non-ampullary. Additionally, a systematic review and pooled analysis was conducted. Among eight patients with ampullary NETs and six patients with non-ampullary NETs, seven and three patients underwent pancreaticoduodenectomy and one and three patients underwent local resection, respectively. The maximum tumor diameter were 11–30 mm in ampullary and 10–100 mm in non-ampullary NETs, respectively. In patients with ampullary NETs, lymph node metastases were suspected in only three cases preoperatively, but five patients actually had regional nodal metastases. Among patients with non-ampullary NETs, lymph node metastases were suspected in none preoperatively, but three of the four patients who underwent lymph node dissection had regional nodal metastases. According to a pooled analysis of 1245 patients in 88 studies, even small tumors confined to the submucosal layer and G1 tumors—ampullary and non-ampullary—have been associated with lymph node metastases. In patients with non-ampullary NETs and lymph node metastasis, 10-year recurrence-free survival rate was 51% for patients who underwent pancreaticoduodenectomy (n = 19) and 53% for patients who underwent partial duodenal resection (n = 9), respectively (p = 0.960). Lymph node metastases were common in association with both ampullary and non-ampullary NETs, and it was difficult to radiologically diagnose metastases. Additionally, there were no clinicopathological factors that could reliably predict the absence of lymph node metastases preoperatively. Therefore, to maximize the ability to achieve a curative resection, pancreaticoduodenectomy is considered appropriate in well-conditioned patients with NETs in the second portion of the duodenum. However, to further clarify the impact of lymph node dissection on survival after duodenal NET resection, a multi-institutional study with a large number of patients, thorough examination of lymph node metastasis, and a long observation period is warranted.

As macroscopic appearance represents tumor microenvironment, it may also reflect the biological and clinicopathological characteristics of a cancer. The aim of the study was to evaluate the clinicopathological significance of the gross appearance of pancreatic ductal adenocarcinoma (PDA). We investigated fresh macroscopic features in 352 cases of PDA and their clinicopathological significance. Three unique gross features were found: a honeycomb-like appearance (diffusely distributed microcysts and interstitial fibrotic thickening), macroscopic necrosis, and a tube/branching structure (apparent small cylindrical or linear structure). A honeycomb-like appearance was present in 24 cases (6.8 %) and significantly associated with low serum CA19-9 level and well-differentiated adenocarcinoma. Macroscopic necrosis was present in 235 cases (66.8 %) and significantly correlated with tumor size, nodal metastasis, nerve plexus invasion, no adjuvant chemotherapy, and distant recurrence. The presence of macroscopic necrosis was significantly associated with shorter disease-specific survival (DSS) and disease-free survival (DFS). The presence of larger areas of necrosis (≥2 mm) was closely associated with shorter survival. A tube/branching structure was found in 179 cases (50.9 %), which was correlated with larger tumor size and no adjuvant chemotherapy and macroscopic necrosis. The presence of a tube/branching structure was significantly associated with shorter DSS and DFS. Multivariate survival analyses showed that the presence of tube/branching structures was an independent negative prognostic factor in patients having PDA. We suggest that the gross appearance of PDA reflects clinicopathological characteristics and may be useful in predicting prognosis.

This study aimed to establish a reliable criterion for early drain removal after pancreaticoduodenectomy (PD) based on predictive factors of clinically relevant postoperative pancreatic fistula (CR-POPF) available on postoperative day 3 (POD3). A total of 300 consecutive patients who underwent PD with pancreaticojejunostomy at our hospital from 2011 to 2015 were analyzed retrospectively. CR-POPF was defined as POPF grade B or C according to the definition by ISGPF. Clinicopathological factors available on or before POD3 were analyzed to identify predictors of CR-POPF. Using obtained predictors, we developed a criterion for no CR-POPF and internally validated its relevance in 100 consecutive patients. The incidence rates of CR-POPF, severe complications (Clavien–Dindo ≥ grade IIIa), and postoperative mortality were 35%, 9.6%, and 0.3%, respectively. Multivariate analysis showed that drain amylase (d-AMY) levels ≥ 350 IU/l on POD3, C-reactive protein (CRP) levels ≥ 14 mg/dl on POD3, preoperative endoscopic retrograde biliary drainage, and no portal vein resection were significant predictors of CR-POPF. Using the strongest predictors (i.e., d-AMY and CRP), we established a criterion for no CR-POPF: d-AMY levels

Hepatocellular carcinoma (HCC) is the sixth-most common cancer and the third leading cause of cancer-related death in the world. However, 40-70% patients eventually suffer from postoperative recurrence within 5 years. HCC recurrence after surgery severely affects prognosis of the patients. Nevertheless, there is an opportunity to improve patients' prognosis if doctors and researchers can recognize the importance of a standardized perioperative management and study it in clinical and pre-clinical settings. Hence, based on our own experience and published studies from other researchers, we develop this consensus regarding multidisciplinary management of locally recurrent and metastatic hepatocellular carcinoma after resection. This consensus consists of the entire course of recurrent hepatocellular carcinoma (RHCC) management, including prediction of recurrence, prevention, diagnosis, treatment and surveillance of RHCC. Consensus recommendations are presented with grades of evidences (Ia, Ib, IIa, IIb, III and IV), and strength of recommendations (A, B, C, D and E). We also develop a decision-making path for RHCC treatment, which can intuitively demonstrate the management for RHCC. It is hoped that we may make some effort to standardize the management of RHCC and ultimately understand how to improve outcomes.

Gadoxetic acid-enhanced magnetic resonance imaging (MRI) in combination with diffusion-weighted MRI (Gd-EOB-MRI/DWI) has become popular for evaluating colorectal liver metastases (CRLM). This retrospective observational study aimed to determine whether this procedure should be indicated prior to hepatectomy in all patients with CRLM. A retrospective survey of relevant data of patients who had undergone hepatectomy for CRLM from 2008 to 2014 was performed. The rates of detection by contrast-enhanced computed tomography (CE-CT) and Gd-EOB-MRI/DWI were evaluated. In addition, relapse-free and overall survivals after primary hepatectomy were compared between patients who had undergone only CE-CT versus those who had undergone both CE-CT and Gd-EOB-MRI/DWI. In all, 419 pathologically confirmed CRLM were resected in 202 hepatectomies in 177 patients. The sensitivity of detection of CRLM was 77 % for CE-CT and 93 % for Gd-EOB-MRI/DWI (P

Postmortem computed tomography (PMCT) has been recently reported to be useful for detecting causes of death in the emergency department. In this study, the incidence and causes of death of type A acute aortic dissection (AAD) were investigated in patients who experienced out-of-hospital cardiopulmonary arrest (OHCPA) using PMCT. PMCT or enhanced computed tomography was performed in 311 of 528 consecutive patients experiencing OHCPA. A total of 23 (7%) of 311 patients were diagnosed with type A AAD based on clinical courses and CT findings. Eighteen consecutive patients who did not experience OHCPA were diagnosed with type A AAD during the same period. Pre-hospital death was observed in 21 (51%) of 41 patients with type A AAD. Bloody pericardial effusion was observed more frequently in patients who experienced OHCPA with type A AAD than in those who did not experience OHCPA with type A AAD (91% vs 28%, respectively; p

Background & Aims The management of pancreatic cysts poses challenges to both patients and their physicians. We investigated whether a combination of molecular markers and clinical information could improve the classification of pancreatic cysts and management of patients. Methods We performed a multi-center, retrospective study of 130 patients with resected pancreatic cystic neoplasms (12 serous cystadenomas, 10 solid pseudopapillary neoplasms, 12 mucinous cystic neoplasms, and 96 intraductal papillary mucinous neoplasms). Cyst fluid was analyzed to identify subtle mutations in genes known to be mutated in pancreatic cysts ( BRAF , CDKN2A , CTNNB1 , GNAS , KRAS , NRAS , PIK3CA , RNF43 , SMAD4 , TP53 , and VHL ); to identify loss of heterozygozity at CDKN2A , RNF43 , SMAD4 , TP53 , and VHL tumor suppressor loci; and to identify aneuploidy. The analyses were performed using specialized technologies for implementing and interpreting massively parallel sequencing data acquisition. An algorithm was used to select markers that could classify cyst type and grade. The accuracy of the molecular markers was compared with that of clinical markers and a combination of molecular and clinical markers. Results We identified molecular markers and clinical features that classified cyst type with 90%−100% sensitivity and 92%−98% specificity. The molecular marker panel correctly identified 67 of the 74 patients who did not require surgery and could, therefore, reduce the number of unnecessary operations by 91%. Conclusions We identified a panel of molecular markers and clinical features that show promise for the accurate classification of cystic neoplasms of the pancreas and identification of cysts that require surgery.

要旨 【目的】外傷患者に対する病院前輸液が生命予後に与える影響は議論が分かれている。今回我々はショックを呈した外傷症例に対し，病院前輸液が来院時のfibrinogen値に与える影響と，ショックに対する改善効果を検討した。【対象】2010年4月から2014年10月までに当院へ搬送された18歳以上の外傷患者で現場にて出血性ショックであったものを対象とし後方視的に診療録調査を行い，病院前輸液施行群と非輸液群に分けて比較検討した。【結果】91例中，非輸液群が50例，輸液群が41例であった。fibrinogen値が200mg/dL未満となる予測因子を求めて多重ロジスティック回帰分析を施行したところ，病院前輸液の調整オッズ比が3.16（95%信頼区間:1.15–8.68）であった。一方，輸液群においては来院時収縮期血圧が有意に高く（非輸液群100.6±26.2mmHg vs 輸液群113.0±27.1mmHg），Base Deficitが有意に低かった（非輸液群4.4 [1.6–9.3] mmol/L vs 輸液群2.6 [0.6–4.7] mmol/L）。院内死亡率に有意差はなかったが，輸液群で低い傾向があった。【結語】病院前輸液はfibrinogen値を低下させる要因であったが，ショックとそれに伴う代謝性アシドーシスを抑制し，少なくとも生命予後を悪化させなかった。 ABSTRACT Background: The survival effect of prehospital intravenous fluid (IVF) administration for severely injured patients remains controversial. This study focuses on the impact of prehospital IVF on the fibrinogen level on admission to the emergency department and also analyzes the beneficial effect of prehospital IVF for fluid resuscitation in shock. Object and Methods: The medical charts of trauma patients aged 18 years or older who presented to the hospital between April 2010 and October 2014 were retrospectively reviewed; patients with hemorrhagic shock at the scene of arrival were identified and classified into two groups depending on whether or not prehospital IVF was administered. Results: Of the 91 patients who met the inclusion criteria, 41 of them received prehospital IVF and 50 did not. Multiple logistic regression analysis showed that the only prognostic factor for a fibrinogen level lower than 200mg/dL included prehospital IVF with an adjusted odds ratio: 3.16 (95% confidence interval: 1.15–8.68). On the other hand, in the IVF group, systolic blood pressure on arrival was significantly higher (no IVF: 100.6±26.2mmHg vs IVF: 113±27.1mmHg), and base deficit was significantly lower (no IVF: 4.4 [1.6–9.3] mmol/L vs IVF: 2.6 [0.6–4.7] mmol/L). In–hospital mortality of the IVF group was 9.8%, which was slightly lower than the no IVF group (14%), but the difference was not significant. Conclusion: Prehospital IVF decreased fibrinogen level in trauma patients, but it also reduced the metabolic acidosis during hemorrhagic shock and did not worsen survival.

695 Background: Although macroscopically curative resection has been performed for pancreatic cancer with positive peritoneal lavage cytology (CY1), the prognosis is poor in most reports. In 2013, the JASPAC01 trial showed that S-1 was superior to Gemcitabine (GEM) as adjuvant chemotherapy for resected pancreatic cancer, and S-1 was also administered to the patients with CY1 who had undergone macroscopically curative resection. Methods: This is a multicenter retrospective observational study that collected data of the patients with pancreatic adenocarcinoma who were diagnosed with CY1 between 2007 and 2015 and had no other noncurable factors. Results: One hundred twenty-seven patients were enrolled from 14 institutions, and 3 were excluded due to liver metastasis or non-adenocarcinoma. The median age was 67 years old and almost patients had PS 0 or 1. Of the 124 patients, 114 underwent macroscopically curative resection and the median overall survival (OS) and recurrence free survival (RFS) were 16.7 and 7.2 months. Of the resected patients, 80 (70%) had no early recurrence and started postoperative adjuvant chemotherapy. Adjuvant chemotherapy regimens were S-1 in 43 patients (54%), GEM in 31 (39%) and others in 6 (7%). The median OS was 21.0 months with S-1 and 19.2 months with GEM (HR: 0.73, 95%CI: 0.44-1.22, P = 0.23), whereas the median RFS was 10.2 and 7.1 months (HR: 0.58, 95%CI: 0.36-0.95, P = 0.03), respectively. Conclusions: After the report of JASPAC01, most patients with pancreatic cancer with CY1 received macroscopically curative resection and treated with S-1 as adjuvant therapy, however the efficacy was insufficient. We should consider appropriate treatment strategies for patients with pancreatic cancer with CY1 intended for surgical resection.

Purpose This study compared the efficacy of absolute ethanol with that of N-butyl-2-cyanoacrylate (NBCA) in portal vein embolization (PVE) before partial hepatectomy. Materials and Methods Between January 2012 and February 2016, 61 patients (43 men, 18 women; median; 69 years of age) underwent PVE using absolute ethanol (January 2012 to January 2014; n = 27) or NBCA (February 2014 to February 2016; n = 34). The primary endpoint was increase in the nonembolized liver volume (NELV)-to-total functional liver volume (TFLV) ratio, and the secondary endpoints were changes in embolized liver volume (ELV) and NELV, changes in laboratory data, and adverse events. Results The increase in the NELV/TFLV ratio was significantly higher in the ethanol group than in the NBCA group (13.0% vs. 9.5%, respectively; P = 0.003). The decrease in ELV was significantly greater in the ethanol group (−191.9 vs. −99.2 mL, respectively; P = 0.001). The increase in NELV did not differ significantly (129.4 vs. 116.0 mL, respectively; P = 0.316). In the ethanol group, grade 3–4 transient elevation of aspartate aminotransferase and alanine aminotransferase occurred in 22 patients (81.5%) and 22 patients (81.5%) patients, respectively, whereas it occurred in 1 patient (3.0%) and 1 patient (3.0%), respectively, in the NBCA group. One patient in the ethanol group (3.7%) showed grade 2 hepatic necrosis, and 2 patients with grade 3 subcapsular biloma (5.9%) and 1 with grade 3 liver abscess (2.9%) occurred in the NBCA group (P = 0.696). Conclusions PVE with ethanol conferred greater increase in the NELV/TFLV ratio than NBCA due to its severe atrophic effect in ELV, but no significant differences in NELV increase were found.

Background/objectives To demonstrate the utility of portal encasement as a criterion for early diagnosis of local recurrence (LR) after pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC). Methods A total of 61 patients who underwent PD for PDAC were included in this retrospective study. Portal stenosis was evaluated by sequential postoperative computed tomography (CT) scans and correlated with disease recurrence. In addition to the conventional LR diagnostic criterion of a growing soft tissue mass, LR was evaluated using portal encasement as an additional diagnostic criterion. Portal encasement was defined as progressive stenosis of the portal system accompanied by a soft tissue mass, notwithstanding the enlargement of the mass. Results Benign portal stenosis was found on the first postoperative CT imaging in 16 patients. However, stenosis resolved a median of 81 days later in all but one patient whose stenosis was due to portal reconstruction during PD. Portal encasement could be distinguished from benign portal stenosis based on the timing of emergence of the portal stenosis. Portal encasement developed in 13 of the 19 patients with LR, including 6 patients in whom the finding of portal encasement led to the diagnosis of LR a median of 147 days earlier with our diagnostic criterion compared with the conventional diagnostic criteria. Conclusions Portal encasement should be considered as a promising diagnostic criterion for earlier diagnosis of LR after PD for PDAC.

The left gastric artery (LGA) is commonly severed when the gastric tube is made for esophageal reconstruction. Sacrifice of the LGA can cause liver ischemic necrosis in patients with an aberrant left hepatic artery (ALHA) arising from the LGA. We experienced a case of life-threatening hepatic abscess after severing the ALHA. Therefore, the purpose of this study is to evaluate clinical outcomes of severing the ALHA. We retrospectively enrolled 176 consecutive patients who underwent esophagectomy with gastric tube reconstruction. They were classified into the ALHA (N = 16, 9.1%) and non-ALHA (N = 160, 90.9%) groups. Univariate analysis was performed to compare the clinicopathological variables. Long-term survival was analyzed using the Kaplan–Meier method in matched pair case–control analysis. The postoperative morbidities were not statistically different between the two groups, although serum alanine aminotransferase levels on postoperative days 1 and 3 were significantly higher in the ALHA group (36 IU/L, 14–515; 32 IU/L, 13–295) than in the non-ALHA group (24 IU/L, 8–163; 19 IU/L, 6–180), respectively (p = 0.0055; p = 0.0073). Overall survival was not statistically different between the two groups (p = 0.26). Severe hepatic abscess occurred in 6.3% of the patients with the ALHA after esophagectomy, even though the results presented here found no statistical differences in morbidity or mortality with or without the ALHA. Surgeons should probably attempt to preserve the ALHA especially in patients with altered liver function while making a gastric tube for esophageal reconstruction.

Background Aggressive hepatectomy with venous resection has a higher risk of postoperative liver failure (POLF) than hepatectomy without venous reconstruction; however, venous reconstruction is technically demanding. We performed a novel two-stage hepatectomy (TSH) without venous reconstruction in a patient with bilobar multiple colorectal liver metastases located near the caval confluence, waiting for the development of intrahepatic venous collaterals between procedures. Case presentation A 60-year-old man was referred to our hospital with sigmoid colon cancer accompanied by intraabdominal abscess and two synchronous liver metastases. One of the liver tumors (tumor 1) was located in segment 8 near the caval confluence and was attached to both the right hepatic vein (RHV) and middle hepatic vein (MHV). The other tumor (tumor 2) in the left lobe invaded the umbilical portion of the portal vein. Both liver metastases decreased in size after four cycles of panitumumab/5-fluorouracil, leucovorin, and oxaliplatin (FOLFOX) therapy. Radical liver resection was planned because tumor 1 had not invaded the MHV. However, three-dimensional volumetric software showed that the non-congested volume of the future liver remnant was estimated at 354 ml, which corresponded to 26.3% of the total liver volume. TSH was scheduled to avoid POLF. We first performed limited resection of segment 8 with resection of the RHV root. After the first hepatectomy, the development of intrahepatic venous collaterals between the RHV and MHV was seen on computed tomography and magnetic resonance imaging. The estimated non-congested future liver remnant was 1242 ml, 78.5% of the total liver volume. Therefore, the patient underwent left hemihepatectomy 58 days after the first hepatectomy. We saw no adhesions around the porta hepatis, and the left hepatic artery and left branch of the portal vein were safely exposed and divided. Intraoperative Doppler ultrasonography revealed intrahepatic venous collaterals arising from RHV to MHV. The patient’s postoperative course was uneventful, and he underwent eight cycles of panitumumab/FOLFOX therapy for 5 months after the second hepatectomy. Conclusions Our TSH strategy helped avoid POLF by waiting for the development of intrahepatic venous collaterals.

A retrospective analysis indicated that the incidence of delayed gastric emptying (DGE) was less after using a circular stapler (CS) for duodenojejunostomy than that after hand-sewn (HS) anastomosis in pylorus-preserving pancreaticoduodenectomy (PpPD). This randomized clinical trial compared the incidence of DGE postoperative after CS duodenojejunostomy with that of conventional HS anastomosis in PpPD. We randomly assigned 101 patients (age 20–80) undergoing PpPD to receive CS duodenojejunostomy (group CS, n = 50) or HS duodenojejunostomy (group HS, n = 51) in two Japanese cancer center hospitals between 2011 and 2013. The patients were stratified by institution and size of the main pancreatic duct (

Background Laparoscopic distal pancreatectomy has been shown to be associated with favorable postoperative outcomes using meta-analysis. However, there have been no randomized controlled studies yet. This study aimed to compare laparoscopic and open distal pancreatectomy using propensity score-matching. Methods We retrospectively collected perioperative data of 2,266 patients who underwent distalpancreatectomyin69institutesfrom2006–2013inJapan.Amongthem,2,010patients were enrolled in this study and divided into two groups, laparoscopic distal pancreatectomy and open distal pancreatectomy. Perioperative outcomes were compared between the groups using unmatched and propensity matched analysis. Results After propensity score-matching, laparoscopic distal pancreatectomy was associated with favorable perioperative outcomes compared with open distal pancreatectomy, including higher rate of preservation of spleen and splenic vessels (P

The survival benefits of additional resection of the positive proximal ductal margin in cases of perihilar cholangiocarcinoma remain to be elucidated. The purpose of this retrospective study was to clarify the optimal indications for additional resection of the invasive cancer-positive proximal ductal margin (PM) METHODS: All patients who underwent hepatectomy for perihilar cholangiocarcinoma between 2000 and 2011 were analyzed. Surgical variables, the status of the PM, prognostic factors, and survival were evaluated.A total of 224 patients were enrolled. Additional resection was performed in 52 of 75 positive PMs of invasive cancer, resulting in 43 negative PMs. The survival of patients with a negative PM treated with additional resection (n = 43) was significantly worse than that of the patients with a negative PM treated without additional resection (n = 149; P = 0.031) and did not significantly differ from that of the patients with a positive PM (n = 32; P = 0.215). A multivariate analysis demonstrated that the carbohydrate antigen 19-9 (CA19-9) level (64 or ≥64), combined vascular resection, pN, pM, the histological grade, perineural invasion, liver invasion, and R status were independent prognostic factors. Only in the subgroups of CA19-964 and pM0, the survival of the patients with a negative PM treated with additional resection was significantly better than that of the patients with a positive PM (P = 0.019 and P = 0.021, respectively).Additional resection of the invasive cancer-positive PMs may be warranted only in limited patients with a lower level of CA19-9 and no distant metastatic disease.

AIM To clarify the histological changes associated with liver atrophy after percutaneous transhepatic portal embolization (PTPE) in pigs and humans. METHODS As a preliminary study, we performed pathological examinations of liver specimens from five pigs that had undergone PTPE in a time-dependent model of liver atrophy. In specimens from embolized lobes (EMB) and nonembolized lobes (controls), we measured the portal vein to central vein distance (PV-CV), the area and number of hepatocytes per lobule, and apoptotic activity using the terminal deoxynucleotidyl transferase dUTP nick-end labeling assay. Immunohistochemical reactivities were evaluated for light chain 3 (LC3) and lysosomal-associated membrane protein 2 (LAMP2) as autophagy markers and for glutamine synthetase and cytochrome P450 2E1 (CYP2E1) as metabolic zonation markers. Samples from ten human livers taken 20-36 d after PTPE were similarly examined. RESULTS PV-CVs and lobule areas did not differ between EMB and controls at day 0, but were lower in EMB than in controls at weeks 2, 4, and 6 (P ≤ 0.001). Hepatocyte numbers were not significantly reduced in EMB at day 0 and week 2 but were reduced at weeks 4 and 6 (P ≤ 0.05). Apoptotic activity was higher in EMB than in controls at day 0 and week 4. LC3 and LAMP2 staining peaked in EMB at week 2, with no significant difference between EMB and controls at weeks 4 and 6. Glutamine synthetase and CYP2E1 zonation in EMB at weeks 2, 4, and 6 were narrower than those in controls. Human results were consistent with those of porcine specimens. CONCLUSION The mechanism of liver atrophy after PTPE has two histological phases: Hepatocellular atrophy is likely caused by autophagy in the first 2 wk and apoptosis thereafter.

Surgical resection is advocated for all stages of pancreatic neuroendocrine tumors (PNETs); whether small PNETs can be managed by observation alone is controversial. The prognoses of patients with non-functional PNET managed by surgical resection or observation alone were retrospectively analyzed. In patients who had undergone resection, correlation of pathologically assessed tumor extension and grade with tumor size were evaluated. Nineteen patients with PNET of median tumor diameters of 12 mm (range 6–38 mm) were followed up by observation for 19–162 months. Increase of tumor size >20 % occurred in three patients, resulting in 5-year progression-free survival of 83 %, but no distant metastases occurred. Surgical resection was performed in 71 patients. Tumor size correlated with the incidence of lymph node or hepatic metastases, portal vein invasion, and Ki-67 index. None of the 18 patients with a tumor size ≤15 mm developed lymph node or distant metastases, and all these patients survived without recurrence for 5–283 months. The smallest tumor size with lymph node metastases was 19 mm. The 5-year recurrence-free survivals of patients with a tumor size ≤15 mm (100 %) was significantly better than patients with tumor sizes 16–20 mm (86 %), 21–30 mm (71 %), 31–50 mm (83 %), and >50 mm (48 %). Because PNETs ≤15 mm in size have little risk of metastases or recurrence, careful observation with serial image studies is acceptable. Once the tumor size exceeds 15 mm, the risk of metastases and recurrence increases significantly.

Aim Prognosis of hypervascular cholangiocellular carcinoma (h-CCC) is reportedly better than that of ordinary hypovascular CCC (o-CCC). The aim of this study is to clarify the histopathological characteristics of h-CCC. Methods On the basis of the findings in the arterial phase of contrast-enhanced computed tomography, 16 cases of mass-forming-type CCC were divided into two groups (h-CCC, n = 8; o-CCC, n = 8). Areas of high (Area H-a) and low (Area H-b) attenuation in h-CCC cases and areas of low attenuation in o-CCC cases (Area O) were delineated. These areas were then evaluated histopathologically to determine the proportion of tumor cells, fibrous stroma, arterial vessel density, and immunohistochemical expression of Vascular endothelial growth factor; angiopoietin-2; cytokeratin 7, CK19, SOX9 and SOX17 genes; epithelial cell adhesion molecule; and the Bmi-1, Ki-67, epithelial membrane antigen and polyclonal carcinoembryonic antigen. Results The areal ratio of tumor cells decreased and that of fibrous stroma increased in the following order: Area H-a, Area H-b and Area O. Values for AVD and neural cell adhesion molecule positivity rate were significantly higher in Area H-a than in Areas H-b or O. Expressions of vascular endothelial growth factor and angiopoietin-2 were significantly higher in Areas H-a and H-b than in Area O. The Ki-67 labeling index increased in the following order: Area H-a, Area H-b and Area O. Conclusion A high areal ratio of tumor cells and AVD as well as a high expression of stem cells and angiogenic markers were observed in cases of h-CCC, whereas the areal ratio of fibrous stroma and malignant potential were low. These results suggest that h-CCC may represent the early stage of CCC.

It has been speculated that intraductal dissemination, via the pancreatic duct, bile duct, or mammary duct, is a unique form of cancer cell spread. However, clinical evidence to confirm this form of dissemination has been lacking. Here we report a case of papillary adenocarcinoma of the ampulla of Vater in which retrograde dissemination to the pancreatic duct was strongly suggested. A 79-year-old woman underwent pancreatoduodenectomy for a 22 mm microinvasive papillary adenocarcinoma of the ampulla. Multiple carcinomas in situ were found in the pancreatic duct distant from the ampulla. Seven months later, she underwent a second operation for a recurrent papillary adenocarcinoma at the pancreato-jejunal anastomosis showing exophytic and expansive growth into the jejunal lumen that connected to an intraductal adenocarcinoma in the pancreatic body. None of these tumors showed invasive growth, or vascular or neural invasion, being separate from each other but sharing identical histological, immunohistochemical, and molecular features; papillary growth, a pancreatobiliary phenotype, the same pattern of genomic loss of heterozygosity, and no mutation of the KRAS, TP53, and GNAS genes. These results imply that this papillary adenocarcinoma of the ampulla of Vater had disseminated to the pancreatic duct in a retrograde manner and recurred in the remnant pancreas.

Early venous return (EVR) is an important radiological feature of hepatic angiomyolipoma (HAML) that can aid in differential diagnosis, but the pathogenic mechanisms of EVR have yet to be elucidated. We present the first HAML case for which a probable mechanism for EVR is described. The patient was a 46-year-old woman, who had a growing 6-cm tumor with EVR in segment 3 of the liver as revealed by dynamic contrast-enhanced computed tomography. Left hepatic lobectomy was performed to prevent tumor rupture. Histopathological and immunohistochemical analyses of the excised tumor indicated HAML. Successive microsections of the tumor were stained with hematoxylin-eosin and Victoria blue to visualize the vascular structure within and around the tumor. These analyses led to three major findings. First, many well-defined thick-walled vessels, such as arteries, were found entering the tumor. Second, many thick-walled vessels within the tumor were connected directly to thin-walled vessels, resembling arteriovenous fistulae. Finally, thin-walled intratumoral vessels were connected directly to the hepatic vein. These histological findings suggested that the rich arterial flow into the tumor was being rapidly drained into the hepatic vein through intratumoral arteriovenous connections. We also detected these same anomalous circulatory pathways in tissue sections from three of four additional HAML cases with EVR. Aberrant arteriovenous fistulae within the tumor may account for many cases of EVR in HAML patients.

Whether the remnant stomach can be safely preserved when performing distal pancreatectomy (DP) in patients with a prior distal gastrectomy (DG) remains unclear because the remnant stomach and pancreatic body/tail share an arterial blood supply via the splenic artery (SPA). A total of 18 patients with prior DG who underwent DP were enrolled in this study. Clinicopathologic data were retrospectively analyzed with a focus on management of the remnant stomach and complications related to ischemia of the remnant stomach. Additionally, intraoperative indocyanine green (ICG) fluorescence angiography was performed to visualize the blood flow and circulation in the remnant stomach. Ten patients underwent a standard DP (DP in conjunction with splenectomy and division of the SPA) with preservation of the remnant stomach. The entire stomach was preserved in seven patients, and three underwent concomitant partial resection of the remnant stomach. No patients in whom the entire remnant stomach was preserved developed postoperative complications associated with it, whereas two of the three patients who underwent partial resection of the remnant stomach developed severe ischemic complications. Intraoperative ICG fluorescence angiography revealed a caudally directed circulation of blood from the esophagogastric junction through the intramural capillary network in the remnant stomach. When performing DP in patients with a prior DG, preservation of the entire remnant stomach was a safe procedure because of the presence of an intramural network that supplies blood to the remnant stomach. In contrast, partial resection of the remnant stomach could be dangerous because of the potential for severe ischemic complications.

Recently, an increasing number of patients with liver metastases from colorectal cancer have received chemotherapy before hepatectomy. However, the effect of chemotherapy on postoperative short-term outcome is not well defined. We retrospectively investigated the postoperative complications of 439 patients who underwent hepatectomy for colorectal liver metastases in our division from 2005 to 2014. Patients were classified into two groups according to the presence (Cx; 84 patients) or absence (NCx; 355 patients) of preoperative chemotherapy. Univariate and multivariate analyses were conducted to determine the predictive factors for postoperative complications. There was neither mortality nor liver failure after surgery. There was no significant difference in the frequency of postoperative complications between Groups Cx and NCx [29 vs 26 % for all complications; both 6 % for bile leakage that required therapeutic intervention; and 2 vs 3 % for Clavien–Dindo (CD) Grade ≥ IIIa, respectively]. In Group Cx, morbidity rates were similar among patients with different chemotherapy regimens. Chemotherapy-related factors (administration of bevacizumab, oxaliplatin or irinotecan, duration of chemotherapy >150 days, and timing of hepatectomy) were not significantly associated with clinically relevant bile leakage and CD ≥ IIIa in multivariate analysis. Even after combination chemotherapy including targeted therapy, hepatectomy for colorectal liver metastases can be performed safely without increasing morbidity or mortality, if the patients fulfill the conventional criteria for surgery.

Hypovascular tumors associated with hepatocellular carcinoma (HCC) can be diagnosed, but it remains unknown whether such lesions should be treated immediately. This study aimed to clarify the clinical significance of treating hypovascular liver nodules. After diagnosis of hypovascular tumors smaller than 3 cm, 104 patients underwent liver resection immediately (Group 1), while 93 patients were placed under observation (Group 2). In Group 1, 98 patients were diagnosed as having HCC (Group 1′), while 80 patients in Group 2 underwent liver resection after vascularization or appearance of other hypervascular HCC (Group 2′), eight patients had been observed, and five patients could not undergo operation due to appearance of other multiple HCCs. To avoid lead time bias for tumor vascularization, survival rates of patients after diagnosis of hypovascular tumors as well as those after operation in the two groups were compared. After a median follow-up of 3.3 years (range 0.6–11.2), the 5-year overall survival rates after liver resection of Group 1′ (74.8 %; 95 % CI 64.3–86.1) was significantly higher than that of Group 2′ (59.2 %; 46.4–75.6; P = 0.027). However, the 5-year overall survival rates after diagnosis of hypovascular liver nodules of Group 1′ (74.7 %; 66.1–85.0) was not significantly different from that of Group 2′ (77.1 %; 67.0–88.6; P = 0.761). Consequently, the 5-year overall survival rate after diagnosis of Group 2 (75.6 %; 64.7–83.1) was not significantly different from that of Group 1 (73.2 %; 67.5–86.1; P = 0.591) by intention-to-treat analysis. It is not necessary to treat hypovascular liver tumors immediately after diagnosis.

Endoscopic nasobiliary drainage (ENBD) is increasingly preferred to percutaneous transhepatic biliary drainage (PTBD) for patients undergoing major hepatectomy including hemihepatectomy or trisectorectomy with extrahepatic bile duct resection. The study was aimed to evaluate whether postoperative outcomes differed according to the types of biliary drainage.Patients who underwent major hepatectomy with bile duct resection for biliary tract cancer between December 2000 and March 2015 were classified into four groups according to their initial biliary drainage type. The preoperative management and postoperative morbidity were compared.Totally, 280 patients were classified into the following groups: no biliary drainage (n = 109), PTBD (n = 99), ENBD (n = 28), and endoscopic retrograde biliary drainage (ERBD; n = 44). Preoperative catheter management including tube exchange or additional tube placement due to cholangitis or poor drainage was most frequently required in the ERBD group (PTBD, 18 %; ENBD, 14 %; ERBD, 43 %; P 0.01). By the time of hepatectomy, 141 patients underwent at least one PTBD (PTBD(+)) and 30 patients were managed only with endoscopic biliary drainage (PTBD(-)). The incidence of major postoperative morbidities (Clavien-Dindo grade ≥ III) in PTBD(+) and PTBD(-) group was 23 and 3 %, respectively (P = 0.01). A multivariate analysis among 171 patients with biliary drainage showed PTBD(+) (P = 0.04; odds ratio = 8.50; 95 % confidential interval [CI], 1.10-65.45) and red blood cells transfusion (P 0.01; odds ratio = 2.72; 95 % CI, 1.22-6.09) were independent predictors of major morbidity.The type of preoperative biliary drainage was associated with the perioperative outcomes of major hepatectomy. Sticking to endoscopic biliary drainage was associated with lower risk of postoperative major morbidity.