Search

BACKGROUND: Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce.METHODS: Surgeons from Japan, Korea, Taiwan, and the U.S., etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5.RESULTS: Response rates for the first- and the second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: 1) Effective retraction of the gallbladder, 2) Always obtaining critical view of safety, and 3) Avoiding excessive use of electrocautery/clipping as vital procedures; and 4) Calot's triangle area and 5) Critical view of safety as important landmarks. For 6) Impacted gallstone and 7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated.CONCLUSIONS: A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI. This article is protected by copyright. All rights reserved.

A man in his 30s, who had undergone retrocolic Billroth II reconstruction for perforated duodenal ulcer, presented with watery diarrhea for 2 years and suspected fatty liver. He was referred to our hospital for management of chronic diarrhea, weight loss, hepatopathy and hypoalbuminemia. Initial upper and lower gastrointestinal endoscopies were negative. Since a small bowel lesion was suspected, peroral single-balloon enteroscopy was performed, which identified feces-like residue near the Billroth II anastomotic site and a connection to the colon separate from the afferent and efferent loops. Transanal single-balloon enteroscopy identified a fistula between the gastrojejunal anastomosis and transverse colon, with the scope reaching the stomach transanally. Barium enema confirmed flow of contrast medium from the transverse colon through the fistula to the anastomotic site, allowing the diagnosis of gastrojejunocolic fistula. Liver biopsy showed relatively severe steatohepatitis (Brunt's classification: stage 2-3, grade 3). Resection of the anastomotic site and partial transverse colectomy were performed to remove the fistula, followed by Roux-en-Y reconstruction. Postoperatively, watery diarrhea resolved and the stools became normal. Hepatopathy and hypoproteinemia improved. One year later, liver biopsy showed marked improvement of steatosis. This case demonstrated marked improvement of both diarrhea/nutritional status and steatohepatitis after treatment of gastrojejunocolic fistula, suggesting that the fistula caused non-alcoholic steatohepatitis.

Endoscopic mucosal dissection (ESD) is a treatment option for oesophagus tumours localized to the mucosa enabling en bloc removal of large lesions. The resulting larger mucosal defects have resulted in an increase in the occurrence of post-treatment strictures. Transplantation of autologous cell sheets, cultured from oral mucosa, has been shown to prevent post-ESD strictures. The aim of the study was to assess the efficacy and safety of cell sheet transplantation after oesophageal ESD in a Western patient population where reflux-associated pre-malignant and malignant conditions predominate.Patients with Barrett's oesophagus associated high-grade dysplasia or early adenocarcinoma where ESD entailed a resection3 cm in length and ≥75% of the circumference were eligible for treatment under hospital exemption. Cell sheets were cultured from buccal mucosa according to Good Manufacturing Practice and were endoscopically applied to the post-ESD defect directly after resection. Patients were followed with weekly endoscopy examinations, including confocal laser microscopy, for a total of four weeks.Five patients were treated. ESD was extensive with resections being circumferential in three patients and 9-10 cm in length in two. The number of transplanted cell sheets ranged from two to six. Three patients developed strictures requiring two to five dilatation sessions.Cell sheet transplantation shows to be safe and feasible in a Western population. Results suggest that transplantation has a protective effect on the mucosal defect after ESD, decreasing both the risk for and extent of stricture formation.

OBJECTIVE Early diagnosis and treatment of cancer may contribute substantially to complete cure, but it remains unknown whether treatment of early hepatocellular carcinoma can actually result in cure. This study was performed to clarify the cancer risk of the background liver after treating early hepatocellular carcinoma. METHODS Early hepatocellular carcinoma is defined as very well-differentiated cancer containing Glisson's triad. The cumulative incidence of classical hepatocellular carcinoma, hypervascular liver cancer detected on imaging studies, after resection of early hepatocellular carcinoma positive for anti-hepatitis C antibody (early hepatocellular carcinoma group, n = 105) was compared with that in patients with chronic liver disease positive for anti-hepatitis C antibody (control group, n = 751) and propensity score-matched patients after resection of classical hepatocellular carcinoma (classical hepatocellular carcinoma group, n = 105). RESULTS After a median follow-up of 4.8 years (range, 0.3-15.0), the cumulative incidence of classical hepatocellular carcinoma at 5 years was 56.9% (95% confidence interval, 44.2-67.7%) in the early hepatocellular carcinoma group and 70.6% (52.5-81.8%) in the classical hepatocellular carcinoma group as compared with 4.6% (2.8-6.4%) in the control group. The risk of the development of classical hepatocellular carcinoma in the early hepatocellular carcinoma group was significantly higher than that in the control group (hazard ratio, 17.5; 95% confidence interval, 12.1-25.3; P

Case series Patients: Male, 48 • Male, 60 • Male, 63 • Male, 69 • Male, 68 • Female, 63 Final Diagnosis: Esophageal cancer Symptoms: None Medication: — Clinical Procedure: — Specialty: Oncology Objective: Rare disease Background: Patients with esophageal achalasia are considered to be a high-risk group for esophageal carcinoma, and it has been reported that this cancer often arises at a long interval after surgery for achalasia. However, it is unclear whether esophageal carcinoma is frequent when achalasia has been treated successfully and the patient is without dysphagia. In this study, we reviewed patients with esophageal carcinoma who were detected by regular follow-up after surgical treatment of achalasia. Case Report: Esophageal cancer was detected by periodic upper GI endoscopy in 6 patients. Most of them had early cancers that were treated by endoscopic resection. All 6 patients had undergone surgery for achalasia and the outcome had been rated as excellent or good. Annual follow-up endoscopy was done and the average duration of follow-up until cancer was seen after surgery was 14.3 years (range: 5 to 40 years). Five patients had early cancer. Four cases had multiple lesions. Conclusions: In conclusion, surgery for achalasia usually improves passage symptoms, but esophageal cancer still arises in some cases and the number of tumors occurring many years later is not negligible. Accordingly, long-term endoscopic follow-up is needed for detection of malignancy at an early stage.

Purpose This study compared the feasibility and safety of endoscopic placement of self-expandable metallic stents (SEMSs) as a bridge to surgery (BTS) between patients with obstructive colorectal cancer (CRC) classified as ColoRectal Obstruction Scoring System (CROSS) 0 and those with CROSS 1 or 2. Methods We conducted a post hoc analysis of two prospective, observational, single-arm multicenter clinical trials and performed a pooled analysis of the data. In total, 336 consecutive patients with malignant colorectal obstruction underwent SEMS placement. The primary endpoint was clinical success, defined as resolution of symptoms and radiological findings within 24 h. Secondary endpoints were technical success and adverse events. Results High clinical (98.0% vs. 98.4%) and technical (96.7% vs. 97.8%) success rates were observed in both groups (CROSS 0 vs. CROSS 1 or 2). The adverse event rate was low. The mean stricture length was lower (3.8 ± 1.2 cm vs. 4.4 ± 1.8 cm) and laparoscopic surgery more common (56.7% vs 52.2%) in the CROSS 0 group than in the CROSS 1 and 2 group. Conclusion This study was the first to compare the degree of stricture in different CROSS groups and demonstrated comparable results with respect to the short-term efficacy and safety of SEMS placement as a BTS for obstructive CRC in CROSS 0, 1, and 2 patients.

Background We compared survival after resection by systematic segmentectomy (SS) versus non-anatomic resection (NAR) in patients with small, solitary hepatocellular carcinomas (HCCs). Methods To control for variables, we used 1-to-1 propensity score matching to compare outcomes after surgery among 615 patients in Japan between 2003 and 2007 with primary solitary HCCs ≤3 cm in diameter who received SS (n = 114) or NAR (n = 114) of one Couinaud segment with complete removal of the portal territory containing the tumor. Results We successfully matched SS and NAR patients with primary HCC tumors ≤3.0 cm and similar liver function and tumor characteristics. The SS group had significantly longer recurrence-free survival (RFS; hazard ratio [HR] 1.56, 95% confidence interval [CI] 1.10-2.21, P = .013) and overall survival (OS; HR 1.67, 95% CI 1.07-2.60, P = .025) than the NAR group. Among patients who lost >400 mL of blood during surgery, had chronic hepatitis, or had cirrhosis, the RFS and OS were better in the SS group than in the NAR group. In Cox proportional hazard analysis, SS offered a better prognosis than NAR. Conclusions Systematic segmentectomy decreases the risk of recurrence and improves OS in patients with primary, solitary HCC tumors of ≤3 cm in diameter.

OBJECTIVE The aim of this study was to evaluate how often left-sided portal hypertension (LPH) develops and how LPH affects the long-term outcomes of patients with pancreatic cancer treated with pancreaticoduodenectomy (PD) and resection of the portal vein (PV)/superior mesenteric vein (SMV) confluence. SUMMARY BACKGROUND DATA Little is known about LPH after PD with resection of the PV/SMV confluence. METHODS Overall, 536 patients who underwent PD with PV/SMV resection were enrolled. Among them, we mainly compared the SVp group [n=285; the splenic vein (SV) was preserved] and the SVr group (n = 227; the SV was divided and not reconstructed). RESULTS The incidence of variceal formation in the SVr group increased until 3 years after PD compared with that in the SVp group (38.7% vs 8.3%, P < 0.001). Variceal bleeding occurred in the SVr group (n = 9: 4.0%) but not in the SVp group (P < 0.001). In the multivariate analysis, the risk factors for variceal formation were liver disease, N factor, conventional PD, middle colic artery resection, and SV division. The only risk factor for variceal bleeding was SV division. The platelet count ratio at 6 months after PD was significantly lower in the SVr group than in the SVp group (0.97 vs 0.82, P < 0.001), and the spleen-volume ratios at 6 and 12 months were significantly higher in the SVr group than in the SVp group (1.38 vs 1.00 and 1.54 vs 1.09; P < 0.001 and P < 0.001, respectively). CONCLUSIONS PD with SV division causes variceal formation, bleeding, and thrombocytopenia.

BACKGROUND Survival benefit of liver resection for noncolorectal liver metastases (NCRLM) remains to be defined. METHODS This multicenter, retrospective cohort analysis included consecutive patients with NCRLM whose primary tumor and all metastases were treated with curative intent between 2000 and 2013. The primary endpoint was 5-year overall survival. Clinicopathological factors that affected prognoses were identified using multivariate Cox regression analyses and were included in a predictive model. RESULTS Data for 205 patients were analyzed. The three most common primary tumor sites were stomach (39%), pancreas (13%), and urinary tract (10%), with adenocarcinomas the main pathology (52%). R0 resection was achieved in 85%, and the overall survival at 5 years was 41%. In the multivariate analysis, synchronous liver metastases, R1/2 resection, and adenocarcinomas and other carcinomas (with gastrointestinal stromal tumors, neuroendocrine tumors G1/G2, and sarcomas set as the reference group) were independent negative indicators of overall survival. A predictive model effectively stratified the NCRLM patients into low-, intermediate-, and high-risk groups with overall 5-year survival rates of 63%, 38%, and 21%, respectively (P

Purpose To investigate the risk factors for post-pancreatectomy hemorrhage (PPH). Methods The incidence, outcome, and risk factors for PPH were evaluated in 1169 patients who underwent pancreatectomy. Results The incidence and mortality rates of PPH were 3% and 11% in all pancreatectomies, 4% and 11% in pancreatoduodenectomy, 1% and 20% in distal pancreatectomy, and 3% and 0% in total pancreatectomy, respectively. Male sex [odds ratio (OR) 2.32], body mass index (BMI) ≥ 25 kg/m2 (OR 3.70), absence of diabetes mellitus (DM; HbA1c ≤ 6.2%; OR 3.62), and pancreatoduodenectomy (OR 3.06) were risk factors for PPH after all pancreatectomies. The PPH incidence was 0%, 1%, 2%, 6%, and 20% in patients with risk scores of 0 (n = 65), 1 (n = 325), 2 (n = 455), 3 (n = 299), and 4 (n = 25), respectively. The differences between risk-score groups 0–2 (2%) and 3–4 (7%) were significant (P P = 0.28). The incidence of POPF post-pancreatoduodenectomy was 20%. BMI ≥ 25 kg/m2 (OR 3.17), serum albumin Conclusion Our study clarified the preoperative risk factors for PPH and recommends using a risk scoring system that includes “absence of DM” for predicting PPH.

Background The use of laparoscopic surgery has become widespread, and many surgeons are striving to acquire the necessary techniques for it. The Endoscopic Surgical Skill Qualification System (ESSQS), established by the Japan Society for Endoscopic Surgery, serves to maintain and improve the quality of laparoscopic surgery in Japan. In this study, we aimed to determine whether ESSQS certification is useful in maintaining and improving the quality of surgical techniques and in standardization of laparoscopic surgery in Japan. Methods This retrospective study used data from the Institute for Integrated Medical Sciences, Tokyo Women’s Medical University, Japan. From January 2016 to October 2017, 241 patients with colorectal cancer underwent laparoscopic surgery. Of them, 220 patients were selected and divided into two groups on the basis of surgery performed by an ESSQS-qualified surgeon (QS group) (n = 170) and a non-ESSQS-QS (NQS) (n = 50). We compared the short-term results in the two groups and examined those before and after propensity score matching (PSM). Results Mean operation time was longer in the NQS group than in the QS group. Furthermore, mean blood loss was significantly less in the QS group. These were similar before and after PSM. The rate of conversion to open surgery was significantly higher in the NQS group before PSM. However, the rate of postoperative complications was not different between the two groups. Conclusions A laparoscopic procedure performed by ESSQS-QS often leads to good short-term outcomes. Thus, the ESSQS system works and is potentially useful in maintaining and improving the quality of surgical techniques and in standardization of laparoscopic surgery in Japan.

The aim of the present study was to clarify the association between preoperative liver function and complications after hepatectomy.The study included 11,686 patients registered in the National Clinical Database for 2015 for whom data on indocyanine green at 15 min (ICG15) and hepatectomy were available. The patients were divided into four groups: group A (ICG1510%; n = 5,661), group B (ICG15 10% to20%; n = 4,381), group C (ICG15 20% to30%; n = 1,173) and group D (ICG1530%; n = 463). Hepatectomy procedures were classified as partial resection (n = 3,934), systematic subsegmentectomy (n = 2,055), monosectionectomy (n = 2,043), bisectionectomy (n = 2,993) and trisectionectomy (n = 208). Complications were classified using the Clavien-Dindo classification (CD) and evaluated by ICG15 category and procedure type.Complications more severe than CD III increased significantly as the operation time lengthened and the intraoperative bleeding volume increased (P0.001). ICG15 category was positively associated with operative death,CD III complications, surgical site infection (SSI), liver failure, and intractable ascites for many of the major hepatectomy procedures, but not with bile leakage. More complications were observed in patients outside the Makuuchi criteria than in those within the criteria.Operation time and intraoperative bleeding volume are significantly associated with severe postoperative complications in patients undergoing hepatectomy. ICG15 is a good indicator predictive of operative death,CD III complications, SSI, liver failure and intractable ascites.

Background We examined the utility of transient hepatic attenuation differences (THADs) detected in the arterial phase of computed tomography for the diagnosis of acute gangrenous cholecystitis (AGC). Methods We examined 83 consecutive patients who underwent cholecystectomy within 72 h of undergoing three-phase dynamic computed tomography scans for acute cholecystitis between 2009 and 2018 (histopathological examination later confirmed 42 with AGC, 41 without). The THAD volume (cm3 ) was calculated by multiplying the total area of the enhancing lesions (traced on axial images) by the thickness of the scan (0.5-cm slices). We evaluated the sensitivity and specificity of the THAD volume and other computed tomography findings of AGC. Results The THAD volume was significantly larger in the AGC group than in the non-gangrenous acute cholecystitis group (P 78 cm3 to be an independent predictor of AGC. Conclusions Acute gangrenous cholecystitis can be diagnosed using THAD volume, resulting in improved treatment and fewer serious complications.

Background/aim The aim of the study was to evaluate surgical outcomes of patients with high-signal intensity (SI) image hepatocellular carcinoma (HCC). Patients and methods Between 2008 and 2013, 257 HCC patients were retrospectively evaluated. A total of 21 patients were diagnosed as high-SI image HCC, 215 as low-SI image HCC, and 21 patients as mixed (high and low)-SI image HCC in the hepatobiliary (HB) phase of MRI. Five-year overall survival (OS) and recurrence-free survival (RFS) were compared among patient groups. Results The 5-year OS and RFS rates were significantly higher in patients with high-SI image HCC (100% and 56%) than in patients with low-SI image HCC (71%; p=0.097 and 38%; p=0.0209) and in patients with mixed-SI image HCC (73%; p=0.0329 and 9%; p=0.0021). High-SI image was an independent prognostic factor for OS (relative risk 0.167, p=0.0178) and RFS (relative risk 0.471, p=0.0322) on multivariate analysis. Conclusion Patients with high-SI image HCC showed favorable long-term survival after curative surgery.

Backgrounds: The optimal lymph node dissection range in patients with non-functioning pancreatic neuroendocrine tumors is not yet clear. In this study, we investigated the site and frequency of lymph node metastasis and the significance of lymph node dissection in patients with non-functioning pancreatic neuroendocrine tumors. Methods: This retrospective study analyzed 74 patients who underwent a curative pancreatectomy for non-functioning pancreatic neuroendocrine tumors between 2000 and 2016. The site and frequency of lymph node metastasis and clinicopathological factors were evaluated. Results: The rate of synchronous lymph node metastasis was 17.6%, with 11.1 and 29.4% for tumors with diameters of 10–19 mm and ≥20 mm, respectively. Lymph node metastasis was not observed for tumors with a diameter Conclusions: This study clarified the site and frequency of lymph node metastasis and the optimal range of lymph node dissection in patients with non-functioning pancreatic neuroendocrine tumors.

Background Hepatopulmonary syndrome (HPS) negatively affects the outcomes of deceased donor liver transplantation (LT). Methods We retrospectively reviewed the clinical records of patients with HPS who underwent LT and studied the impact of risk factors on clinical outcomes to determine strategies to overcome complications. Patients with symptoms of hypo-oxygenemia and a shunt ratio >15% on 99mTc-MAA lung perfusion scintigraphy were defined as having HPS. Results Forty-eight patients in 10 centers were enrolled. Diseases included biliary atresia, liver cirrhosis, non-alcoholic steatohepatitis, congenital hepatic fibrosis, and others. The length of ICU stay was 2-170 days. The respirator was used for 41.6% of patients on post-operative day (POD) 3 and 20.8% on POD 14. The patient survival rate was 87% at 1 year and 82% at 5 years. The causes of hospital mortality were sepsis, thrombotic microangiopathy, intracranial bleeding, pulmonary fibrosis, and transplant rejection. An amount of shunt ratio prior to LT was a significant risk factor for hospital mortality. Hypoxia from POD 3 to POD 14 was a risk factor for biliary stenosis. The shunt ratio of all surviving patients significantly improved. Conclusion Although LT is feasible for patients with HPS, early transplantation and avoiding hypo-oxygenemia immediately after transplantation are important.

Background and aim We evaluated the characteristics of hepatocellular carcinoma (HCC) in patients who had non-alcoholic fatty liver disease (NAFLD) without cirrhosis. Methods We prospectively followed NAFLD patients at our University hospital. NAFLD was diagnosed from detection of steatosis by histology or imaging, no alcohol intake, and exclusion of other liver diseases. Cirrhosis was defined by histological features, imaging data, and symptoms. We compared NAFLD-related HCC with or without cirrhosis and non-cirrhotic NAFLD with or without HCC. Results There were 48 non-cirrhotic HCC patients and 71 cirrhotic HCC patients. Multiple logistic regression analysis revealed that other than liver function factors, male gender (OR: 5.603, 95%CI: 1.577-19.900), light drinker (OR: 2.797, 95%CI: 1.031-7.589), and tumor size (OR: 1.031, 95%CI 1.009-1.055) differ significantly between these two groups. The recurrence rate was significantly lower in the non-cirrhotic HCC group than the cirrhotic HCC group, with risk factors being des-γ-carboxy prothrombin and the number of HCCs. The non-cirrhotic HCC group showed significantly better survival because of absence of non-cancerous liver failure. Comparison between non-cirrhotic NAFLD patients with or without HCC (n = 612) revealed the following risk factors for HCC: male gender (OR: 7.774, 95%CI: 2.176-27.775), light drinker (OR: 4.893, 95%CI: 1.923-12.449), and high FIB4 index (OR 2.634, 95%CI: 1.787-3.884). Conclusion In patients with non-cirrhotic NAFLD, important risk factors for HCC were male gender, alcohol consumption, and the FIB4 index. HCC recurrence and survival were only influenced by the tumor stage. We should be aware of alcohol consumption as a modifiable risk factor for HCC.

The new T1 pancreatic cancer by the eighth edition of the AJCC staging system discards the concept of “extension beyond the pancreas” and focuses on size only. Furthermore, the new T1 is divided into T1a, T1b, and T1c based on size. The evidence pertaining to these changes has not been evaluated. This is to evaluate the feasibility of the new T1 definition in the pancreas head cancer cohort. Data from 540 patients with T1 pancreatic ductal adenocarcinoma as defined by the eighth edition were collected from Korea, Japan, and the USA. Invasive IPMNs were excluded. Survival analyses were performed. Of the 540 patients, 181 patients were T1 according to the seventh edition and 359 were down-staged to T1 from the former T3 because the concept of “extension beyond the pancreas” was discarded. The 5-year survival rate and the median survival of T1 patients were 30.6% and 27 months, respectively. Comparing tumors that extend beyond the pancreas (new T1) and those confined within the pancreas (original T1), the latter showed significantly longer median survival (43 vs. 24 months, p

The initial value problem for the two dimensional dissipative quasi-geostrophic equation of the critical and the supercritical cases is considered. Anomalous diffusion on this equation provides slow decay of solutions as the spatial parameter tends to infinity. In this paper, uniform estimates for far field asymptotics of solutions are given., 9 pages

BACKGROUND Since there is no reliable evidence on the safety of pancreaticoduodenectomy (PD) in chronic hepatic dysfunction (CHD) including liver cirrhosis (LC), the effects of CHD on patients undergoing PD were investigated. METHODS This multi-institutional retrospective study analyzed 529 patients with CHD, including 105 patients diagnosed with LC, who underwent PD at 82 high-volume institutions between 2004 and 2013. RESULTS The in-hospital mortality rate was 5.9%. The incidence of postoperative hepatic decompensation upon discharge and refractory ascites was 10.2% and 8.9%, respectively. For hepatic decompensation, the serum aspartate aminotransferase (AST) of more than 50 IU/l and portal hypertension (PHT) were independent significant risk factors. For refractory ascites, prothrombin activity of

Background Chemotherapy with or without surgery is the first-line treatment for stage III/IV gastric cancer, while surgery is the first-line treatment for stage I/II gastric cancer. Accordingly, it is important to distinguish between stage III/IV and stage I/II gastric cancer, but clinical staging is less accurate than pathological staging. This study was performed to develop a clinical score that could distinguish stage III/IV gastric cancer from stage I/II gastric cancer. Methods We reviewed 2722 patients who underwent gastrectomy at our hospital from January 1996 to December 2015. As pretreatment factors potentially related to tumor stage, we assessed age, sex, tumor markers, tumor diameter, tumor location, tumor histology, and macroscopic type. Factors showing significance on multivariate analysis were used to develop the Clinical Stage Prediction score (CSP score), and a cutoff value for the score was determined by receiver operating characteristics analysis. Results According to multivariate analysis, clinical factors associated with stage III/IV disease were elevation of the carcinoembryonic antigen level, tumor diameter ≥ 60 mm, circumferential gastric involvement, esophageal infiltration, mucinous adenocarcinoma, and macroscopic types 2–4. The CSP score was obtained by weighting these factors according to the non-standardized β-coefficient. Receiver operating characteristics analysis indicated that the optimum cutoff value of the CSP score was 17 points. Among 1042 patients with a CSP score ≥ 17 points, 820 patients (78.7%) had stage III/IV gastric cancer. Conversely, among 1680 patients with a CSP score

To identify the pioneers of right anatomical hepatectomy (RAH), and clarify the development of associated operative procedures, concepts, and the future, we reviewed the “hidden” literature published in Eastern and Western countries since the 1940s. We searched the English and non-English literature on RAH through web search engines, text books and documents, and also referred to experts’ comments. Non-English literature, other than in Japanese, was translated. Changes in the anatomical concept, anatomical identification, vascular control technique, approaches, pre-operative management, and other aspects of RAH were analyzed. Honjo and Lortat-Jacob, in 1949 and 1951, respectively, reported the first cases of successful RAH; since then, RAH has been used in the treatment of liver malignancies worldwide. Vascular in-flow control is divided into intrafascial, extrafascial or transfissual access. The anatomical border along the main hepatic veins was proposed for transection, and anterior approaches have been suggested as alternative options in the hazardous situation of right liver rotation. In the laparoscopic era, several procedures and positions have been devised for RAH. In summary, RAH and related anatomical hepatectomy have been established as treatment methods for 70 years, and the future of RAH includes new concepts, approaches, and techniques to optimize patient safety and disease curability.

Background Hepatocellular carcinoma (HCC) with tumor thrombus (TT) in the right atrium is a critical condition. The general consensus is to perform hepatectomy prior to cavo-atrial thrombectomy because of the risk of uncontrollable bleeding during the liver transection after heparinization. However, sudden cardiac arrest due to the ball-valve effect and pulmonary embolism have been reported in cases of TT. Cavo-atrial thrombectomy prior to hepatectomy for HCC with TT in the right atrium was successfully performed to prevent sudden cardiac arrest and pulmonary embolism. Case presentation Tumor thrombectomy under cardiopulmonary bypass with heparin and electrical ventricular fibrillation prior to hepatectomy was successfully performed to prevent sudden cardiac arrest or pulmonary embolism in a 75-year-old woman with a huge HCC and TT in the right atrium. After the neutralization of heparin, right hepatectomy with tumor thrombectomy in the inferior vena cava was performed. The total operation time was 9 h, and the total blood loss was 8200 mL. The patient’s postoperative course was uneventful, and she was discharged 14 days after surgery. One year after surgery, she is alive with HCC recurrence in the lung. Conclusions Cavo-atrial thrombectomy prior to hepatectomy for HCC with TT in the right atrium can be performed safely to prevent sudden cardiac arrest and pulmonary embolism by collaboration of cardiovascular surgeons and gastroenterological surgeons.

Objective: Upfront surgery is the standard treatment for resectable pancreatic ductal adenocarcinomas (R-PDACs); however, these tumors often recur. We investigated the factors governing recurrence and prognosis in patients with R-PDAC. Methods: We analyzed 359 patients who underwent upfront surgery for R-PDAC between 2000 and 2016, and evaluated the relationship between clinicopathological factors and recurrence/outcomes. Results: The rate of recurrence was 74% while the median time to recurrence was 1.2 years. On multivariate analysis, carbohydrate antigen 19-9 (CA19-9) >37 U/mL (hazard ratio [HR]: 2.02), tumor size >2.6 cm (HR: 1.50), pathological grade 3 (HR: 2.58), lymph node metastasis (LNM; HR: 1.65), residual tumor (HR: 1.47) and forgoing adjuvant chemotherapy (HR: 1.31) were risk factors for a shorter recurrence-free survival; the median survival time (MST) was 2.8 years. On multivariate analysis, CA19-9 > 37 U/mL (HR: 1.99), tumor size >2.6 cm (HR: 1.43), pathological grade 3 (HR: 2.93), pathological portal vein invasion (HR: 1.48), LNM (HR: 1.79) and forgoing adjuvant chemotherapy (HR: 1.39) were risk factors for shorter disease-specific survival intervals. When examining outcomes according to preoperatively measurable factors (CA19-9 > 37 U/mL and tumor size >2.6 cm), the median time to recurrence and MSTs of patients with none (n = 83), one (n = 112) and both (n = 164) risk factors were 3.2, 1.8 and 0.8 years; and 7.2, 4.0 and 1.7 years, respectively. Conclusions: CA19-9 > 37 U/mL and tumor size >2.6 cm were preoperative independent risk factors for early recurrence and poor outcomes in patients with R-PDAC. Therefore, preoperative treatment should be considered for such patients.

Background: Postoperative pancreatic fistula (POPF) is a harmful complication after pancreaticoduodenectomy (PD). Grade C POPF, as defined by International Study Group of Pancreatic Fistula (ISGPF), is the most life-threatening complication. This study aims to evaluate risk factors for Grade C POPF after PD. Methods: This is a prospective, multicenter collaboration study based in Japan and Taiwan. Between 2014 and 2017, 3,022 patients were enrolled in this study and 2,762 patients were analysed after 260 patients were excluded (discontinuation of protocol treatment: n=241, incomplete information: n=19). We analysed risk factors of Grade C POPF based on the 2005 ISGPF scheme (sepsis, organ dysfunction, haemorrhage, reoperation, and/or death) and then separately by the updated 2016 ISGPF scheme (organ failure, reoperation, and/or death). Findings: Among 2,762 patients that underwent PD, 93 patients (3∙4%) developed Grade C POPF as defined by 2005 ISGPF and 46 patients (1∙7%) developed Grade C POPF as defined by 2016 ISGPF. We found eight independent risk factors associated with Grade C POPF as defined by 2005 ISGPF on multivariate analyses; male sex, body mass index (BMI) ≥25∙0 kg/m2, chronic steroid use, preoperative serum C-reactive protein ≥1∙0 mg/dL, soft pancreas, main duct size

We report a rare case of marked elevation of α-fetoprotein in the absence of hepatocellular carcinoma caused by a relapse of hepatitis C virus (HCV) infection. A 58-year-old man underwent liver transplantation to treat hepatocellular carcinoma caused by HCV-related liver cirrhosis. The HCV was of genotype 2a, and the ribonucleic acid titer was >8.0 log IU/mL. Direct-acting antiviral drugs were prescribed for 12 weeks; however, the HCV infection relapsed after treatment had ended, and α-fetoprotein levels increased to 8,981 ng/mL. Imaging did not reveal any malignancies. The patient initiated interferon therapy, at which time AFP levels decreased, and the HCV was successfully cleared.

Background / Aim The National Clinical Database (NCD) in Japan is a nationwide registry that collects the data of more than 1,200,000 surgical cases annually from over 3500 hospitals. Based on the NCD data, this study compared the perioperative outcomes of major laparoscopic liver resection (LLR) with those of major open liver resection (OLR) using the propensity score matching method. Methods We collected data on 15,191 major hepatectomy cases (929 major LLR cases and 14,262 major OLR cases), and investigated the short-term outcomes in well-matched groups. Results In the LLR group, 30-day mortality, in-hospital mortality, and operative mortality were 0.9%, 1.7%, and 1.7% respectively. The mean blood loss in the LLR group (865.4 ± 1148.2 mL) was significantly less than in the OLR group (1053.8 ± 1176.6 mL), and the median postoperative hospital stay for the LLR patients (21.37 ± 19.71 days) was significantly shorter than for the OLR patients (26.25 ± 24.53 days). The complication rate in the LLR group (16.4%) was significantly lower than that in the OLR group (23.5%). Conclusion LLR in selected patients is currently safely performed as well as OLR even in patients requiring major hepatectomy, associated with less blood loss, shorter hospital stays, and fewer complications. This article is protected by copyright. All rights reserved.

Background/Purpose Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC. Methods A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT. Results The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons. Conclusions Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.

The main objective of this study was to design a recyclable TEMPO (2,2,6,6-tetramethylpiperidinyl-N-oxyl) derivative that could be used as a catalyst in an ionic liquid solvent for the aerobic oxidation of alcohols by using NaNO2 and HCl as co-catalysts. To this end, a TEMPO derivative bearing a quaternary ammonium group, [4-Bu2MeN-TEMPO][PF6] (1), was prepared. It was subsequently shown that this ionic TEMPO derivative is an efficient catalyst for the aerobic oxidation of a variety of primary and secondary alcohols. It exhibits a synergistic effect with ionic liquid solvents and readily outperforms analogous oxidations in methylene chloride. Moreover, the ionic TEMPO could be recycled five times with no loss of activity.

The initial-value problem for the drift–diffusion equation arising from the model of semiconductor device simulations is studied. The dissipation on this equation is given by the fractional Laplacian ( − Δ ) θ / 2 . Large-time behavior of solutions to the drift–diffusion equation with 0 θ ≤ 1 is discussed. When θ > 1 , large-time behavior of solutions is known. However, when 0 θ ≤ 1 , the perturbation methods used in the preceding works would not work. In this paper, the asymptotic expansion of solutions with high-order is derived.

Background Wisteria floribunda agglutinin (WFA)-sialylated mucin core polypeptide 1 (MUC1) was investigated as a new glycoprotein marker for cholangiocarcinoma (CC) using glycoproteomics technologies. In this multicenter study, WFA-sialylated MUC1 levels in serum and bile samples were measured to determine their diagnostic capability in biliary tract carcinoma (BTC) and intrahepatic (Ih) CC. Methods The study included 244 patients with BTC, 59 patients with IhCC, 287 patients with benign biliary tract diseases, and 44 control subjects. Results Serum WFA-sialylated MUC1 levels were significantly higher in patients with either BTC or IhCC than in control subjects and those with benign biliary tract diseases. Patients with IhCC showed higher WFA-sialylated MUC1 levels than patients with tumors at other sites. No significant differences in WFA-sialylated MUC1 levels were found with regard to cancer stage or tissue type. Receiver operating characteristic curve analysis showed that WFA-sialylated MUC1 was superior to carbohydrate antigen 19-9 (CA19-9) and carcinoembryonic antigen (CEA) for the diagnosis of benign biliary tract diseases, BTC, and IhCC, as well as for stage I and II carcinomas. Significantly higher levels of biliary WFA-sialylated MUC1 were observed in BTC/IhCC than in benign biliary tract diseases. The diagnostic capability of biliary WFA-sialylated MUC1 was also superior to that of CA19-9, and diagnostic sensitivity was higher than that of biliary cytology for BTC/IhCC. Conclusions WFA-sialylated MUC1 is a useful novel biomarker for BTC/IhCC. In the future, this measurement should be applied in the clinical setting.

BACKGROUND The objective of this study was to validate the board certification system of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) using the data of hepatectomy cases from the National Clinical Database (NCD) of Japan. METHODS Minimal required annual numbers of high-level hepato-biliary-pancreatic (HBP) surgeries were 50 for a board-certified A training institution and 30 for a board-certified B training institution. Records of 14,970 patients who had undergone hepatectomy of more than one segment (MOS), excluding lateral segmentectomy, during 2011 and 2012 were analyzed according to the category of board-certified institution and with or without participation of board-certified instructors or expert surgeons. RESULTS Thirty-day mortality and operative mortality of 14,970 patients after MOS hepatectomy were 1.9% and 3.8%, respectively. Operative mortality rates after MOS hepatectomies performed at certified A institutions, certified B institutions, and non-certified institutions were 3.1%, 3.8%, and 4.5%, respectively (P < 0.001). The operative mortality rates after MOS hepatectomies performed with participation of certified instructors or expert surgeons were better than those without (3.5% vs. 4.3%, P = 0.012). A multiple logistic regression model showed that the cutoffs of high-level HBP surgeries performed per year at hospitals that predicted operative mortality after MOS hepatectomies were 10 and 50. CONCLUSIONS Competences and requirements for board-certified institutions, instructors, and expert surgeons to perform hepatectomy were found to be appropriate.

To evaluate the significance of the anterior approach without the Pringle maneuver during right hepatectomies with caudate lobectomies for perihilar cholangiocarcinomas (PHCs).From January 2011 to 2015, 25 consecutive patients underwent right hepatectomies with caudate lobectomies using the anterior approach without the Pringle maneuver for PHC (group A). Between 2003 and 2011, 44 patients were operated on for PHC using the classic right approach (group B). We compared the groups with respect to the patients' characteristics and the short-term surgical outcomes.Group A had significantly lower postoperative mean maximum levels of aspartate aminotransferase (294 U/L versus 453 U/L; P = 0.044), lower frequencies of maximum aspartate aminotransferase or alanine aminotransferase levels that exceeded 500 U/L (8.0% versus 32%; P = 0.036), shorter total Pringle maneuver times (7.1 versus 46.3 min; P0.001), lower Pringle maneuver frequencies (0.76 maneuvers versus 5.1 maneuvers; P0.001), less bleeding (1237 mL versus 1646 mL; P = 0.025), and shorter postoperative systemic inflammatory response syndrome durations (2.3 h versus15.4 h; P0.001) compared with group B.This approach can be performed safely, and it seems to limit the hemodynamic disturbance of the remnant left liver.

Liver cancer, which is most often associated with virus infection, is prevalent worldwide, and its underlying etiology and genomic structure are heterogeneous. Here we provide a whole-genome landscape of somatic alterations in 300 liver cancers from Japanese individuals. Our comprehensive analysis identified point mutations, structural variations (STVs), and virus integrations, in noncoding and coding regions. We discovered mutational signatures related to liver carcinogenesis and recurrently mutated coding and noncoding regions, such as long intergenic noncoding RNA genes (NEAT1 and MALAT1), promoters, CTCF-binding sites, and regulatory regions. STV analysis found a significant association with replication timing and identified known (CDKN2A, CCND1, APC, and TERT) and new (ASH1L, NCOR1, and MACROD2) cancer-related genes that were recurrently affected by STVs, leading to altered expression. These results emphasize the value of whole-genome sequencing analysis in discovering cancer driver mutations and understanding comprehensive molecular profiles of liver cancer, especially with regard to STVs and noncoding mutations.

The techniques of laparoscopic liver resection (LLR) have developed rapidly in selected centers, while global adoption of this approach has been cautious. The costs of LLR compared to open resection (OLR) are considered an important metric in evaluating this approach and may be a barrier to adoption in some centers. To formulate a consensus statement using the Zurich-Danish consensus model to the question of “What are the comparative outcomes of cost for LLR and OLR, minor and major?” a systematic search of the literature was conducted. Results were presented to the jury in September 2014 and updated in August 30, 2015. Adjustments for currency conversions and inflation were not performed due to limitations in available data. Thirty-four studies were reviewed, and 11 relevant papers were selected for inclusion. No randomized control studies were found. Five studies were case-matched comparisons, while the remaining studies were retrospective reviews. The number of patients in each study ranged from 28 to 74, and the cumulative number of patients was 643 comparing 350 OLR to 293 LLR. Overall median hospital stay was lower for LLR at 4.6 versus 7.4 days. This remained valid when only the case-matched studies were analyzed, 4.6 (n = 178) versus 6.6 days (n = 266). The median overall total costs were 16.3 % lower (range 0 to −22 %) for LLR compared to OLR. This remained valid in the subgroup analysis of the case-matched studies, with a median 17.4 % lower costs for the LLR. Median OR costs were 3 % higher for LLR (range −9 to 40 %) but 32.9 % lower for hospital ward costs (range 0 to −60 %) when compared to OLR. Currently, the published literature indicates that overall hospital costs are less for LLR when compared to OLR (Level of evidence 3a and 3b). This evidence is strongest for minor hepatic resections. The decreased cost is based on savings in hospital ward costs and likely related to a significantly shorter hospital stay for LLR.

Highlights • G-CSF producing gallbladder carcinoma is rare and has a poor prognosis. • We report a long term survival of G-CSF producing gallbladder carcinoma. • We suggest multidisciplinary therapy prolong the survival of patients with G-CSF producing gallbladder carcinoma., Introduction It is extremely rare for gallbladder carcinoma to produce granulocyte-colony stimulating factor (G-CSF) and such tumors have a poor prognosis. Presentation of case A 67-year-old man was admitted with continuous fever. Laboratory tests showed a leukocyte count of 27,980/μL, serum C-reactive protein (CRP) of 9.2 mg/dL and serum G-CSF of 225 pg/mL. Imaging revealed an irregular gallbladder mass about 90 mm in diameter with peripheral enhancement that also involved the liver and transverse colon. G-CSF producing gallbladder carcinoma was diagnosed. We performed cholecystectomy, partial resection of segments 4 and 5 of the liver, partial resection of the transverse colon, and gastrostomy. Histopathological examination showed gallbladder carcinoma (pT3, pN0, M0, G2, and pStage IIIA by the UICC classification, version 7). On immunohistochemical staining, tumor cells were positive for G-CSF. The leukocyte count was normalized postoperatively and fever subsided immediately after surgery. Two months later, the leukocyte count rose to 56,820/μL and metastases to the liver and lymph nodes were detected by CT. Chemotherapy (gemcitabine plus cisplatin) was started and the leukocyte count was normalized after the first course. The patient has continued chemotherapy and has survived for 16 months postoperatively. Discussion G-CSF producing gallbladder carcinoma has a poor prognosis and most patients die within 12 months of starting therapy. It is rare for patients with recurrence to survive for 16 months after surgery, as in the present case. Conclusion Multidisciplinary therapy (surgery and chemotherapy) may prolong the survival of patients with G-CSF producing gallbladder carcinoma, especially those with recurrence.

A 56-year-old man was diagnosed with aplastic anemia and paroxysmal nocturnal hemoglobinuria at 43 years of age and treatment with cyclosporin A was started. Liver cirrhosis, ascites, and thrombus in the hepatic veins were found at 56 years of age and Budd-Chiari syndrome (BCS) was diagnosed according to angiography findings. He was treated with diuretics and paracentesis was performed several times, but with limited efficacy. A Denver® peritoneovenous shunt (PVS) was inserted into the right jugular vein; his ascites and renal function improved immediately and his general condition has remained good for 12 months since starting the above treatment regimen. A PVS is a treatment option for ascites due to BCS.

Background This retrospective study aimed to evaluate clinicopathological findings of remnant pancreatic cancers in survivors of invasive ductal adenocarcinomas of the pancreas (PDAC). Methods A group of 23 patients out of 826 who had curative resections for PDAC between 1980 and 2011 was identified and treated for metachronous pancreatic cancer. Results The following tubular adenocarcinomas were found at the first surgery: 3 well differentiated, 17 moderately differentiated, 1 papillary, and 1 poorly differentiated. Treatments for the remnant pancreas consisted of remnant pancreatectomy in 12 patients, chemotherapy in 6, and the best supportive care in 5. The mean time to treatment was 74.2 months. The 12 patients who received remnant resections had 10 PDACs and 2 intraductal papillary mucinous carcinomas. The median survival time was 31.6 months, and 8 patients are still alive. Conclusions Long-term survivors after curative resection for pancreatic cancer should receive follow-up for remnant pancreatic cancer, and aggressive resection should be considered for more favorable prognosis of PDAC.