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The fast-track surgery protocol, including perioperative immunonutritional management, is increasingly gaining attention for the prevention of surgical site infections （SSIs）. To analyze the association between the fast-track surgery protocol employed at a single center and outcomes, including SSIs and the length of hospital stays. This retrospective analysis included 217 patients who underwent hepatectomy at the study department between January 2009 and February 2014. Patients were divided into two groups: those managed by a conventional protocol （group C, n＝75） and those managed by the fast-track surgery protocol （group F, n＝142）. There were no significant differences in patient characteristics or factors between the two groups. However, serum albumin and total cholesterol levels before surgery were significantly higher in group F than in group C, and pre-hepatectomy C-reactive protein （CRP） levels were lower in group F than in group C. Moreover, serum albumin and CRP levels at postoperative day 7 were better in group F than in group C. The operations were longer in group F than in group C （312 vs. 286 min） and blood loss volume was less （385 g in group F vs. 428 g in group C）. SSI rates were significantly lower in group F （4.2％, n＝6） than in group C （13.3％, n＝10）, and the length of hospital stay was significantly shorter in group F （16.7 days） than in group C （25.8 days）. The fast-track surgery protocol as a perioperative management strategy may improve preoperative nutritional status and postoperative inflammation, with subsequent reductions in SSI rates and the length of hospital stay in patients undergoing hepatectomy.

Here we review the prognosis of patients with unsuspected gallbladder carcinoma（GBC）, detected after laparoscopic cholecystectomy（LC）in a single institute. We reviewed the medical records of patients diagnosed with gallbladder stones on admission, who underwent LC. Carcinoma involving the gallbladder was found in 22 of 2,770 patients（0.9％）via postoperative pathological examination. This GBC group spanned 58-87 years of age（mean, 75 years; 13 females and 9 males）. The preoperative diagnosis was gallbladder stones with acute/chronic cholecystitis or adenomyomatosis of the gallbladder in all patients. We performed an additional surgery in 6 of 15 patients with pT2 and T3 disease; of these, 3 patients with pT2 disease and 1 with pT3 experienced bile spillage during the LC. The mean survival of patients with unexpected GBC was 21 months, with bile spillage occurring as a complication of LC identified as a potential risk factor for shorter survival（15.3 vs. 32.5 months）. We identified patients with pT2 and pT3 disease after LC, and two patients with pT2 and 1 with pT3 who had bile spillage during LC died of peritoneal dissemination within 28 months, despite additional surgery. Occasional seeding caused by bile spillage during LC should be carefully avoided to minimize the risk of developing unsuspected GBC after LC.

The most common site of distant metastasis from colorectal cancer is the liver, and hepatectomy presents the best curative treatment for recurrence of colorectal liver metastasis （CRLM）. This study aimed to identify factors of prognostic value for repeat hepatectomy for CRLM and to determine whether a third such procedure could similarly produce favourable outcomes for CRLM. We analyzed data for 161 patients in our department with colorectal metastasis. Of these, 22 patients underwent repeat hepatectomy for recurrent metastasis, with 16 undergoing a second hepatectomy and 6 a third hepatectomy. We analyzed patient characteristics, tumor status, operation-related variables, and short- and long-term outcomes. Univariate analysis for repeat hepatectomy identified the following five prognostic risk factors: T factor （＞SE） of the primary cancer, number of tumors involved in the initial hepatectomy （＞5）, interval from first to second hepatectomy （＜1year）, number of tumors involved in second hepatectomy （＞3）, and post-operation time （＞30days）. By multivariate analysis, T factor （＞SE） of the primary cancer, number of tumors in the initial hepatectomy （＞5）, and number of tumors in the second hepatectomy （＞3） were independently associated with a worse survival after surgery for CRLM. Although surgical outcomes of the third hepatectomy were not compared with those of the first and second hepatectomy, there were no obvious differences, nor did the 1-, 3-, and 5-year survival rates differ significantly among the three groups. Repeat hepatectomy for CRLM could improve long-term survival. In addition, patients undergoing a third hepatectomy showed a similar survival benefit to those having one or two resections.

Solid pseudopapillary neoplasm (SPN) of the pancreas has generally been regarded as a low-grade malignant tumour that preferentially develops in young women and can have a good prognosis with surgery. Among the few patients who have died from metastatic SPN are mostly those whose tumours harbour an undifferentiated component characterized by diffuse sheets of cells with increased nuclear atypia and proliferative index. We herein report a case of an aggressive, fatal, solid pseudopapillary neoplasm (SPN) of the pancreas in a 63-year-old woman complaining of epigastric pain. Despite having undergone surgical resection for a 10 cm pancreatic mass and multiple liver metastases, the patient later died due to uncontrollable metastases 36 months after the initial surgery. Histological examination showed that the tumour displayed unusual high-grade malignant features, showing diffuse sheets of cells with increased nuclear atypia and proliferative activity, along with conventional low-grade malignant features. The tumour was subsequently recognized as an SPN with foci of high-grade malignant transformation according to the 2010 World Health Organization classification. Immunohistochemical studies revealed that p16-RB pathway alterations contributed to the high-grade malignant transformation. The present case report suggests the necessity for developing diagnostic and treatment methods targeting p16 and RB for high-grade variants of SPN.

Single-port laparoscopic surgery（SPLS）has attracted attention in the field of minimally invasive surgery; however, the associated technical difficulty has delayed its adoption by all surgeons. Reduced-port laparoscopic surgery might be easier to perform than SPLS, and in this prospective study, we compared surgeon stress and workload between reduced-port laparoscopic cholecystectomy（RPLC）and conventional laparoscopic cholecystectomy（CLC）. Twenty consecutive patients were assigned to undergo either RPLC or CLC between July 2016 and April 2017. Two surgeons performed the operations. The differences in surgeon workload and stress between RPLC and CLC were evaluated. Patient factors and operative outcomes were not significantly different between RPLC and CLC. In the surgeon-reported Surgery Task Load Index, the task demand subscale was significantly higher for RPLC than for CLC（P＝0.005）, although the salivary amylase levels were not significantly different between RPLC and CLC. RPLC was similar to CLC with respect to surgeon stress. Considering workload, the task demand was higher in CLC than in RPLC, which therefore might be an acceptable alternative to CLC for treating benign gallbladder disease.

Various methods, devices, and techniques have been developed to improve safety during laparoscopic hepatectomy procedures. Among these, the Pringle maneuver （PM） is widely used to minimize blood loss during liver transections; however, the risk of ischemic injury associated with this technique is increased by poor hepatic reserve and regeneration dysfunction secondary to liver cirrhosis. This retrospective study evaluated the short-term outcomes and feasibility of precoagulation for endoscopic hepatectomy without PM in patients with liver cirrhosis. Eleven patients with liver cirrhosis who also underwent endoscopic hepatectomy for hepatocellular carcinoma were recruited to undergo either microwave tissue coagulation or radiofrequency ablation for precoagulation before liver transection. A wedge resection without the PM was performed in all patients, with seven patients selected for bipolar radiofrequency ablation and four patients for microwave coagulation therapy. The procedures included video-assisted thoracoscopic hepatectomy in two patients and laparoscopic hepatectomy in nine patients. One patient who underwent radiofrequency ablation developed postoperative bleeding （Clavien-Dindo grade Ⅲ）. In conclusion, precoagulation can help to minimize intraoperative blood loss without the PM, contributing to effective resection of liver tumors. We propose that precoagulation could serve as a standard technique for endoscopic hepatectomy in patients with cirrhosis.

True left-sided gallbladder (sinistroposition) is a rare anatomic anomaly in which the gallbladder is found to the left of the falciform ligament under the left lobe of the liver. Though uncommon, it is important for the surgeon to identify this anomaly because the ductal anatomy is unique and the surgery is technically challenging. Multiple case reports have documented safe management of sinistroposition encountered during conventional laparoscopic cholecystectomy. We present a case of sinistroposition encountered during a single-incision laparoscopic cholecystectomy. We conclude that this single-site laparoscopic technique is not only safe when sinistroposition is encountered, but it may actually provide certain ergonomic benefits for surgeons.