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The concept of osteosarcopenia, which is concomitant osteopenia and sarcopenia, has been proposed as a prognostic indicator for cancer patients. The aim of this study was to evaluate the prognostic significance of osteosarcopenia in patients with intrahepatic cholangiocarcinoma (IHCC).The subjects of this retrospective study were 41 patients who underwent hepatic resection for IHCC. Osteopenia was assessed with pixel density in the mid-vertebral core of the 11th thoracic vertebra and sarcopenia was assessed by the psoas muscle areas at the third lumbar vertebra. Osteosarcopenia was defined as the concomitant occurrence of osteopenia and sarcopenia. We analyzed the association of osteosarcopenia with disease-free and overall survival and evaluated clinicopathologic variables in relation to the osteosarcopenia.Eighteen (44%) of the 41 patients had osteosarcopenia. Multivariate analysis identified osteosarcopenia (hazard ratio 3.38, 95% confidence interval: 1.49-7.68, p 0.01) as an independent predictor of disease-free survival, and age ≥ 65 years (p = 0.03) and osteosarcopenia (hazard ratio 6.46, 95% confidence interval: 1.76-23.71, p 0.01) as independent predictors of overall survival.Preoperative osteosarcopenia may be a predictor of adverse prognosis for patients undergoing hepatic resection for IHCC, suggesting that preoperative management to maintain muscle and bone intensity could improve the prognosis.

Although laparoscopic hepatectomy has been widely used in the management of liver tumors for its reduced invasiveness and magnified view, in the caudate lobe it remains challenging especially for patients with cirrhosis. Thus, this study aimed to evaluate patients undergoing laparoscopic hepatectomy for hepatic tumors in the caudate lobe and establish strategies for performing such procedure.Laparoscopic hepatectomy in the caudate lobe was performed in nine patients. We performed inflow control to reduce bleeding during hepatic transection and retraction of the left lateral section to the cranial side to obtain a sufficient surgical field using a Nathanson liver retractor. We approached tumors in the Spiegel lobe (SP) from caudal side for segment 1 (S1) partial hepatectomy and from caudal and left side for Spiegel lobectomy, the lower paracaval portion (PC) from caudal side for S1 partial hepatectomy, and the upper PC from caudal and bilateral side for total caudate lobectomy.In 6 cases the tumors were in the SP and in 3 cases in the PC. The types of laparoscopic hepatectomy performed were total caudate lobectomy (n=1), Spiegel lobectomy (n=2), and partial hepatectomy of segment 1 (n=6). All the tumors were curatively resected, and no patient had complications. Operative time for tumors located in the PC was significantly longer than that for tumors located in the SP. Laparoscopic hepatectomy in the caudate lobe was safely performed for five patients with liver cirrhosis.Laparoscopic hepatectomy in the caudate lobe may become the standard surgical technique with hepatic inflow control, sufficient surgical field exposure, and appropriate approach.

BACKGROUND/AIM The aim of this study was to investigate the risk factors of surgical site infection (SSI) in patients who underwent liver resection for colorectal liver metastases (CRLM). PATIENTS AND METHODS A total of 151 patients who underwent liver resection for CRLM were included in this study. We investigated the relationship between the patient characteristics and perioperative factors and the incidence of SSI. RESULTS Nineteen (13%) of these patients developed SSI. Multivariate analysis revealed that modified Glasgow Prognostic Score (mGPS) (1 or 2, odds ratio 3.86, p=0.03) and presence of an enterostomy (yes, odds ratio 3.93, p=0.04) were significant and independent risk factors for SSI. CONCLUSION A higher mGPS and an enterostomy were risk factors for SSI in patients who underwent a liver resection for CRLM.

Nutritional status assessment is essential in cancer patients because a poor nutritional status has been associated with poor outcomes; however, the impact of rapid turnover proteins (RTPs), such as prealbumin, transferrin, and retinol-binding protein, on the outcomes of hepatocellular carcinoma (HCC) has not been well-investigated. We therefore examined the prognostic significance of RTPs in patients with HCC after curative resection. This study included 150 patients who underwent elective hepatic resection for HCC between January 2011 and December 2018. The prealbumin, transferrin, and retinol-binding protein levels were classified into two groups (high vs. low); the RTP score (0–3) was calculated as the sum of each RTP measurement (high = 0; low = 1). We retrospectively investigated the relationship between the RTP score and disease-free and overall survival. Multivariate analysis showed that a high RTP score (P = 0.022), presence of sarcopenia (P = 0.001), and stage III or higher (P = 0.005) were independent predictors of disease-free survival, while a high RTP score (P

BACKGROUND/AIM Detection of hepatocellular carcinoma using intraoperative ultrasonography (IOUS) is indispensable for successful laparoscopic hepatectomy (LH). This study was performed to evaluate patients with intraoperatively unidentified tumours undergoing LH. PATIENTS AND METHODS Seven patients who underwent LH for hepatocellular carcinoma and whose tumours were not detected using IOUS were included in this study. Clinical features, preoperative imaging, intraoperative imaging, surgical procedures, and pathological findings were evaluated. RESULTS Using gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging, all the tumours were enhanced in the arterial phase and rapidly washed out, becoming hypointense to the remainder of the liver. All tumours except one were

Purpose To achieve a negative margin when removing tumors adjacent to the hepatic vein, it is important to resect the two tertiary Glissonean pedicles that straddle the hepatic vein. The smallest unit that achieves anatomical resection of small tumors adjacent to the vein is a double cone unit (DCU). Patients and methods: We here report four patients who underwent laparoscopic DCU resection of hepatic tumors among 127 who had undergone laparoscopic hepatectomy at the Jikei Medical University Hospital from 2020 through 2021. DCU resection was considered when computed tomography imaging showed the hepatic vein was near the tumor and the tumor was relatively small (

Frailty, represented by sarcopenia and osteopenia, has been associated with worse survival after hepatectomy in patients with hepatocellular carcinoma. Recently, the concept and term "osteosarcopenia" have been proposed, which has been associated with worse outcome in several malignancies.This study included 227 patients who underwent elective hepatic resection for hepatocellular carcinoma. Osteopenia was evaluated with computed tomographic measurement of pixel density in the midvertebral core of the 11th thoracic vertebra. The skeletal muscle index (SMI) was evaluated with psoas muscle areas at the third lumbar vertebra. Osteosarcopenia was defined as the concomitant occurrence of osteopenia and low SMI. We retrospectively investigated the relationship between osteosarcopenia and disease-free and overall survival.Osteosarcopenia was identified in 27 (12%) of the patients. Multivariate analysis showed that osteosarcopenia (P .001), C-reactive protein-to-albumin ratio ≥0.02 (P = .002), and stage ≥III (P ≤ .001) were independent predictors of disease-free survival, while osteosarcopenia (P .001), Child-Pugh grade B (P = .002), C-reactive protein-to-albumin ratio ≥0.02 (P = .001), low SMI (P ≤ .001), and stage ≥III (P ≤ .001) were independent predictors of overall survival.Preoperative osteosarcopenia may be a prognostic factor in patients with hepatocellular carcinoma after hepatic resection. Our results suggests that the preoperative maintenance of skeletal muscle and bone density may potentially improve prognosis.

Introduction The aim of this study is to investigate the relationship between preoperative serum transferrin level and long-term outcomes in patients with colorectal liver metastases after hepatic resection. Methods We retrospectively investigated 72 patients who underwent hepatic resection for colorectal liver metastases and explored the relationship between serum transferrin level and long-term outcomes. Results In multivariate analysis, H3 (odds ratio 3.43, 95% confidence interval 1.11–10.89 and P = 0.03) was an independent and significant predictor of the disease-free survival, and a transferrin level ≥ 190 mg/dl (odds ratio 0.20, 95% confidence interval 0.05–0.79 and P = 0.02) and the time to recurrence after hepatectomy Conclusions The serum transferrin level is a useful predictor of poor overall survival in patients with colorectal liver metastases after hepatic reaction.

Several kinds of systemic inflammatory response, classified into two types: C-reactive protein (CRP)-based type and blood cell count-based type, were reported as a prognostic indicator in patients with pancreatic cancer (PC). However, there is no consensus which types is more sensitive predictor in patients with PC. Therefore, we here developed a novel biomarker, C-NLR, which consists of both CRP and neutrophil-to-lymphocyte ratio (NLR), and we evaluated the prognostic significance of C-NLR in patients with PC after pancreatic resection. A total of 217 patients was comprised in this study. We retrospectively investigated the relation between C-NLR and disease-free survival (DFS) and overall survival (OS) after pancreatic resection. Optimal cutoff level of C-NLR was defined as 0.206 by a ROC analysis. By multivariate analysis, age (P = 0.024), TNM stage (P

A hepatic cone-unit represents an anatomical unit dominated by a smaller Glissonean pedicle. Anatomical resection of a tumor located in an intersegmental plane is challenging, but could be achieved effectively by performing multiple cone-unit resection. We performed double cone-unit laparoscopic resection of hepatocellular carcinoma located on the intersegmental plane between segments 6a, b. The liver parenchyma covering the posterior Glissonean pedicle was divided along Rouviere's sulcus, the Glissonean branches of segments 6a, b were isolated and ligated, and indocyanine green (ICG) negative counterstaining was performed. The hepatic parenchyma was dissected along the demarcation line to identify the right hepatic vein and the double cone-unit resection was then completed with a negative surgical margin. Thus, double cone-unit laparoscopic hepatectomy with ICG negative counterstaining may be a feasible option for tumors located in an intersegmental plane.

Background Although indications of laparoscopic hepatectomy have been expanded, the laparoscopic approach after right hepatic lobectomy has a very high burden. The purpose of this study was to evaluate patients undergoing laparoscopic repeat hepatectomy for recurrent hepatic tumors after open right lobectomy. Patients and methods Five cases of laparoscopic repeat hepatectomy for recurrent hepatic tumors after open right lobectomy were included in the study. Results All the tumors in segment 3 were intraoperatively detected and curatively resected by partial hepatectomy. The tumors in segment 2 could not be detected intraoperatively due to hypertrophic liver deformity and adhesion. They were curatively resected by anatomical subsegmental approach. Conclusion For recurrent tumors located in segment 2 after right lobectomy, anatomical subsegmental approach should be preferred, not only from an oncological standpoint, but also for securing curative laparoscopic resection and overcoming anatomical difficulties.

Objectives The aim of this study was to clarify the effectiveness of combination chemotherapy targeting gemcitabine (GEM)-induced nuclear factor kappa B as adjuvant therapy for pancreatic cancer. Methods Patients who were planned after curative surgery (residual tumor classification R0 or R1) for pancreatic cancer to receive six cycles of adjuvant chemotherapy of regional arterial infusion of nafamostat mesilate with GEM between June 2011 and April 2017 were enrolled in this single-center, institutional review board-approved phase II trial (UMIN000006163). The Kaplan-Meier method was used to estimate disease-free survival and overall survival. Results In 32 patients [male/female: 18/14; age: median, 65.5 years (range, 48-77 years); pathological stage (Union for International Cancer Control 8th): IA/IB/IIA/IIB/III, 2/2/9/18/1, respectively] who met the eligibility criteria, the median overall survival and disease-free survival were 36.4 months (95% confidence interval, 31.7-48.3) and 16.4 months (95% confidence interval, 14.3-22.0), respectively. Grade 4 treatment-related hematological toxicities were seen in 5 patients (15.6%) (all neutropenia). One patient developed grade 3 nonhematological toxicities (rash). Conclusions Adjuvant chemotherapy with regional arterial infusion of nafamostat mesilate and GEM is safe and has potential as an option in adjuvant setting after curative surgery for pancreatic cancer.

The aim of this study was to evaluate the clinical utility of a novel diagnostic algorithm based on serum d-dimer levels for venous thromboembolism (VTE) after hepatectomy. We retrospectively analyzed 742 consecutive patients who underwent hepatectomy in our hospital from 2009 to 2019. From 2015, we routinely measured serum d-dimer level postoperatively and computed tomography was performed when d-dimer level was ≥ 20 μg/mL. VTE was diagnosed in 26 patients and pulmonary embolism (PE) was diagnosed in 18 patients. Multivariate analysis revealed that resected liver weight ≥ 120 g is a significant predictor of VTE (P = 0.011). The incidence of VTE from 2015 to 2019 was greater than that from 2009 to 2014 (5.0% versus 2.1%, P = 0.044). The number of low-risk PE patients between 2015 and 2019 was significantly greater than that between 2009 and 2014 (P = 0.013). There was no in-hospital mortality of patients with PE from 2015 to 2019. Patients who undergo hepatectomy are at high risk for VTE, especially when the resected liver weight is high. The proposed diagnostic algorithm based on serum d-dimer levels for VTE after hepatectomy can be useful for early diagnosis.

To evaluate omega-3 fatty acid-rich enteral nutrient effects in patients with unresectable or recurrent biliary tract or pancreatic cancers during chemotherapy. Enteric nutritional supplements containing omega-3 fatty acids (Racol®) was administered to aforementioned patients with cancers during chemotherapy. The skeletal muscle mass and blood test data were obtained pre-administration and 28 and 56 days after. Patients with pancreatic cancer were administered the digestive enzyme supplement pancrelipase (LipaCreon®) 28 days after the start of Racol® administration. The number of chemotherapies skipped due to neutropenia was recorded for 2 months before and after enteral nutrient initiation. In all 39 patients, the skeletal muscle mass increased on day 56 versus baseline (median 17.3 kg vs. 14.8 kg, p p = 0.03), and retinol-binding protein (mean: 2.56 mg/dL vs. 2.42 mg/dL, p = 0.05) increased. Patients with pancreatic cancer showed increased blood eicosapentaenoic acid concentration on day 56 versus baseline (median: 48.1 μg/mL vs. 37.0 μg/mL, p = 0.04) and increased skeletal muscle mass (median 16.8 kg vs. 14.4 kg, p = 0.006). Baseline median neutrophil count increased significantly from 2200/μL at baseline to 2500/μL (p = 0.04). Patients with biliary tract cancer during chemotherapy also exhibited increased skeletal muscle mass following omega-3 supplementation (median 17.3 kg vs. 15.8 kg, p = 0.01). In patients undergoing chemotherapy for unresectable or post-recurrence pancreatic and biliary tract cancers, high-omega-3 fatty acid nutrition therapy use improved skeletal muscle maintenance and chemotherapy dosing intensity.

Aim This study sought to evaluate the incidence, risk factors, and clinical outcomes of portal vein thrombosis after hepatectomy. Furthermore, we proposed a novel classification and treatment strategy for portal vein thrombosis after hepatectomy. Methods We retrospectively analyzed 398 patients who underwent hepatectomy and enhanced computed tomography imaging within 14 days after surgery in our hospital from 2009 to 2019. Portal vein thrombosis was classified into three categories according to the location of the thrombus – main, hilar, and peripheral – with main portal vein thrombosis further subclassified into three grades. Each patient's treatment strategy was determined based on their portal vein thrombosis classification and grading. From 2015, enhanced computed tomography imaging was performed routinely on patients who underwent anatomical hepatectomy on postoperative day 7. Results Portal vein thrombosis was diagnosed in 57 patients (14.3%) during the study period. Multivariate analysis revealed that a Pringle maneuver time of 75 minutes or longer was a significant predictor of portal vein thrombosis (P = .012). In total, 52 patients (91%) with portal vein thrombosis recovered by surgery, anticoagulant therapy, or without specific treatment. There was no instance of mortality recorded. Conclusions Patients who undergo hepatectomy are at high risk for portal vein thrombosis, especially when the Pringle maneuver time is long. The proposed classification and treatment strategy may be useful for clinical management of patients with portal vein thrombosis after hepatectomy., Patients who undergo hepatectomy are at high risk for portal vein thrombosis, especially when the Pringle maneuver time is long. The proposed classification and treatment strategy may be useful for clinical management of patients with portal vein thrombosis after hepatectomy.

The aim of the study was to compare proportions of chronic postoperative inguinal pain (CPIP) and other surgical outcomes between transinguinal preperitoneal repair with modified Kugel patch (MK) and Lichtenstein repair (LR). Two-hundred adult male patients with primary unilateral inguinal hernia were randomized into MK or LR groups. The primary endpoint was CPIP, pain at 6 months after surgery. Secondary outcomes included recurrence rate, incidence of postoperative complications, time until return to activities, inguinal pain and sensory disturbances assessed at 1 week, 1 month, 3, 6, and 12 months after the operation using an 11-point numerical rating scale (NRS). The study was an intention-to-treat analysis. In comparison of MK (n = 100) and LR (n = 100) with similar backgrounds, proportions of CPIP were similar (7.2 vs. 11.1%, p = 0.3452). Favorable outcomes for MK were duration of operation (32 vs. 40 min, p

Background The administration of direct-acting antiviral agents in patients with liver cirrhosis and hepatitis C has been shown to improve liver function and long-term prognosis after sustained virological response (SVR) is achieved. However, in patients with portal hypertension (PH) at the time of SVR, PH may persist despite improvement in liver function. Case presentation An 82-year-old woman with liver cirrhosis due to hepatitis C was treated with direct-acting antiviral agents and achieved SVR. During follow-up, computed tomography revealed a low-density tumor in the left lateral region of the liver with dilation of the left intrahepatic bile duct. Considering the patient’s advanced age and PH persistence with a mild decrease in liver reserve function after SVR, preoperative percutaneous transhepatic portal embolization (PTPE) and partial splenic embolization (PSE) were performed concomitantly. Laparoscopic left hemihepatectomy was performed 8 days after the PTPE and PSE. The patient was discharged 8 days after surgery without any postoperative complications. Conclusions Laparoscopic left hemihepatectomy after preoperative management of PH was performed safely in a patient after the elimination of hepatitis C.

Background Previously, we developed an image-guided navigation system (IG-NS) incorporating augmented reality (AR) technology. Nevertheless, the system could still only aid the operator by presenting imagery and was short of achieving the goal of developing a real navigation system. Therefore, we developed a recognized position-guided navigation system (RP-NS) and herein reported the functionality and usefulness of this system in a phantom model for clinical applications. Methods We developed RP-NS which was reconstructed by adding the positional recognition and instruction functions with the cautions by displaying the images on the monitor with a voice to the IG-NS. We evaluated accuracy of positional recognition and instruction functions using phantom model. By utilizing the chronological recording of the tip position of the surgical apparatus, the surgical precision of the operators was assessed. Finally, the feasibility of improvements in surgical precision using this system was evaluated. Results The RP-NS indicated an accuracy of the position recognition functions with an error of 2.7 mm. The surgeons could perform partial hepatectomies within mean value of 7.5% error as compared with calculated volume according to the instruction. Improvements in surgical precision using this system were obtained on the surgeons with different levels. Conclusions The RP-NS was highly effective as a navigation system owing to precise positional recognition and adequate instruction functions. Therefore, these results indicate that the use of this system may complement differences in proficiency, and numerically evaluate surgical skills and analyze tendencies of surgeons. This article is protected by copyright. All rights reserved.

BACKGROUND/AIM After primary resection of hepatocellular carcinoma (HCC), the impact of patient's characteristics at the initial hepatectomy, on long-term remnant liver function has not been reported. The aim of this study was to identify factors associated with the deterioration of remnant liver function among patients who developed recurrent HCC. PATIENTS AND METHODS A total of 51 patients with intrahepatic recurrence after initial hepatic resection for HCC were included. We retrospectively investigated the relation between patient characteristics and the degree of deterioration of remnant liver function upon recurrence. RESULTS In univariate analysis, significant predictors of deterioration of remnant liver function consisted of preoperative gastro-esophageal varices (p=0.0101), preoperative transcatheter arterial chemoembolization (p=0.0230) and hepatectomy beyond Makuuchi's criteria (p=0.0101). In multivariate analysis, the only significant independent predictor of deterioration of remnant liver function was hepatectomy beyond Makuuchi's criteria (p=0.0498). CONCLUSION Hepatectomy beyond Makuuchi's criteria at the initial hepatectomy may predict deterioration of remnant liver function upon recurrence of HCC.

Background To achieve safety of the operation, preoperative simulation became a routine practice for hepatobiliary and pancreatic (HBP) surgery. The use of intraoperative ultrasonography (IOUS) is essential in HBP surgery. There is a limitation in the use of IOUS in laparoscopic surgery (LS), for which a new intraoperative system is expected. We have developed an image-guided navigation system (IG-NS) for open HBP surgery since 2006, and we have applied our system to LS. The aim of this study is to evaluate the results of clinical application of IG-NS in LS. Materials and methods Eight patients underwent LS using IG-NS; LS consisted of cholecystectomy and hepatectomy in four patients each. After registration, the 3D models were superimposed on the surgical field. We performed LS while observing the navigation image. Moreover, we developed a support system for operations. Results The average registration error was 8.8 mm for LS. Repeated registration was effective for organ deformation and improved the precision of IG-NS. By using various countermeasures, identification of the tumor's position and the setting of the resection line became easy. Conclusion As IG-NS provided real-time detailed and intuitive information, this intraoperative assist system may be an effective tool in LS.

Background Laparoscopic trisectionectomy is a technically challenging procedure with high rate of postoperative morbidity [ 1 , 2 ]. Arantius' ligament approach is useful to expose the root of middle hepatic vein, which is required in left trisectionectomy [ 3 ]. Methods This video illustrates laparoscopic left trisectionectomy using Arantius' ligament approach. A 63-year-old man, with chronic kidney disease, had intrahepatic cholangiocarcinoma with a diameter of 8 cm, located in the segment 4 and anterior section of the liver. The tumor was close to the umbilical portion of the left portal vein and future liver remnant was 770 ml (49.5% of the whole liver) after left trisectionectomy. Video After the pneumoperitoneum and the mobilization of the left lateral segment, the root of left and middle hepatic vein was exposed by division of Arantius’ ligament and parenchymal transection of dorsal surface around the root of left hepatic vein. Next, the left Glissonian pedicle was controlled and divided. The Glissonean pedicle for the anterior section was then isolated and divided. Demarcation line was then observed using indocyanine green negative counterstaining. Parenchymal transection was completed followed by the division of the common trunk of the left and middle hepatic veins. Results The operation time was 294 min, and the blood loss was 400 g. The patient was discharged on postoperative day 16 after conservative treatment for temporary kidney injury. Pathological examination revealed intrahepatic cholangiocarcinoma with negative surgical margin. Conclusion The Arantius’ ligament approach could be a feasible procedure for left trisectionectomy.

Under laparoscopy-specific caudal and lateral view, Aranitius’ ligament could be the landmark for the root of the venous trunks in the left hepatic lobe.1–3 We performed laparoscopic hepatic extended medial segmentectomy including the middle hepatic vein (MHV) using the Arantius’ approach. An 86-year-old man was referred to our hospital for hepatocellular carcinoma, 4.5 cm in size, located in the medial hepatic segment (Video 1). After pneumoperitoneum and placement of four working ports, the Arantius’ ligament was exposed, isolated, and divided. The liver parenchyma underneath the Arantius’ ligament was opened to widely expose the root of the MHV, umbilical fissure vein (UFV), and left hepatic vein (LHV). After dividing the Glissonean branches for segment 4 (G4), the parenchymal tissue between MHV and LHV was divided. The trunk of the MHV was fully exposed and was divided using the endo-stapling device. Parenchymal resection was further proceeded along the dorsal side of the MHV, and the planned hepatectomy was completed. The operation time was 337 min, and the estimated blood loss was 400 g. His postoperative course was uneventful, and he was discharged on postoperative day 10. The significance of Arantius’ ligament approach is short-cut exposure of the MHV as the anatomical landmark during the initial process of the surgery under laparoscopy-specific caudal and lateral view, and is a reasonable technique in extended medial segmentectomy including the MHV.

Pancreatic neuroendocrine tumor (PNET) cases are increasing; however, the treatment indication and procedure remain unestablished. The present study evaluated the indication, feasibility and safety of laparoscopic distal pancreatectomy (LDP) with our technique for PNET. A total of 13 patients with insulinoma and nonfunctional PNET

The aim of this retrospective study was to evaluate a revised classification system for predicting the difficulty of laparoscopic partial liver resection. Patients who had undergone initial laparoscopic partial liver resection for a solitary lesion from January 2012 to February 2021were classified into two groups according to the type of procedure performed, “scooping-out” versus “cutting.” The participants were then further divided into “small” and “large” subgroups according to the tumor’s depth and diameter. Finally, they were categorized into two groups, namely “standard” and “advanced.” Operative outcomes were compared between the two groups and the proposed revised system for classifying difficulty of laparoscopic partial liver resection compared with the existing scoring system. Of the 65 procedures assessed, 40 were categorized as standard and 25 as advanced. Tumor size (P

Caudate hepatectomy is one of the most difficult procedures among liver surgeries because of its deep location and proximity to the inferior vena cava (IVC), particularly in patients with a history of open hepatectomies. 1,2,3 METHODS: A 77-year-old man underwent three open hepatectomies for hepatocellular carcinoma (HCC), including a sub-segmentectomy of S6 and partial hepatectomies of S7 and S8 during follow-up for hepatitis C virus-associated liver cirrhosis. However, HCC recurred in the caudate lobe behind the IVC (Supplemental video file 1). We lysed the severe adhesion in the upper abdomen, including the liver hilum, and exposed the ventral surface of the caudate lobe. We then used a Nathanson retractor to ventrally retract the severely enlarged left lobe. To counteract the severe adhesion that prevented us from controlling the hepatoduodenal ligament, we used the laparoscopic Satinsky vascular clamp for hilar inflow control. Using the anterior approach, we performed parenchymal resection from the distal side of the caudate lobe. Then, we gradually exposed the ventral surface of the IVC and separated the caudate lobe from the IVC. The IVC ligament was divided, and the caudate lobe, including the tumor behind the IVC, was removed.The operation time was 229 min with a total hepatic hilar clamping time of 69 min and blood loss of 10 mL. The patient was discharged on postoperative day 8 without any complications. Pathological examination revealed moderately differentiated HCC (pT1N0M0) with a negative surgical margin.The laparoscopic approach using specialized laparoscopic instruments is feasible for a tumor located in the caudate lobe behind the IVC, even in patients with a history of multiple open hepatectomies.

It has been known that repeat laparoscopic hepatectomy (RLH) after open hepatectomy is technically challenging because of adhesions around the hilum. It is quite often that conventional tourniquet technique for the Pringle maneuver is difficult in RLH, and we introduced Laparoscopic Satinsky Vascular Clamp (LSVC) for inflow control in RLH. The Spiegel lobe is the anatomical landmark in LSVC technique. If a space behind the hepatoduodenal ligament and the Spiegel lobe was obtained, LSVC was applied laterally from the left side of the hepatoduodenal ligament, whereas LSVC was vertically applied for those with obstruction of a space behind the hepatoduodenal ligament. We performed 14 cases of RLH for those with histories of open hepatectomies by lateral (n = 6) and vertical (n = 8) LSVC technique with successful inflow control, confirmed by intraoperative Doppler ultrasound. Five patients underwent 2 or more previous histories of hepatectomies. The RLH included segmentectomy (n = 1), subsegmentectomy (n = 2) and partial hepatectomy (n = 11). The median time for the Pringle maneuver, operative time, and blood loss was 47 min, 237.5 min, and 160 mL. All the patients completed pure laparoscopic hepatectomy. In conclusion, LSVC technique is a safe and reliable technique for the Pringle maneuver in RLH.

The superiority of outcomes associated with anatomical resection (AR) versus those associated with non-anatomical resection (NAR) remains controversial in patients with hepatocellular carcinoma (HCC). The aim of this study was to evaluate the significance of AR on therapeutic outcomes of patients with small HCCs (≤ 5 cm), using propensity score–matched (PSM) analysis. A total of 195 patients who had undergone elective hepatic resection for small HCCs (≤ 5 cm) were included in this study. We conducted PSM analysis for baseline characteristics (age, sex, hepatitis virus status, retention rate of indocyanine green at 15 min, and Child-Pugh grade), preoperative serum α-fetoprotein, and tumor characteristics (tumor size, tumor number, portal vein invasion, and surgical margin status) to eliminate potential selection bias. The prognostic significance of AR on the disease-free and overall survival was analyzed in patients selected by PSM analysis. Applying PSM analysis, the patients were divided into PSM-AR (N = 66) and PSM-NAR (N = 66) groups. Disease-free survival was significantly better in the PSM-AR group than that of the PSM-NAR group (P = 0.018), while there was no significant difference in the overall survival between the PSM-AR and PSM-NAR groups (P = 0.292). The univariate HRs of the PSM-AR group were 0.55 (95% CI, 0.33–0.90) for disease-free survival and 0.61 (95% CI, 0.24–1.53) for overall survival, respectively. Remnant liver recurrence was significantly lower in the AR group (P = 0.014). AR may improve the disease-free survival in HCC patients with tumors of ≤5 cm diameter.

Aim We investigated the prognostic impact of osteosarcopenia, which is the combination of osteopenia and sarcopenia, in patients with colorectal liver metastases (CRLM) after hepatic resection. Methods One hundred and eighteen patients were analyzed retrospectively. Osteopenia was evaluated with computed tomographic measurement of pixel density in the midvertebral core of the 11th thoracic vertebra. Sarcopenia was evaluated with psoas muscle areas at the third lumbar vertebra. Osteosarcopenia was defined as the concomitant occurrence of osteopenia and sarcopenia. Results Osteosarcopenia was identified in 38 (32%) of the patients. In univariate analysis, the overall survival was significantly worse in patients with lymph node metastases (P = .01), extrahepatic lesion (P = .01), sarcopenia (P = .02), osteosarcopenia (P, This study aimed to investigate the impact of preoperative osteosarcopenia, which is defined as the concomitant occurrence of osteopenia and sarcopenia, on the outcomes of patients with colorectal liver metastases (CRLM) after hepatic resection in conjunction with other nutritional markers including sarcopenia and osteopenia, as well as inflammatory parameters. We found that osteosarcopenia was the strong predictor for outcomes in patients who underwent liver resection for CRLM. To the best of our knowledge, this is the first study to report the prognostic value of osteosarcopenia in patients with malignancies.

Although pancreatectomy with lymph node (LN) and nerve plexus dissection has usually been performed for pancreatic cancer, recent randomized controlled trials have questioned its survival benefits. However, superior mesenteric artery (SMA) LN dissection has still been included in standard treatment guidelines. A total of 94 patients who underwent pancreaticoduodenectomy for resectable pancreatic cancer without LN enlargement around the SMA on imaging were identified between 2008 and 2017. Disease-free survival (DFS), overall survival (OS), and complications were compared between those with LN and hemicircumferential nerve plexus dissection around the SMA (SMA ly+) and those without thorough LN and nerve plexus dissection around the SMA (SMA ly−) after adjusting for major prognostic factors. A total of 78 and 16 patients with SMA ly+ and SMA ly− were identified, respectively. Our data demonstrated no difference in DFS and OS rates between both groups (P = 0.18 and 0.83, respectively). Patients with SMA ly+ had significantly more complications, particularly severe diarrhea, compared to those with SMA ly− (P = 0.001). LN and nerve plexus dissection around the SMA did not prolong survival and significantly increased the frequency of severe diarrhea, suggesting that performing in all cases carries less practical significance.

A soft remnant texture of the pancreas is commonly accepted as a risk factor for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). However, its assessment is subjective. The aim of this study was to evaluate the significance of intraoperative amylase level of the pancreatic juice as a risk factor of POPF after PD.This study included 75 patients who underwent PD between November 2014 and April 2020 at Jikei University Hospital. We investigated the relationship between pancreatic texture, intraoperative amylase level of pancreatic juice, results of the pathological evaluations, and the incidence of POPF.Twenty-three patients (31%) developed POPF. The significant predictors of POPF were non-ductal adenocarcinoma (p 0.01), soft pancreatic remnant (p 0.01), high intraoperative blood loss (p 0.01), high intraoperative amylase level of pancreatic juice (p 0.01), and low pancreatic fibrosis (p 0.01). Multivariate analysis revealed that the significant independent predictors of POPF were high intraoperative blood loss (p 0.01) and high intraoperative amylase level of pancreatic juice (p = 0.02). Receiver operating characteristic (ROC) analysis showed that the cut-off value for the intraoperative amylase level of pancreatic juice was 2.17 × 10