With accompanying video, Hasegawa and colleagues report the first successful closure of an enterocutaneous fistula following pancreatoduodenectomy using an over-the-scope clip system. A 75-year-old patient achieved complete and durable healing without recurrence, demonstrating that this minimally invasive approach is a safe and effective option for managing postoperative fistulas.
Chyle leak (CL) is a relevant complication of pancreatic surgery, but its incidence, risk factors, clinical and oncologic impacts, and nutritional relevance remain inconsistent and limited.
We retrospectively reviewed patients who underwent pancreaticoduodenectomy for pancreatic head cancer from 2007 to 2023 at a single institution. The clinical impact of CL was evaluated by prolonged hospital stays and immune-nutritional status, assessed using the Controlling Nutritional Status (CONUT) score at discharge. Oncologic impact included the administration of adjuvant chemotherapy, the surgery-to-chemotherapy interval, overall survival (OS), and recurrence-free survival (RFS). Predictors of CL were identified through multivariate analyses.
CL occurred in 70 patients (13.8%) and was significantly associated with prolonged hospital stay (OR: 1.947, p = 0.045) and poor CONUT score at discharge (> 6; OR: 1.820, p = 0.036). CL did not significantly impact oncologic outcomes, including adjuvant chemotherapy (p = 0.732), surgery-to-chemotherapy interval (p = 0.235), 5-year OS (p = 0.978), or 5-year RFS (p = 0.919). Independent predictors of CL included hypertension, lymph node metastasis, delayed gastric emptying, minimally invasive surgery (MIS), and operative time.
CL is associated with prolonged hospital stay and poor nutritional status at discharge, but shows no significant impact on long-term oncologic outcomes.
We aimed to investigate the microbiological characteristics of pathogens isolated from blood cultures (BCs) of patients with acute cholangitis (AC) after biliary-enteric anastomosis and biliary intervention (BI).
A retrospective analysis was conducted on 366 patients with AC and bacteremia between 2015 and 2024 at Hiroshima University Hospital. Patients were categorized into three groups: post-biliary reconstruction-associated AC (PBR-AC), BI-associated AC (BI-AC), and common AC (C-AC). Patients' clinical and microbiological data were statistically analyzed in each group.
The most frequently isolated pathogens were Escherichia coli and Klebsiella spp., accounting for > 50% of isolates in all groups. ESCPM spp. (Enterobacter spp., including Klebsiella aerogenes, Serratia marcescens, Citrobacter freundii complex, Providencia spp., and Morganella morganii) were significantly associated with PBR- and BI-AC compared with C-AC. No significant differences in the prevalence of anaerobic bacteria were observed among the groups.
The prevalence of ESCPM spp. isolated from BCs was significantly higher in the PBR- and BI-AC groups than in the C-AC group. The presence of biliary-enteric anastomosis or BI history should be checked when determining the treatment strategy for AC. Cefepime may be a better antibiotic option for PBR- and BI-AC, particularly in severe cases.
This study aimed to evaluate the outcomes of patients with unresectable cholangiocarcinoma (CCA) who underwent portal vein embolization (PVE) with a focus on overall survival (OS) and the frequency of biliary drainage (BD).
In this retrospective analysis, we evaluated 255 patients with unresectable CCA; 56 patients underwent PVE but ultimately remained unresectable. Propensity score matching (PSM) was used to minimize the potential confounding factors. The primary outcome was the OS, while the secondary outcome was BD frequency.
The PVE-unresectable group showed lower OS than that in the non-PVE-unresectable group both before and after PSM (median OS: 238.5 vs. 371.0 days, p = 0.006; 238.5 vs. 483.5 days, p = 0.002, respectively). Unresectable PVE status was a predictor of worse survival both before and after PSM (hazard ratio [HR] = 2.06, p < 0.001 and HR = 2.46, p < 0.001, respectively). Chemotherapy improved survival before and after PSM (HR = 0.45, p < 0.001 and HR = 0.41, p = 0.003, respectively). The BD frequency was higher in the PVE-unresectable group than in the non-PVE-unresectable group before and after PSM (0.693 vs. 0.470 procedures per month, p = 0.010).
Patients with unresectable CCA who underwent PVE had worse survival outcomes and required BD. Optimizing systemic therapy and BD strategies may improve the outcomes.
Nakano and colleagues developed an artificial intelligence-enhanced navigation system for robotic hepatectomy, enabling early identification of the inferior vena cava and major hepatic vein roots. Using semantic segmentation on 1030 annotated images, the model showed reliable performance and may help reduce complications, enhance safety, and support minimally invasive liver surgery.
Lymph node (LN) metastasis in extrahepatic cholangiocarcinoma (eCCA) is associated with poor prognosis, but the impact of specific metastatic sites is unclear. This study investigated the clinical significance of LN metastasis around the common hepatic artery (N [CHA]) in eCCA.
A total of 291 patients who underwent curative resection for eCCA between 2002 and 2022 were retrospectively reviewed. Patients were classified as N1 (CHA), N1 (other, regional LN metastasis without CHA), or N0. Clinical characteristics and long-term outcomes were compared. The short-to-long axis ratio (SLR) of CHA nodes on preoperative CT was evaluated for diagnostic value.
Of 291 patients, 164 had perihilar and 127 had distal cholangiocarcinoma. The N1 (CHA), N1 (other), and N0 groups included 33, 103, and 155 patients, respectively. Five-year cancer-specific survival (CSS) rates were 6.9% (N1 [CHA]), 24.7% (N1 [other]), and 60.3% (N0). N1 (CHA) and N1 (other) had CSS hazard ratios of 3.34 and 1.86, respectively (p < 0.01). The area under the receiver operating characteristics curve for SLR in predicting N1 (CHA) was 0.779.
N1 (CHA) is a strong negative prognostic factor in eCCA. CHA node status may serve as a useful imaging-based marker of biological resectability.
With accompanying video, Okuda and colleagues demonstrate the Arantius ligament hanging maneuver in laparoscopic caudate lobectomy for tumors in the paracaval portion. This technique provides a clear operative field and facilitates accurate parenchymal dissection along the planned transection line, providing a useful aid for safe and precise laparoscopic caudate lobectomy.
A robust prognostication model after liver resection for hepatocellular carcinoma (HCC) can guide clinical management. We aimed to develop a prognostication model for HCC recurrence and survival following liver resection, comparing between Cox proportional hazards (CPH) and supervised machine learning models.
We studied all patients who underwent liver resection for HCC between January 1, 2000 and October 31, 2022 at our institution. We aimed to predict recurrence-free survival following resection and identify risk categories for HCC recurrence. The CPH model and two supervised machine learning models (random survival forest [RSF] and extreme gradient boosting [XGB]) were used. Model performance was assessed with C-index, time-dependent area under curve (tdAUC) and Brier score.
We studied 1290 patients, with 737 (57.1%) experiencing an event (HCC recurrence or death) over a median follow-up duration of 19.2 months. The CPH model had the overall best performance (C-index: 0.663, tdAUC at 6 months: 0.752; 1 year: 0.740; 2 years: 0.722; 5 years: 0.624). Using this model, patients stratified based on risk score could be discriminated between low, intermediate, and high-risk groups (p < 0.001).
A CPH-derived prognostication model was effective for predicting and risk stratifying recurrence and survival following liver resection for HCC.
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