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.
Ultrasound-guided minimally invasive liver resection on inclined surfaces presents challenges in accurately setting transection lines.
This study aimed to propose IKOMAP formulas to calculate the distance (Y) from the point directly above the tumor (Point C) to the optimal marking point (Point A) on inclined surfaces. The goal was to reliably reach Point D, which represents the shortest distance from the tumor while maintaining assigned surgical margins on the transection line. The formula was derived using five parameters: the probe incidence angle (a), hepatic resection angle (b), tumor radius (U), tumor depth (V), and resection margin distance (Z). The deepest point on the assumed straight transection line was defined as point B.
From triangle ABC, Y = BC × tan(90° − b + a), and from triangle BDE, BC = (U + Z)/sin(90° − b + a) + U + V. Substituting these values yields the final formula: Y = {(U + Z)/sin(b − a) + (U + V)/tan(b − a)}.
IKOMAP formulas enable the precise calculation of the optimal marking point on inclined surfaces, ensuring surgical margin accuracy based on the preset and assigned parameters.
In this study, we investigated the criteria that predict the long-term survival benefits after surgical resection in patients with pancreatic cancer accompanied by liver oligometastasis.
In total, 60 patients from 34 high-volume Japanese centers who underwent surgical resection for liver oligometastasis between 2005 and 2020 were included. Univariate and multivariate methods of survival analyses were performed. All patients were followed up for at least 36 months.
Overall survival (OS) was significantly longer in the preoperative chemotherapy group than in the up-front surgery group (37.4 vs. 20.4 months, p = 0.001). In the operation with preoperative chemotherapy group, a complete response was observed in eight patients (28.6%). The 1-, 3-, and 5-year OS rates were 92.9%, 50.0%, and 35.7%, respectively. The multivariate analysis showed that low CA19-9 (< 100 U/mL; HR: 0.25; 95% CI: 0.06–0.96; p = 0.043), low CEA (< 5 U/mL; HR: 0.14; 95% CI: 0.04–0.48; p = 0.002), and resectable (R) or borderline resectable pancreatic cancer invading the portal vein (BR-PV) status (HR: 0.19; 95% CI: 0.07–0.51; p < 0.001) were positive prognostic factors. The median OS of the patients who met all three criteria was 106.6 months.
Preoperative chemotherapy is essential for the treatment of liver oligometastases. Despite the high recurrence rates, patients who met the specific criteria have a favorable prognosis with liver resection.
Although portal vein (PV) contact ≤ 180° in pancreatic body/tail ductal adenocarcinoma (PbtCa) is a criterion for resectable, adequate evidence has not been established yet.
This retrospective study analyzed 1693 patients with PbtCa who underwent distal pancreatectomy across 31 institutions in Japan. Clinicopathological factors, survival, and recurrence pattern were compared among non-PV contact, PV contact, and celiac axis (CeA) contact groups.
Overall survival (MST: 28.3 months) and the positive surgical margin rate (23%) in the PV contact (n = 168) were worse than those of non-PV contact (n = 1353, 47.9 months [p < 0.001], 13% [p = 0.001]), and were comparable with CeA contact (n = 172, 26.4 months [p = 0.136], 26% [p = 0.447]). Incidence of local recurrence (26%) and peritoneal recurrence (20%) in the PV contact were comparable to those in the CeA contact (21%, p = 0.309, and 19%, p = 0.915). Cox proportional hazards analysis revealed PV contact (hazard ratio, 1.295; p = 0.003) as independent prognostic factors for overall survival.
PbtCa with PV contact should be considered borderline resectable because of a high positive surgical margin rate and poor survival, similar to those in PbtCa with CeA contact.
This study was registered in the UMIN Clinical Trial Registry (UMIN-CTR: UMIN000041642)
Although pancreaticobiliary maljunction (PBM) is associated with a high incidence of biliary cancer, it often goes undiagnosed. This means that the true prevalence of PBM and the incidence of biliary cancer are unknown. High confluence of the pancreaticobiliary ducts (HCPBD) may be an intermediate PBM variant, though reports are scarce. In this study, we aimed to determine the true prevalence of PBM and HCPBD and the actual incidence of biliary cancer.
We retrospectively analyzed data from adults who underwent cholecystectomy for benign gallbladder disease and compared them to those with gallbladder and bile duct cancers. The common channel (CC) and narrow distal segment (NDS) were measured using magnetic resonance cholangiopancreatography to diagnose PBM and HCPBD.
PBM and HCPBD were identified in 0.44% and 0.88% of 2046 benign cholecystectomies, 16% and 4.2% of gallbladder cancers, and 1.3% and 3.8% of bile duct cancers, respectively (p < 0.01).
The overall prevalence was 0.44%. Combined with national data, the gallbladder cancer incidence in PBM was estimated to be 2.4% over one decade, which is 38-fold higher than that in the general population. Approximately 1% of the population have HCPBD, which may be a risk factor for biliary cancer.
With accompanying video, Toyonaga and colleagues demonstrate their use of a novel highly rotatable sphincterotome during balloon endoscopy-assisted ERCP in patients with surgically altered anatomy. The device enables precise control and axis alignment, facilitating successful selective pancreatobiliary duct cannulation in anatomically challenging cases.
The remnant stomach after distal gastrectomy (DG) which receives its blood supply mainly from the splenic artery (SPA), is at high risk for gastric ischemia following distal pancreatectomy (DP). We investigated the risk factors for ischemic necrosis of the remnant stomach (INS) during or after DP in DG patients.
We collected 414 patients who underwent DP after DG between July 2009 and December 2019 by distributing questionnaires to members of the Japanese Society of Pancreatic Surgery (JSPS) in 2020, and the risk factors for INS were analyzed in 364 eligible patients.
INS developed in 17 (4.7%) patients. A multivariate logistic regression analysis revealed that dissection of the left inferior phrenic artery (LIPA) during DP (odds ratio [OR] 51.9, p < 0.001), current DP for pancreatic cancer (OR 6.19, p = 0.017), and previous DG for gastric cancer (OR 6.12, p = 0.017) were independent risk factors for INS.
Preservation of the LIPA is necessary to avoid INS when DP is performed in DG patients. Additionally, careful surgical management is required in patients undergoing DP for pancreatic cancer and who have undergone DG for gastric cancer because they are candidates for INS after DP.
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