Annals of hepato-biliary-pancreatic surgery最新文献

Backgrounds/aims: The status of portal lymph nodes is a critical factor in determining eligibility for hepatic artery infusion pump (HAIP) therapy. However, methods for detecting occult positive nodes and understanding their clinical implications remain inadequately defined.

Methods: We conducted a retrospective evaluation of a cohort of patients with metastatic colorectal cancer who underwent HAIP. An independent, blinded radiologist reviewed pre-operative imaging to identify predictors for nodal positivity. We performed Kaplan-Meier survival analyses to explore the relationship between hepatic nodal staging and patient survival.

Results: The study comprised 33 patients, with a median follow-up of 23.5 months (range 2-56 months). The imaging review did not accurately identify patients with hepatic nodal disease. Patients without hepatic nodal metastases (n = 23) had a significantly longer median overall survival (OS) of 27 months compared to those with hepatic nodal metastases, who had a median OS of 11 months (hazard ratio = 4.8, p ≤ 0.01). Hepatic nodal positivity (hLN+) was associated with primary nodal positivity (pLN+, p = 0.036), and all patients with hLN+ were also pLN+.

Conclusions: Hepatic nodal metastases are a predictor of survival in patients receiving HAIP therapy for colorectal liver metastases. Primary nodal positivity may aid in the selection of HAIP candidates by increasing the suspicion of hepatic nodal positivity.

The primary clinical factor influencing survival in uveal melanoma (UM) is the onset of liver metastases. Managing uveal melanoma liver metastases (UMLM) remains difficult, as conventional systemic therapies infrequently yield durable responses and are linked with poor outcomes. Nonetheless, liver surgery continues to be the preferred strategy for improving prognosis in patients with potentially resectable metastases. Additionally, under certain conditions, debulking of the tumor has demonstrated effectiveness in delaying hepatic metastatic disease progression when it is technically achievable. This report describes our surgical approach to bilobar liver metastases from UM with hepatic vein infiltration, emphasizing both surgical techniques and outcomes, and explores the potential for maximal tumor reduction in UMLM following an extended disease-free interval between primary UM treatment and liver metastasis detection.

Backgrounds/aims: Gallbladder and biliary tract cancers (GBCs) are rare malignancies with poor prognoses, and surgical resection remains the only curative intervention. This study examined perioperative red blood cell (RBC) transfusion patterns among GBC patients in Korea and explored clinical and sociodemographic determinants associated with transfusion.

Methods: Utilizing National Health Insurance Service (NHIS) data from 2012 to 2020, we identified 20,564 patients with GBC. Associations between perioperative RBC transfusion and various sociodemographic and clinical characteristics were assessed. Trends in transfusion rates were analyzed using the average annual percentage change (AAPC).

Results: Of the cohort, 6,795 (33.0%) received perioperative RBC transfusions, with a mean age of 70.1 years. Increased likelihood of transfusion was observed among females, individuals with low income, and those residing outside metropolitan areas. Treatment in non-tertiary hospitals, higher Charlson comorbidity index, undergoing multiple surgical procedures, and the presence of extrahepatic cholangiocarcinoma were significantly correlated with transfusion. The transfusion rate declined from 38.4% in 2012 to 29.9% in 2020 (AAPC = -3.2, 95% confidence interval [95% CI]: -3.7, -2.8), with consistent reductions observed across all age groups and a marked decrease for cholecystectomy (AAPC = -7.2, 95% CI: -9.4, -5.0).

Conclusions: Perioperative RBC transfusion rates in patients with GBC have declined over the past decade. Nevertheless, women, patients with lower income, and those managed at non-tertiary hospitals continue to receive transfusions at higher rates.

Backgrounds/aims: Iatrogenic bile duct injuries (IBDIs) are an uncommon but potentially severe complication of laparoscopic cholecystectomy. The aim of this study was to assess both peri-operative and long-term outcomes of the current surgical management of IBDIs in Ireland and to estimate the associated costs.

Methods: Patients who underwent management for IBDIs following laparoscopic cholecystectomy between 2014 and 2024 were retrospectively identified from the three hepatobiliary (HPB) centres in Ireland. Data collected included demographics, surgical details, and perioperative as well as long-term outcomes. Cost analysis was conducted using the activity-based funding in-patient price list from the healthcare pricing office.

Results: A total of 34 patients underwent surgical intervention for IBDIs. Of these, 26 patients (76.4%) underwent Roux-en-Y hepaticojejunostomy, while primary bile duct repair was performed in five patients (14.7%). Three patients (8.8%) required right hepatectomy in conjunction with hepaticojejunostomy. Ten (29.4%) patients required re-operation, including four of the five who initially underwent primary repair. One patient ultimately required orthotopic liver transplant, and there were three (12.5%) peri-operative deaths. No statistically significant differences in peri-operative outcomes were observed between intra-operative and post-operative diagnosis of BDI. The median direct in-patient treatment cost was estimated at  €85,961.

Conclusions: IBDIs pose a considerable risk of long term complications and mortality with substantial costs to the health service. Subspecialist HPB referral is key to successful management, which typically involves bilio-enteric anastomosis and occasional liver resection if associated with major vascular injury.

Backgrounds/aims: Although mortality after pancreaticoduodenectomy (PD) has decreased, morbidity remains high. The Modified Frailty Index (mFI) and hand grip strength (HGS) assessed preoperatively have been shown to predict postoperative morbidity and mortality after PD in retrospective studies. Our study aimed to evaluate the role of mFI and HGS in predicting outcomes following PD.

Methods: A prospective observational study conducted from June 2021 to March 2023 enrolled all consecutive patients undergoing PD. Preoperatively, patient characteristics, mFI, and HGS were calculated. Postoperative complications were graded according to the Clavien-Dindo (CD) classification. The statistical association between these complications with high mFI and weak HGS was analyzed.

Results: A total of 180 patients were enrolled in the study. Major complications (CD grade ≥ 3) and 90-day mortality occurred in 10.5% and 3.3% of patients, respectively. The proportion of patients with weak HGS was significantly higher among those who developed major complications (14 of 19) compared to those who did not (28 of 161) (p < 0.001). In contrast, high mFI did not reach statistical significance (p = 0.063). Additionally, weak HGS showed a statistically significant association with 90-day mortality (14.3% vs. 0%, p < 0.001), hospital stay > 8 days (83.3% vs. 24.6%, p < 0.001), 90-day re-admission (19.4% vs. 4.3%, p = 0.002), and overall complications (30.7% vs. 5.7%, p < 0.001), compared to normal HGS. Weak HGS was a significant predictor of major complications in multivariate analysis (adjusted odds ratio, 11.52; p < 0.0001).

Conclusions: HGS is a simple tool used preoperatively to assess functional sarcopenia and has been identified as an independent predictor of major complications following PD.

Backgrounds/aims: Liver cancer (LC) remains a major contributor to morbidity and mortality globally. This study seeks to provide updated insights into the epidemiological trends of LC in South Korea by examining changes in incidence, mortality, and survival rates between 1999 and 2022, with the goal of guiding public health interventions and informing clinical decision-making.

Methods: This retrospective cohort study utilized data from Korea Central Cancer Registry (KCCR) for primary LC cases, classified as code C22 according to the International Classification of Diseases, tenth version (ICD-10), diagnosed from 1999 to 2022. Crude rates and age-standardized rates (ASRs) were determined. Additionally, subgroup analyses were conducted separately for hepatocellular carcinoma (HCC, C22.0) and intrahepatic cholangiocarcinoma (IHCC, C22.1).

Results: Between 1999 and 2022, both the incidence and mortality rates of HCC showed marked decreases. The annual percent change of ASR for incidence and mortality was -2.99% and -4.89%, respectively. There was a notable rise in 5-year survival rates for HCC, especially among patients with localized-stage disease. Conversely, IHCC incidence stabilized and mortality rates showed minimal change. Although patients with localized IHCC achieved significantly higher survival rates following surgical resection, only a small proportion of IHCC cases were diagnosed at a localized stage (22.4%).

Conclusions: Analysis of LC trends in Korea reveals a persistent reduction in incidence and significant improvements in early detection and survival rates for HCC. Despite these gains, IHCC continues to pose clinical difficulties, underscoring the need for further studies to enhance early diagnosis.

Backgrounds/aims: Pancreaticoduodenectomy (PD) is a surgical procedure commonly used for periampullary and pancreatic head tumors. Despite surgical advancements, postoperative morbidity remains substantial, with delayed gastric emptying (DGE) being a frequent complication. This prospective study evaluates the impact of Braun enteroenterostomy (BE) on DGE.

Methods: Twenty-five consecutive patients undergoing PD were enrolled between May 2023 and August 2024. The retrospective control group consisted of 72 patients who underwent standard PD during the previous four years. The primary outcome measured was the incidence of DGE. Secondary outcomes included the occurrence of postoperative complications and length of stay.

Results: The overall incidence of DGE was lower in the Braun group (33.3%) compared to the non-Braun group (46.8%) (p = 0.032). Grade B DGE was less frequent in the Braun group, and no Grade C DGE in either group. Braun group demonstrated a smaller mean pancreatic duct diameter (3.96 mm) than the non-Braun group (5.35 mm) (p = 0.011), yet there was a decrease in the incidence of clinically significant postoperative pancreatic fistula (POPF) (Grade B (8.3% vs. 19.4%, p = 0.045) and no Grade C in the Braun group. The mean postoperative hospital stay was significantly shorter in the Braun group (12.5 days) versus the non-Braun group (15.7 days) (p = 0.027). Univariate analysis identified a history of weight loss and elevated CA19-9 associated with DGE, Grade B POPF as an independent risk factor for DGE.

Conclusions: Incorporating BE during PD correlates with a lower incidence of DGE, especially for Grades B and C, as well as a reduced rate of Grade B POPF and a shorter postoperative hospital stay.

Backgrounds/aims: Gallbladder and biliary tract diseases include benign diseases of the gallbladder and biliary (BGB) as well as malignant neoplasms of the gallbladder and biliary tract (MGB). This study aimed to evaluate the global epidemiological trends and risk factors of gallbladder and biliary tract diseases, and to forecast their future trajectory.

Methods: The estimated annual percentage change from 1990 to 2021 was calculated to evaluate trends in the age-standardized prevalence rate (ASPR), incidence rate (ASIR), death rate (ASDR), and disability-adjusted life years (DALYs) of gallbladder and biliary diseases.

Results: At a regional level, higher socio-demographic index was linked to increased ASPR and ASIR for both BGB and MGB. In terms of geography, Central Europe reported the highest ASPR and ASIR among BGB patients. For MGB, the High-income Asia Pacific region demonstrated the highest ASPR, ASIR, and ASDR. Among individual countries, Honduras, Mexico, and Romania exhibited the greatest ASPR among those with BGB in 2021. The Republic of Korea reported the highest ASPR for MGB. In addition, Chile, Republic of Korea, and Thailand had a notably high ASIR, ASDR, and age-standardized DALYs for MGB. Female were more frequently affected by BGB than males.

Conclusions: Despite a decline in age-standardized incidence and mortality rates, gallbladder and biliary tract diseases still impose a considerable health burden worldwide. Their prevalence demonstrates substantial regional, socioeconomic, age, and sex differences. Global health practitioners and policymakers should focus on timely identification of high-risk groups and initiation of targeted prevention strategies.

Ex vivo liver resection and autotransplantation (ELRAT) is a technically demanding yet increasingly viable option for the treatment of otherwise unresectable tumors with vascular involvement. We describe the case of a 50-year-old female diagnosed with an extensive hepatocellular carcinoma involving the retrohepatic inferior vena cava (IVC) and major hepatic veins, deemed unresectable. After undergoing transarterial chemoembolization and stereotactic body radiation therapy, which resulted in significant tumor necrosis, reduction in lesion size, and a substantial decline in alpha-fetoprotein levels, the patient subsequently underwent ELRAT with IVC reconstruction. Although postoperative complications occurred, such as an incisional hernia and IVC stenosis that necessitated stent insertion, she has remained free of recurrence 24 months following surgery, demonstrating the potential of preoperative therapy to enhance ELRAT outcomes.

The occurrence of cholangiocarcinoma following choledochal cyst excision is a rare clinical entity. In cases with extensive lymphadenopathy, where poor oncologic prognosis is anticipated, immune checkpoint inhibitors have recently shown promise as a therapeutic approach in biliary tract cancer. We describe a case involving successful minimally invasive pylorus-preserving pancreaticoduodenectomy in this unusual patient, following neoadjuvant immune chemotherapy. A 44-year-old female, who had previously undergone bile duct excision for choledochal cyst on November 28, 2022, presented with abdominal pain in July 2024. Imaging revealed an 8-cm mass in the pancreatic head, with multiple metastatic lymph nodes noted in the epigastrium, mesentery, retroperitoneum, and both common iliac chains. Endoscopic ultrasound-guided biopsy identified atypical cells with necrosis suggestive of poorly differentiated carcinoma, but immunohistochemistry did not confirm pancreatic origin. Positron emission tomography-computed tomography revealed absence of additional primary malignancy, though it showed multiple enlarged lymph nodes and findings indicative of possible peritoneal seeding. Considering the patient's prior history of choledochal cyst resection and extensive perihilar lymphadenopathy, a diagnosis of cholangiocarcinoma was favored. Neoadjuvant chemoimmunotherapy with durvalumab, gemcitabine, and cisplatin was administered across 11 cycles. Subsequent imaging demonstrated significant tumor regression, prompting surgical exploration on April 11, 2025. Intraoperatively, extensive adhesions surrounding the hepaticojejunostomy and pancreas were encountered. Pancreaticoduodenectomy was completed utilizing the pre-existing Roux limb for pancreaticojejunostomy. Frozen section analysis of the peritoneum and mesentery was negative for malignancy. Final histopathology confirmed complete remission. This case highlights the potential feasibility and safety of minimally invasive surgery in this rare clinical scenario.