Annals of hepato-biliary-pancreatic surgery最新文献

Backgrounds/aims: While large-for-size syndrome is uncommon in liver transplantation (LT), it can result in fatal outcome. To prevent such fatality, we manufactured 3D-printed intra-abdominal cavity replicas to provide intuitive understanding of the sizes of the graft and the patient's abdomen in patients with small body size between July 2020 and February 2022.

Methods: Clinical outcomes were compared between patients using our 3D model during LT, and patients who underwent LT without 3D model by using 1 : 5 ratio propensity score-matched analysis.

Results: After matching, a total of 20 patients using 3D-printed abdominal cavity model and 100 patients of the control group were included in this study. There were no significant differences in 30-day postoperative complication (50.0% vs. 64.0%, p = 0.356) and the incidence of large-for-size syndrome (0% vs. 7%, p = 0.599). Overall survival of the 3D-printed group was similar to that of the control group (p = 0.665), but graft survival was significantly superior in the 3D-printed group, compared to the control group (p = 0.034).

Conclusions: Since it showed better graft survival, as well as low cost and short production time, our 3D-printing protocol can be a feasible option for patients with small abdominal cavity to prevent large-for-size syndrome after LT.

Backgrounds/aims: Liver transplantation (LT) is now a critical, life-saving treatment for patients with liver cirrhosis or hepatocellular carcinoma. Despite its significant benefits, biliary complications (BCs) continue to be a major cause of postoperative morbidity. This study evaluates the fluorescence intensity (FI) of the common bile duct (CBD) utilizing near-infrared indocyanine green (ICG) imaging, and examines its association with the incidence of BCs within three months post-LT.

Methods: This investigation analyzed data from nine living donor LT (LDLT) recipients who were administered 0.05 mg/kg of ICG prior to bile duct anastomosis. Real-time perfusion of the CBD was recorded for three minutes using an ICG camera, and FI was quantified using Image J (National Institutes of Health). Key parameters assessed included F max, F_1/2 max, T_1/2 max, and the slope (F max/T max) to evaluate the fluorescence response.

Results: BCs occurred in two out of nine patients. These two patients exhibited the longest T_1/2 max values, which were linked with lower slope values, implicating a potential relationship between extended T_1/2 max, reduced slope, and the occurrence of postoperative BCs.

Conclusions: The study indicates that ICG fluorescence imaging may serve as an effective tool for assessing bile duct perfusion in LDLT patients. While the data suggest that an extended T_1/2 max and lower slope may correlate with an increased risk of BCs, further validation through larger studies is required to confirm the predictive value of ICG fluorescence imaging in this setting.

Backgrounds/aims: Given the high mortality associated with gallbladder cancer (GBC), the efficacy of adjuvant therapy (AT) remains controversial. We audited our data over an 11-year period to assess the impact of AT.

Methods: This study included all patients who underwent curative resection for GBC from 2007 to 2017. Analyses were conducted of clinicopathological characteristics, surgical details, and postoperative therapeutic records. The benefits of adjuvant chemotherapy (CT) or chemoradiotherapy (CTRT) were evaluated against surgery alone using SPSS version 20 for statistical analysis.

Results: The median age of patients (n = 142) was 50 years. The median overall survival (OS) was 93, 34, and 30 months with CT, CTRT, and surgery alone respectively (p = 0.612). Multivariate analysis indicated that only disease stage and microscopically involved margins significantly impacted OS and disease-free survival (DFS). CT showed increased effectiveness across all prognostic subsets, except for stage 4 and margin-positive resections. Following propensity score matching, median DFS and OS were higher in the CT group than in the CTRT group, although the differences were not statistically significant (p > 0.05).

Conclusions: Radically resected GBC patients appear to benefit more from adjuvant CT, while CTRT should be reserved for cases with high-risk features.

Backgrounds/aims: In recent years, many minimally invasive techniques have been introduced to reduce the number of ports in laparoscopic cholecystectomy (LC), offering benefits such as reduced postoperative pain and improved cosmetic outcomes. ArtiSential^® is a new multi-degree-of-freedom articulating laparoscopic instrument that incorporates the ergonomic features of robotic surgery, potentially overcoming the spatial limitations of laparoscopic surgery. ArtiSential^® LC can be performed using only two ports. This study aims to compare the surgical outcomes of ArtiSential^® LC with those of single-fulcrum LC.

Methods: This retrospective study compared ArtiSential^® LC and single-fulcrum LC among LCs performed for gallbladder (GB) stones at the same center, analyzing the basic characteristics of patients; intraoperative outcomes, such as operative time, estimated blood loss, and intraoperative GB rupture; and postoperative outcomes, such as length of hospital stay, incidence of postoperative complications, and postoperative pain.

Results: A total of 88 and 63 patients underwent ArtiSential^® LC and single-fulcrum LC for GB stones, respectively. Analysis showed that ArtiSential^® LC resulted in significantly fewer cases of surgeries longer than 60 minutes (30 vs. 35 min, p = 0.009) and intraoperative GB ruptures (2 vs. 10, p = 0.007). In terms of postoperative outcomes, ArtiSential^® LC showed better results in the respective visual analog scale (VAS) scores immediately after surgery (2.59 vs. 3.73, p < 0.001), and before discharge (1.44 vs. 2.02, p = 0.01).

Conclusions: ArtiSential^® LC showed better results in terms of surgical outcomes, especially postoperative pain. Thus, ArtiSential^® LC is considered the better option for patients, compared to single-fulcrum LC.

Solid pseudopapillary neoplasms (SPNs) are uncommon pancreatic tumors that primarily affect young females. We report a case of a 24-year-old female diagnosed with SPN and liver metastasis during a routine examination. Imaging revealed an 8-cm pancreatic mass with multiple liver metastases. Histopathology confirmed SPN. Subsequent next-generation sequencing revealed a CTNNB1 mutation. The patient underwent a total pancreatectomy with splenectomy, right hemihepatectomy, and intraoperative radiofrequency ablation. Two years after the surgery, she remained complication-free. She is under regular surveillance. This case underscores the importance of early detection and comprehensive management of SPN.

To examine the feasibility and safety of robotic radical resection (RRR) for hilar cholangiocarcinoma (HCCA). A PRISMA-compliant meta-analysis with meta-regression was conducted, including studies reporting outcomes of RRR in patients with HCCA. Six studies comprising 295 patients were included. In highly selected patients (body mass index [BMI] < 25 kg/m" ; tumor size < 3 cm), RRR of HCCA proved safe and feasible (Clavien-Dindo ≥ III complications: 14.8% [95% confidence interval 8.7%-20.8%]; 30-day mortality: 1.9% [0%-4.2%]; conversion to open surgery: 1.9% [0%-4.2%]; intraoperative blood loss: 210 mL [119-301 mL]; operative time: 481 minutes [339-623 minutes]; R0 resection rate: 82.2% [75.0%-89.4%]; retrieved lymph nodes: 12 [9-16]). Younger age (p = 0.008), higher BMI (p = 0.009), larger tumors (p = 0.048), and performing liver resections (p = 0.017) increased blood loss. American Society of Anesthesiologists status ≥ III (p < 0.001) and Bismuth IV disease (p < 0.001) increased operative times. Preoperative biliary drainage (p = 0.027) enhanced R0 resection rates. RRR led to less bleeding (mean difference [MD]: -184 mL, p = 0.0005), longer operative times (MD: 162 minutes, p = 0.001), and improved R0 resection rates (odds ratio: 3.29, p = 0.006) compared with the open approach. Subject to selection bias and type 2 error, RRR for HCCA might be safe and feasible in highly selected patients (favorable BMI and tumor size). The findings should not be taken as definitive conclusions but may be used for hypothesis generation in subsequent trials.

Backgrounds/aims: Assessing surgical difficulty in laparoscopic cholecystectomy (LC) is challenging due to variations in surgeon proficiency and institutional protocols. This study evaluates surgeons' perspectives on procedural difficulty and examines how intraoperative findings and preoperative imaging contribute to refining difficulty assessment criteria.

Methods: A cross-sectional survey was conducted among 50 laparoscopic surgeons in India, providing insights into tolerances for surgical duration and blood loss, reasons for conversion, and predictors of complexity. Responses were analyzed using SPSS, with statistical significance set at p < 0.05.

Results: Among surveyed surgeons, 82.0% were male, and 78.0% worked in private institutions and 52.0% had performed over 1,000 LCs. Conversion to open surgery was primarily influenced by significant blood loss (68.0%) and biliary injury (94.0%). While 38.0% preferred surgeries under 60 minutes, 26.0% imposed no time constraints. Key intraoperative challenges included dense adhesions, cholecysto-enteric fistulas, and fibrosis. Less experienced surgeons reported greater challenges with scarring adhesions and anatomical variations, but no significant differences were found for other factors like edematous or necrotic changes. Preoperative imaging was considered essential by most surgeons.

Conclusions: This study underscores the limited reliability of traditional parameters for assessing difficulty in LC. Surgeons highlighted the importance of objective intraoperative findings and preoperative imaging in predicting surgical challenges. Factors such as adhesions, fibrosis, and anatomical variations significantly impact LC difficulty, with decisions regarding conversion to open surgery largely driven by individual judgment rather than experience. Standardized grading systems incorporating these factors could improve surgical planning, reduce complications, and enhance patient outcomes.

Backgrounds/aims: To determine short-term and long-term outcomes after pancreas preserving total duodenectomy (PPTD).

Methods: A case series and a complementary meta-analysis were conducted. All patients with (pre)neoplastic lesions of duodenum who underwent PPTD in a tertiary center for pancreatic surgery between May 2009 and October 2022 were included for the case series. All studies in the literature with a sample size of 10 or more patients reporting outcomes of PPTD were included for the meta-analysis.

Results: A total of 439 patients (18 from case series and 421 from literature) were analyzed. Clavien-Dindo (CD) I complications in 2.9% (95% confidence interval [CI] 0.6%-5.2%), CD II complications in 21.1% (14.6%-27.6%), CD III complications in 18.1% (9.3%-26.9%), CD IV complications in 2.7% (0.5%-4.9%), and CD V complications in 2.2% (0.2%-4.2%) of patients were found. Probabilities of overall survival and recurrence-free survival at 15 years were 87% and 86%, respectively. There was no significant difference in the risk of mortality (odds ratio [OR]: 0.82, p = 0.830), total complications (OR: 0.77, p = 0.440), postoperative pancreatic fistula (OR: 0.43, p = 0.140), delayed gastric emptying (OR: 0.70, p = 0.450), or postoperative bleeding (OR: 0.97, p = 0.960) between PPTD and pancreaticoduodenectomy.

Conclusions: PPTD is safe and feasible for (pre)neoplastic lesions of duodenum not involving the pancreatic head. The risk of severe complications (CD > III) is low and long-term outcomes are favorable. Whether PPTD provides advantages over more radical techniques in terms of long-term outcomes remains controversial and requires further research.

The liver hanging maneuver (LHM), introduced by Belghiti et al. in 2001, has been widely adapted to various hepatectomy techniques to reduce blood loss and facilitate parenchymal transection. However, its primary limitation is the risk of vascular injury, particularly near the inferior vena cava (IVC). In this report, we describe a modified "Loop-Hanging" maneuver designed as an alternative to enhance exposure during parenchymal transection and improve the control of Glissonean pedicles. In this case, we employed the technique during an open right hemihepatectomy on a 47-year-old male patient with a complex bile duct injury following two unsuccessful Roux-en-Y hepaticojejunostomies (RYHJ). The patient was referred to our institution due to an RYHJ stricture. Imaging identified a right hepatic artery pseudoaneurysm and a fistula to the biliary limb. After two failed attempts at endovascular embolization, a surgical approach was determined through multidisciplinary discussions. During the surgery, the liver was looped with a nasogastric tube positioned anterior to the IVC, allowing gentle upward traction that facilitated the transection, minimized bleeding, and enhanced pedicle control. The LHM is known to reduce blood loss but carries risks for patients with anatomical variations, scarring, or cirrhosis. Our "Loop-Hanging" technique retains the core advantages of LHM, simplifies the process, and diminishes the risk of vascular injury. Further research is required to assess its safety and broader applicability.