Annals of hepato-biliary-pancreatic surgery最新文献

Backgrounds/aims: Reconstruction of hepatic venous outflow is crucial in living donor liver transplantation (LDLT) to prevent graft congestion. This study evaluated the feasibility, long-term patency, complications, and survival rates of single-orifice hepatic venous outflow reconstruction using right lobe grafts.

Methods: A prospective study was conducted involving 52 patients who underwent LDLT with right lobe grafts at 108 Military Central Hospital, Vietnam, from January 2019 to December 2020, with follow-up extending until December 2024. The technique included forming a single triangular orifice by joining the middle hepatic vein (MHV) and right hepatic vein, utilizing extended right lobe grafts with the MHV or modified right lobe grafts where MHV reconstruction was performed using polytetrafluoroethylene grafts. Outcome measures included ultrasound, CT scans, and regular clinical follow-up.

Results: Ten patients (19.3%) required MHV reconstruction. Mean reconstruction time was 17.4 minutes; cold ischemic time averaged 40.9 ± 6.3 minutes. Intraoperative patency was achieved in all cases, with 96.2% showing complete graft perfusion. Five-year patency was 94.2%. MHV complications occurred in three patients (5.8%): two stenoses (3.8%, conservatively managed) and one fatal occlusion (1.9%). Anastomotic diameter ≤ 30 mm significantly increased complication risk (odds ratio [OR], 14.286; 95% confidence interval [CI]: 1.121-183.823; p = 0.011). Five-year survival was 84.6% (95% CI: 75.2%-93.9%), with rates of 100% for cirrhosis, 85.7% for hepatocellular carcinoma, and 58.8% for acute-on-chronic liver failure.

Conclusions: Single-orifice hepatic venous outflow reconstruction is simple, efficient, and reliable in LDLT, achieving high long-term patency and low complication rates without cadaveric grafts.

Backgrounds/aims: Obstructive jaundice, resulting from bile duct obstruction, is associated with increased morbidity and mortality due to impaired bile flow, dysbiosis of the gut microbiota, enhanced bacterial translocation, and hepatocellular injury. Persistent biliary obstruction can further progress to hepatic fibrosis and ultimately cirrhosis. Probiotics might help modulate microbiota and reduce liver injury. This study investigates the effect of Lactococcus lactis D4 on Ki-67 expression and liver fibrosis in rats with obstructive jaundice.

Methods: Fifteen male Wistar rats (10-16 weeks old) were divided into three groups: sham (laparotomy only), BDL (bile duct ligation without treatment), and BDL-LLD4 (BDL followed by L. lactis D4). After 7 days, liver wedge biopsies were taken for Ki-67 immunohistochemical staining and assessment of fibrosis using the METAVIR score.

Results: The highest mean Ki-67 expression was observed in the BDL-LLD4 group (14.20 ± 3.35), significantly higher than in the sham (7.60 ± 2.61; p < 0.05) and BDL groups (3.40 ± 1.34; p < 0.01). The Metavir fibrosis score was lower in the BDL-LLD4 group, but not significantly, suggesting reduced liver damage.

Conclusions: Administration of L. lactis D4 in an obstructive jaundice model resulted in a significant upregulation of Ki-67 expression and attenuation of liver fibrosis compared to the BDL group. These results suggest that L. lactis D4 exhibits hepatoprotective effects by promoting liver regeneration and suppressing fibrogenesis, thereby supporting its potential as an adjunctive probiotic therapy for liver disease and preventing postoperative liver failure.

Pancreaticoduodenectomy remains the only curative intervention for periampullary and pancreatic head cancers, with R0 resection being essential for long-term survival. Nonetheless, the predictive value of preoperative imaging, particularly following neoadjuvant therapy, often remains inadequate. Committing to irreversible surgical steps too early can lead to futile procedures associated with significant morbidity. Here, we introduce the innovative "Total Non-Division Technique," which strategically combines the superior mesenteric artery (SMA)-first approach and total mesopancreas excision (TMpE) to ensure resectability prior to performing any irreversible maneuvers. The procedure initiates with the Cattell Braasch Valdoni manoeuvre, Kocherisation and division of the ligament of Treitz which facilitates a 270-degree duodenal-jejunal derotation, clarifying the SMA and SMV anatomical relationship. Employing a combined posterior and right medial SMA-first approach allows for early vascular control while safeguarding aberrant hepatic arteries. TMpE (type 2 or 3) is achieved en bloc, providing radical clearance within pl-Ph-II between the SMA and celiac axis. Irreversible surgical actions are intentionally deferred until R0 resectability is established, supporting intraoperative decision-making and allowing for procedure abandonment should oncological criteria not be fulfilled. This surgical method enhances rates of R0 resection and reduces morbidity linked to non-curative operations. By avoiding early bile duct transection, contamination risk is minimized, and delayed pancreatic division optimizes margin status and haemostasis. This innovative approach is safe and follows established principles of oncologic surgery, while introducing an intraoperative "path of escape," analogous to Sun Tzu's doctrine of strategic flexibility, ensuring that irreversible commitments are undertaken only upon clear oncological justification.

Alveolar echinococcosis is an uncommon and potentially life-threatening disease caused by the parasite Echinococcus multilocularis. Although incidence has been increasing, it continues to be an overlooked infectious disease in North America. In this case, the patient presented with jaundice, cholestatic hepatitis, and 14 kg weight loss over two months. He was subsequently diagnosed with metastatic alveolar echinococcosis affecting the spleen, biliary tract, and liver. Due to the extensive nature of his disease, he was initially considered unsuitable for curative resection. The patient was assessed for liver transplantation by a multidisciplinary team including Hepatobiliary/ Transplant Surgery, Transplant Hepatology, Transplant Infectious Diseases, and an Infectious Diseases physician experienced in managing alveolar echinococcosis. The patient and team opted for medical management given the high perioperative morbidity and substantial risk of disease recurrence. After percutaneous drain placement and 2.5 years of albendazole monotherapy, significant regression of the disease permitted curative intent left hepatectomy with en-bloc cholecystectomy. The surgery was completed successfully and the patient continues albendazole therapy following evidence of residual disease on PET-CT. This case illustrates the challenges inherent in the management of advanced alveolar echinococcosis, reviews decision-making regarding transplantation, and underscores the importance of a multidisciplinary approach to disease management.

Backgrounds/aims: Choledocholithiasis with gallbladder in situ presents a complex surgical challenge. The transcystic approach offers a minimally invasive alternative to choledochotomy; however, its adoption remains limited. This study assessed the safety, efficacy, and reproducibility of this method.

Methods: This retrospective study involved 71 patients diagnosed with choledocholithiasis and gallbladder in situ, all of whom underwent transcystic bile duct exploration at a primary care hospital. Demographic, clinical, and intraoperative variables were analyzed to determine predictors of bile duct injury.

Results: Transcystic exploration achieved successful completion in 92.9% of cases and a duct clearance rate of 94%. The most common complication was bile duct injury, showing a significant association with previous endoscopic or percutaneous procedures (p = 0.031), increased preoperative leukocyte count (p = 0.050), and advanced age (median 72.7 vs. 60.4 years; p = 0.031). Conversion to choledochotomy elevated the risk of injury, and incomplete duct clearance correlated with higher complication rates. No specific intraoperative techniques or devices exhibited a significant impact on outcomes. Imaging at six months demonstrated no persistent strictures, supporting the likelihood of transient inflammatory changes.

Conclusions: The transcystic approach is a safe, effective, and reproducible first-line intervention for choledocholithiasis with gallbladder in situ. Patient-specific and disease-related factors primarily determine bile duct injury risk, rather than the surgical technique itself. Further prospective randomized studies are needed to confirm these findings.

Backgrounds/aims: The role of preoperative biliary drainage (PBD) in improving perioperative outcomes for patients with obstructive jaundice remains controversial. This retrospective study aims to evaluate the impact of PBD in patients with varying severities of jaundice and to identify optimal strategies to minimize complications and mortality following pancreaticoduodenectomy (PD).

Methods: This retrospective clinical study included 240 patients with obstructive jaundice who underwent PD. Patients were categorized into severe Jaundice group (SJ group) and moderate Jaundice group (MJ group). Preoperative, intraoperative, and postoperative clinical data were compared based on whether PBD was performed. Additionally, the association between PBD duration and postoperative complications and mortality after PD was assessed.

Results: Among 115 patients in the SJ group, 94 received PBD, whereas 46 of the 125 patients in the MJ group received PBD. In the SJ-PBD group, the rate of postoperative bile leakage was significantly lower compared with the direct surgery group; however, overall complication rates did not differ. In the MJ-PBD group, the incidence of incision-related complications increased significantly, with no notable reduction in overall postoperative complications. Patients who underwent PBD for at least 10 days experienced lower rates of severe complications (Clavien-Dindo grade ≥ 3) than patients with PBD duration less than 10 days (14.3% vs. 25.5%, p = 0.012).

Conclusions: PBD should be considered in obstructive jaundiced patients with total bilirubin > 256 μmol/L, particularly those presenting with systemic functional impairment. A minimum PBD duration of 10 days appears beneficial for reducing the risk of serious postoperative complications and mortality.

Backgrounds/aims: This study evaluated the feasibility and outcomes of surgical treatment for metachronous periampullary carcinoma following curative resection of primary extrahepatic bile duct cancer.

Methods: A retrospective review was conducted of seven patients who underwent pancreaticoduodenectomy (PD) for metachronous periampullary cancer after prior curative surgery for extrahepatic bile duct cancer.

Results: The mean age at the second surgery was 66.7 years (range, 43-81 years). Initial malignancies included three hilar cholangiocarcinomas, one middle bile duct cancer, and three gallbladder cancers. Subsequent primary tumors consisted of three distal bile duct cancers, three pancreatic head cancers, and one duodenal cancer. The mean interval between the first and second cancers was 47 months (range, 13-121 months). No perioperative deaths occurred. Postoperative complications developed in three patients (42.9%): chyle leakage (Clavien-Dindo grade II) in two (28.6%) and a grade C postoperative pancreatic fistula requiring reoperation (grade IIIb) in one (14.3%). Both chyle leaks were managed conservatively. During follow-up, four patients died of recurrence at 5, 12, 19, and 24 months postoperatively. One patient underwent video-assisted thoracoscopic surgery for pulmonary metastasis 2 months after PD and remains alive 22 months later without recurrence. Two patients are disease-free at 38 and 92 months of follow-up.

Conclusions: PD for second primary periampullary cancer after resection of extrahepatic bile duct cancer appears feasible and potentially effective. Although no perioperative mortality occurred, major complications were observed. Larger studies are needed to confirm these preliminary findings.

Backgrounds/aims: To evaluate the impact of unplanned conversion to open surgery on resection margin status and postoperative complications in patients undergoing minimally-invasive resection of colorectal liver metastases (CRLM).

Methods: This study performed a proportion meta-analysis and meta-regression using random-effects modelling in accordance with PRISMA guidelines. Studies with at least 15 patients that reported conversion to open surgery in individuals receiving minimally-invasive CRLM resection were included. The association of unplanned conversion with postoperative outcomes was analyzed.

Results: Eighty-six studies encompassing 18,138 patients were analyzed. The overall conversion rate was 5.8% (95% CI 5%-6.6%). Conversion was associated with improved R0 resection rates (coefficient: 2.167, p < 0.001) but was also linked to increased postoperative mortality (coefficient: 7.585, p = 0.001) and morbidity (coefficient: 1.737, p = 0.003); there was no significant impact on 5-year overall survival (coefficient: 0.700, p = 0.989) or 5-year disease-free survival (coefficient: -72.900, p = 0.157). Specifically, conversion due to oncological concern was associated with higher rates of R0 resection (coefficient: 0.638, p = 0.005); conversion resulting from iatrogenic injuries was associated with lower R0 resection rates (coefficient: -1.478, p < 0.001); conversion for technical difficulties was associated with lower postoperative morbidity (coefficient: -0.380, p = 0.006).

Conclusions: Unplanned conversion to open may carry prognostic and oncological implications for minimally-invasive resection of CRLM. Although conversion due to bleeding and iatrogenic injury is routinely considered, conversion prompted by technical difficulties or oncological concerns should not be considered failure, as it may be associated with improved patient outcomes.

Backgrounds/aims: Portal annular pancreas (PAP) is an anomaly where pancreatic tissue surrounds the portal vein (PV). We present a case series from our institution and a systematic review of PAP patients who underwent pancreatoduodenectomy (PD).

Methods: We conducted a retrospective review of patient records from a tertiary referral center, from January 2014 to June 2024, who underwent PD to identify those with PAP. Additionally, a literature search was performed and articles discussing PAP patients who underwent PD were included.

Results: The incidence of PAP was 0.4% (7 out of 1,750 PD cases). Of these, three (42.85%) patients developed clinically relevant postoperative pancreatic fistula (CR-POPF). Following the literature review, 34 articles with 57 patients (including our study) were considered. Reconstruction of the dominant stump, which included the main pancreatic duct, was performed using pancreatojejunostomy in 88.88% of cases and pancreatogastrostomy in 11.11% of cases. The non-dominant stump was managed with en-bloc extended resection (ER) of PAP, leftward of the PV, offering a single-cut surface for pancreatojejunostomy (41.51%), by stapling (26.41%) or suturing the stump (16.98%), stump-pancreatogastrostomy (5.66%), and electrocautery (5.66%). CR-POPF rates for ER, suturing and stapling were 22.72%, 37.5%, and 53.85%, respectively (p = 0.12).

Conclusions: Preoperative recognition of PAP is crucial to customize surgical procedures to effectively manage the non-dominant stump.

Backgrounds/aims: Arterial resection in pancreatic cancer remains controversial. This study evaluates outcomes of pancreatic resection with arterial involvement following neoadjuvant chemotherapy.

Methods: Retrospective analysis of 100 pancreatic adenocarcinoma patients undergoing resection after neoadjuvant FOLFIRINOX (2010-2024): 26 with arterial resection (ArP), 39 with portal-venous resection (PoP), and 35 without vascular involvement (NoP). Primary outcomes included perioperative morbidity, mortality, and survival.

Results: ArP patients had significantly more stage III disease (73.1% vs 58.9% vs 28.6%, p < 0.001) but achieved acceptable R0 resection rates (76.9% vs 84.6% vs 91.4%, p = 0.04). ArP procedures required longer operative time (386 ± 71 minutes), greater blood loss (1,100 ± 560 mL), and more transfusions (57.7%; all p < 0.001). Major complications (Clavien-Dindo ≥ III) were higher in ArP (26.9% vs 21.6% vs 8.6%, p = 0.03), with extended ICU stays (3.5 ± 1.5 vs 2.0 ± 1.0 vs 1.0 ± 0.5 days). Ninety-day mortality was 0% (ArP), 2.5% (PoP), and 5.7% (NoP) (p = 0.78). Despite shorter disease-free survival in ArP (7.4 vs 9.7 vs 13.2 months, p = 0.01), median overall survival was comparable (ArP: 19.1, PoP: 18.3, NoP: 22.7 months; p = 0.0652).

Conclusions: Arterial resection following neoadjuvant therapy in selected pancreatic cancer patients demonstrates acceptable perioperative risk and achieves survival outcomes comparable to less advanced cases. This approach is justified in experienced high-volume centers for appropriately selected patients with favorable response to neoadjuvant therapy, offering potential cure in rare circumstances.