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Background: The effectiveness and extent of regional lymph node dissection in primary duodenal cancer (DC) remains unclear. This study aimed to analyze the prognostic factors and lymph node metastasis (LNM) patterns in DC. Methods: Fifty-three patients who underwent surgical resection for DC between January 1998 and December 2018 at two institutions were retrospectively analyzed. Univariate and multivariate analyses were performed on the prognostic factors of resected DC. Moreover, the relationships between depth of tumor invasion and incidence of LNM and between tumor location and LNM stations were analyzed. Results: The five-year survival rate of the study population was 68.9%. Multivariate survival analysis demonstrated that histologic grade G2–G4, presence of LNM, pT3–4, and elevated preoperative CA19-9 were the independent poor prognostic factors. No patient with pTis–T2 had LNM. On the other hand, LNM was found in 70% of patients with pT3–4. Among 36 patients who underwent pancreaticoduodenectomy (PD), LNM around the pancreatic head was observed, regardless of the duodenal cancer site, including the duodenal bulb and the third to the fourth portion. Conclusions: Histologic grade G2–G4, presence of LNM, pT3–T4, and elevated preoperative CA19-9 were the independent poor prognostic factors in patients with resected DC. Our results suggested that lymph node dissection could be omitted for DC Tis–T1a. Moreover, based on the high frequency of LNM in T3–4 cases, PD with lymph node dissection in the pancreatic head region was considered necessary for T3–4 DC at any site. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to elucidate the effects of laparoscopic liver resection (LLR) vs open liver resection (OLR) for major complications (Clavien‐Dindo classification grade ≥ IIIa) in obese individuals with hepatocellular carcinoma (HCC). Methods: The clinical records of 339 and 733 patients who underwent LLR and OLR, respectively, for HCC between 2000 and 2019 were retrospectively reviewed. Body mass index (BMI) groups were classified according to the definitions of the World Health Organization: underweight group, BMI ≤ 18.4 kg/m2 (LLR vs OLR: 27 vs 47); normal weight, BMI 18.5‐24.9 kg/m2 (211 vs 483); overweight, BMI 25.0‐29.9 kg/m2 (85 vs 181); and obese, BMI ≥ 30.0 kg/m2 (16 vs 22). The effects of obesity on major complications after LLR and OLR were investigated. Results: In total, 18 (5.3%) and 127 (17.3%) patients presented with major complications after LLR and OLR, respectively. There was no significant difference in the incidence of major complications after OLR in the four BMI groups. However, a stepwise decrease in the incidence of major complications after LLR was observed from the underweight to the obese group. In addition, a multivariate analysis revealed that increased BMI was an independent preventive factor for major complications after LLR (P =.026, odds ratio: 0.84). The estimated adjusted risk of major postoperative complications decreased with increased BMI in the LLR group, while the risk did not decrease in the OLR group (P for interaction =.048). Conclusion: Laparoscopic liver resection is beneficial for obese patients and is superior to OLR. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to evaluate the indications of laparoscopic repeat liver resection (LRLR) for recurrent hepatocellular carcinoma from the viewpoint of its difficulty. Methods: One hundred and one patients who underwent LRLR and 59 patients who underwent open repeat liver resection (ORLR) were included. The difficulty was classified according to the preoperative predictive factors for difficult LRLR, including an open approach during previous liver resection, history of two or more previous liver resections, history of previous major liver resection, tumor near the resected site of the previous liver resection, and intermediate or high difficulty with the difficulty scoring system. We compared the surgical outcomes between the LRLR and ORLR groups based on the difficulty class (low‐ or intermediate difficiulty class, 0 to 3 predictive factors; high difficiulty class, 4 or 5 factors). Results: In the low‐ or intermediate difficiulty class, intraoperative blood loss and the proportion of patients with postoperative complications were significantly lower in LRLR than in ORLR, and the duration of the postoperative hospital stay was significantly shorter in LRLR than in ORLR. In the high difficiulty class, total operative time and operative time before starting hepatic parenchymal resection were significantly longer in LRLR than in ORLR, and there were no significant differences in other surgical outcomes between the two groups. Conclusion: LRLR is recommended for patients in the low or intermediate difficulty class. However, LRLR does not have an advantage with longer operative time for patients in the high difficulty class compared with ORLR. [ABSTRACT FROM AUTHOR]

Background: Despite the recently increasing number of elderly patients undergoing liver resection, the impact of advancing age on postoperative infections (PIs) incidence and risk remains unclear. This study aimed to investigate the impact of advancing age on PIs incidence and status. Methods: This retrospective study included 744 patients undergoing liver resection without biliary reconstruction or combined resection of other organs. Multivariable analysis with a restricted cubic spline was used to evaluate the impact of advancing age on PIs and to determine its association with PIs risk in patients undergoing open and laparoscopic liver resection (OLR and LLR, respectively). Results: Multivariable analysis demonstrated that advancing age was significantly associated with increased PIs risk (P = 0.017). The spline curve showed that the odds ratio for PIs sharply increased starting approximately at 65 years of age. Unadjusted restricted cubic splines assessing the subcategories of PIs demonstrated that advancing age was associated with increased risks of organ/space surgical site infection and sepsis (P = 0,064 and 0.048, respectively). Multivariable analysis revealed that LLR was associated with the lower PIs risk compared with OLR (P = 0.025), whereas the lower PIs risk with LLR was not significantly obscured by advancing age (P = 0.29). Conclusions: Advancing age was associated with increased risk of PIs, including organ/space surgical site infections and sepsis, after liver resection especially in patients aged ≥ 65 years. [ABSTRACT FROM AUTHOR]

Aim: We investigated effects of direct‐acting antiviral (DAA)–induced sustained virological response (SVR) after liver resection in patients with hepatitis C virus (HCV)–related hepatocellular carcinoma (HCC) for postoperative recurrence and survival. Methods: Surgical outcomes in 18 patients with postoperative DAA‐induced SVR (HCC‐DAA group) were compared with those in 23 patients with preoperative DAA‐induced SVR (DAA‐HCC group) and those in 10 patients who did not receive DAA therapy (control group). Patients who received DAA therapy >1 year after surgery and those with recurrence <1 year after surgery were excluded. Results: Serum concentrations of aminotransferases improved 1 year after surgery in both the HCC‐DAA and DAA‐HCC groups. The number of HCC‐DAA patients with albumin‐bilirubin (ALBI) grade 1 increased from 11 to 15. The disease‐free survival rate did not differ between HCC‐DAA group (3 years, 60%) and the other two groups (DAA‐HCC group, 92% and control group, 60%). The 3‐year overall survival rates were better in the DAA‐HCC group (84%) and HCC‐DAA group (100%) than in the control group (46%; all ps < 0.05 according to Holm's test). Multivariable analysis revealed that tumor stage was an independent risk factor for postoperative recurrence, and ALBI grade at 1 year after surgery was predictive of postoperative survival, but DAA‐induced SVR was neither. Conclusions: Although postoperative DAA‐induced SVR itself may not suppress postoperative recurrence, improvement in liver function as a result of DAA administration after surgery may prolong postoperative survival. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to investigate the predictive factors and classifications for difficulty of laparoscopic repeated liver resection (LRLR) in patients with recurrent hepatocellular carcinoma. Methods: Sixty patients who underwent LRLR were included. Potential predictive factors for difficult LRLR included the approach of the previous liver resection (laparoscopic or open), the number of previous liver resections, a history of cholecystectomy in previous liver resection, the operative procedure of previous liver resection, whether the tumor was near the resected site of the previous liver resection, non‐surgical treatments before the present surgery, and the difficulty scoring system for laparoscopic liver resection. The relationship between these factors and perioperative outcomes were evaluated to investigate the predictive factor for difficult LRLR. Results: Univariate and multivariate analyses demonstrated that an open approach during previous liver resection, two or more previous liver resections, a history of previous liver resection with not less than sectionectomy, tumor near the resected site of the previous liver resection, and intermediate or high difficulty in the difficulty scoring system were independent risk factors for prolonged operative time and/or severe adhesion of LRLR. Three difficulty classifications were then suggested based on the number of these five predictive factors. The difficulty classification reflected operative time, intraoperative blood loss, and incidence of postoperative complication. Conclusion: The difficulty of LRLR may be predicted by three difficulty classifications using five preoperative predictive factors. [ABSTRACT FROM AUTHOR]

Introduction: We investigated the indications for laparoscopic liver resection (LLR) of mass‐forming intrahepatic cholangiocarcinoma (MF‐ICC), including the need for lymph node dissection for improved postoperative prognosis. Methods: This study involved 36 patients who underwent surgery for solitary peripheral MF‐ICC. Fifteen patients underwent LLR, and 21 underwent open liver resection (OLR). Surgical outcomes and prognostic factors were investigated to determine the indications for LLR. Results: No significant differences were observed in perioperative outcomes between patients who underwent LLR and OLR. A significantly worse disease‐free survival (DFS) rate was observed in patients who preoperatively had a tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum carbohydrate antigen (CA) 19‐9 and carcinoembryonic antigen (CEA) levels. A significantly worse overall survival (OS) rate was observed in patients with a tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum CA19‐9 levels. Therefore, a tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum CA19‐9 and CEA levels were determined to be preoperative prognostic factors. DFS and OS rates were significantly better in patients without these factors. Moreover, in six patients without these factors who underwent LLR, neither lymph node metastasis nor postoperative recurrence was observed. Conclusion: A tumor diameter ≥3 cm, vascular invasion on diagnostic imaging, and elevated serum CA19‐9 and CEA levels are preoperative prognostic factors for peripheral MF‐ICC. LLR is indicated for patients without these factors. [ABSTRACT FROM AUTHOR]

Background: There are many reports about limited surgery for intraductal papillary mucinous neoplasms (IPMNs) of the pancreas. However, there is no consensus on limited surgery for IPMNs. The primary objective of this study was to define the clinical indications for limited surgery for IPMNs. Methods: The data of 98 patients who underwent curative resections for IPMN were retrospectively analyzed. IPMNs were classified into four different pathological grades: low-grade dysplasia (LGD), intermediate-grade dysplasia (IGD), high-grade dysplasia (HGD), and invasive carcinoma (Inv-IPMN). Inv-IPMNs were divided into T1a, T1b, and T1c or over T1c (≥T1c). Based on preoperative radiological findings, IPMNs were stratified into the three groups using the 2012 International Consensus Guidelines: worrisome features, high-risk stigmata (HRS), and others. Results: There were no positive lymph node cases and no recurrent cases of LGDs, IGDs, and HGDs. On the other hand, positive lymph node cases in T1a, T1b, and ≥T1c were seen in 37.5, 20, and 22.2% of cases, respectively. The recurrence rates of T1a, T1b, and ≥T1c were 50, 40, and 55.6%, respectively. Of the HRS cases, 30 (73.2%) were malignant and 25 (61%) were Inv-IPMN. HRS showed sensitivity of 92.6%, specificity of 77.5%, and accuracy of 81.6% to identify Inv-IPMN by preoperative imaging. Conclusions: Limited surgery such as parenchyma-sparing pancreatectomy should be avoided for all cases of Inv-IPMNs, because every Inv-IPMN including T1a has the potential for lymph node metastasis and recurrence. HRS had high preoperative diagnostic ability for predicting Inv-IPMN. For cases that meet HRS criteria, pancreatectomy with lymphadenectomy is needed, and limited surgery should be withheld. [ABSTRACT FROM AUTHOR]

Background: We researched the origin and progression of anaplastic pancreatic cancer (APC) from the viewpoints of cell lineage, epithelial‐mesenchymal transition (EMT) and cancer stem‐like cells (CSC). Methods: Using specimens from patients with APC and differentiated pancreatic ductal adenocarcinoma (PDAC), expression of sex‐determining region Y‐box 9 (SOX9), E‐cadherin, vimentin, ZEB1, Snail, N‐cadherin, CD24 and CD44 was estimated using immunohistochemistry. Results: Almost all cases were positive for SOX9 expression. APC cases were negative, but many PDAC cases were positive for the expression of E‐cadherin. A much higher number of APC cases than PDAC cases were positive for the expression of other EMT related proteins and for the expression of CSC related proteins. The ductal cancerous component of APC accounted for an average of 12% of the cancerous lesion and the expression of each marker in this component was similar to that of PDAC cases. Conclusions: Anaplastic pancreatic cancer had pancreatic duct cell like features and might gain dedifferentiate components through EMT and the acquisition of CSC properties. Highlight Due to its rarity, the biological features of anaplastic pancreatic cancer, including the origin and mechanism of dedifferentiation, have not been elucidated. Miura and colleagues demonstrated that anaplastic pancreatic cancer might have pancreatic duct cell‐like features and dedifferentiated components related to epithelial‐mesenchymal transition and acquisition of cancer stem cell properties. [ABSTRACT FROM AUTHOR]