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Background: Drainage fluid amylase (DFA) is useful for predicting clinically relevant postoperative pancreatic fistula (CR-POPF) after distal pancreatectomy (DP). However, difference in optimal cutoff value of DFA for predicting CR-POPF between open DP (ODP) and laparoscopic DP (LDP) has not been investigated. This study aimed to identify the optimal cutoff values of DFA for predicting CR-POPF after ODP and LDP., Methods: Data for 294 patients (ODP, n = 127; LDP, n = 167) undergoing DP at Kobe University Hospital between 2010 and 2021 were reviewed. Propensity score matching was performed to minimize treatment selection bias. Receiver operating characteristic (ROC) analysis was performed to determine the optimal cutoff values of DFA for predicting CR-POPF for ODP and LDP. Logistic regression analysis for CR-POPF was performed to investigate the diagnostic value of DFA on postoperative day (POD) three with identified cutoff value., Results: In the matched cohort, CR-POPF rates were 24.7% and 7.9% after ODP and LDP, respectively. DFA on POD one was significantly lower after ODP than after LDP (2263 U/L vs 4243 U/L, p < 0.001), while the difference was not significant on POD three (543 U/L vs 1221 U/L, p = 0.171). ROC analysis revealed that the optimal cutoff value of DFA on POD one and three for predicting CR-POPF were different between ODP and LDP (ODP, 3697 U/L on POD one, 1114 U/L on POD three; LDP, 10564 U/L on POD one, 6020 U/L on POD three). Multivariate analysis showed that DFA on POD three with identified cutoff value was the independent predictor for CR-POPF both for ODP and LDP., Conclusions: DFA on POD three is an independent predictor for CR-POPF after both ODP and LDP. However, the optimal cutoff value for it is significantly higher after LDP than after ODP. Optimal threshold of DFA for drain removal may be different between ODP and LDP., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The safety and efficacy of laparoscopic liver resection (LLR) have been reported worldwide. However, those of LLR for tumors located in Couinaud's segment 8 are not sufficiently investigated., Methods: We retrospectively analyzed 108 patients who underwent liver resection for hepatocellular carcinoma (HCC) in segment 8 at Kobe University Hospital and Hyogo Cancer Center between January 2010 and December 2021. The patients were categorized in LLR and open liver resection (OLR) groups, and 1:1 propensity score matching (PSM) was performed to compare surgical outcomes between the groups., Results: Forty-seven and 61 patients underwent LLR and OLR, respectively. After PSM, each group contained 34 patients. There was no significant difference in operation time between the groups (331 min vs. 330 min, P = 0.844). Patients in the LLR group had significantly less blood loss (30 mL vs. 468 mL, P < 0.001) and shorter length of postoperative hospital stay (10 days vs. 12 days, P = 0.015) than those in the OLR group. There was no significant difference in the occurrence of postoperative complications between the groups (12% vs. 9%, P = 0.690). Further, the 1-year cumulative incidence of recurrence was not significantly different between the groups (16% vs. 19%, P = 0.734)., Conclusions: The surgical outcomes and short-term prognosis of LLR were similar or better than those of OLR. LLR could be an effective and safe procedure, even for lesions located in segment 8, which is considered a difficult anatomical location for LLR., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Less intra-abdominal adhesions are expected following laparoscopic surgery. Although an initial laparoscopic approach for primary liver tumors may have advantages in patients who require repeat hepatectomies for recurrent liver tumors, this has not been sufficiently investigated., Methods: Patients who underwent repeat hepatectomies for recurrent liver tumors at our hospital between 2010 and 2022 were retrospectively analyzed. Of 127 patients, 76 underwent laparoscopic repeat hepatectomy (LRH), of whom 34 patients initially underwent laparoscopic hepatectomy (L-LRH) and 42, open hepatectomy (O-LRH). Fifty-one patients underwent open hepatectomy as both the initial and second operation (O-ORH). We analyzed surgical outcomes between L-LRH and O-LRH groups and between L-LRH and O-ORH groups using propensity-matching analysis for each pattern., Results: Twenty-one patients each were included in L-LRH and O-LRH propensity-matched cohorts. The L-LRH group had a lower rate of postoperative complications than the O-LRH group (0 vs 19%, P = 0.036). When we compared surgical outcomes between L-LRH and O-ORH groups in another matched cohort with 18 patients in each group, in addition to the lower rate of postoperative complications, the L-LRH group had additional favorable surgical outcomes including shorter operation time and lower blood loss volume than the O-ORH group (291 vs 368 min, P = 0.037 and 10 vs 485 mL, P < 0.0001)., Conclusions: An initial laparoscopic approach would be favorable for patients undergoing repeat hepatectomies, as it leads to lower risk of postoperative complications. Compared with O-ORH, the advantage of the laparoscopic approach may be enhanced when it is repeatedly adopted., (© 2023. The Society for Surgery of the Alimentary Tract.)

Stapling is the standard method for pancreatic transection during laparoscopic distal pancreatectomy. Although most surgeons use a 60 mm cartridge stapler, space limitations created by laparoscopic surgery make the instrument difficult to handle, especially during pancreatic transection at the neck. Therefore, we currently use a 45 mm cartridge stapler for laparoscopic pancreatic transection at the neck. Between October 2019 and December 2020, we performed pancreatic transection using a 45 mm cartridge stapler in 27 patients. Fifteen patients experienced biochemical leakage, but no patients developed clinically relevant pancreatic fistula. The compactness of the 45 mm cartridge has several benefits: (1) less space is required for flexing, opening, and closing the device; (2) it enables easy insertion of the lower jaw behind the pancreas, even if the dissected space behind the pancreas is narrow; (3) less obstruction of the surgeons' view prevents accidental injury to the surrounding tissues and vessels. These benefits may enable safe pancreatic transection., (© 2022. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Background: Anatomic liver resection (ALR) has been established to eliminate the tumor-bearing hepatic region with preservation of the remnant liver volume for liver malignancies. Recently, laparoscopic ALR has been widely applied; however, there are few reports on laparoscopic segmentectomy 2. This study aimed to present the standardization of laparoscopic segmentectomy 2 with surgical outcomes., Methods: This study included seven patients who underwent pure laparoscopic segmentectomy 2 by the Glissonean approach from January 2020 to December 2021. Four of them had hepatocellular carcinoma, two had colorectal liver metastasis, and one had hepatic angiomyolipoma, which was preoperatively diagnosed with hepatocellular carcinoma. In all patients, preoperative three-dimensional (3D) simulation images from dynamic CT were reconstructed using a 3D workstation. The layer between the hepatic parenchyma and the Glissonean pedicle of segment 2 (G2) was dissected to encircle the root of G2. After clamping or ligation of the G2, 2.5 mg of indocyanine green was injected intravenously to identify the boundaries between segments 2 and 3 with a negative staining method under near-infrared light. Parenchymal transection was performed from the caudal side to the cranial side according to the demarcation on the liver surface, and the left hepatic vein was exposed on the cut surface if possible., Results: The mean operative time for all patients was 281 min. The mean blood loss was 37 mL, and no transfusion was necessary. Estimated liver resection volumes significantly correlated with actual liver resection volumes (r = 0.61, P = 0.035). After the operation, one patient presented with asymptomatic deep venous and pulmonary thrombosis, which was treated with anticoagulant therapy. The mean length of hospital stay was 8.9 days., Conclusion: Laparoscopic segmentectomy 2 by the Glissonean approach is a feasible and safe procedure with the preservation of the nontumor-bearing segment 3 for liver tumors in segment 2., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Resecting liver tumors located in Couinaud's segment VII is challenging; the efficacy and safety of laparoscopic liver resection for segment VII lesions compared to open liver resection remain unclear., Methods: Medical records of 84 patients who underwent liver resection of segment VII at Kobe University Hospital and Hyogo Cancer Center between 2010 and 2021 were retrospectively analyzed. Surgical outcomes were compared between laparoscopic liver resection and open liver resection groups using propensity matching analysis., Results: Thirty-one and 53 patients underwent laparoscopic liver resection and open liver resection, respectively. After propensity matching, 29 patients were included in each group. The laparoscopic liver resection group had a significantly longer operation time (407 vs. 305 min, P = 0.002), lower blood loss (100 vs. 230 mL, P = 0.004), and higher postoperative alanine aminotransferase levels (436 vs. 252 IU/L, P = 0.008) than the open liver resection group. In patients with liver cirrhosis, the proportion of patients with postoperative liver-specific complications was higher in the laparoscopic liver resection group than in the open liver resection group (57% vs 11%, P = 0.049), although there was no significant difference in postoperative liver-specific complication rates between the groups in patients without liver cirrhosis., Conclusions: For liver resection of segment VII, laparoscopic liver resection led to higher postoperative liver damage than open liver resection. Open liver resection may be better for patients with liver cirrhosis to avoid postoperative liver-specific complications. Laparoscopic liver resection could be an acceptable procedure for patients without liver cirrhosis, with some merits such as less blood loss., (© 2022. The Society for Surgery of the Alimentary Tract.)

Undifferentiated pleomorphic sarcoma(UPS)is a non-epithelial malignant tumor with a high rate of recurrence and metastasis. The frequent metastasis site is lung, lymph node, liver and bone. Pancreatic metastasis is rare. 71-year-old woman whose course after right foot UPS resection had been followed up at our hospital. But multiple bone and muscle metastasis occurred 1 year after operation. She had resection or radiation for the recurrence. 3 years after the first operation, PET-CT and EUS-FNA revealed pancreatic tail metastasis. The tumor grew up in 6 months, so we performed laparoscopic distal pancreatectomy. The patient recovered uneventfully and was discharged on post-operative day 14. Currently 5 years and 6 months have passed since the first surgery and she is alive. Function-preserving and minimally invasive surgery for UPS pancreatic metastasis is considered to be essential.

A woman in her 80s was diagnosed with pancreatic tail cancer by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). We performed laparoscopic distal pancreatectomy followed by adjuvant chemotherapy with S-1 for 6 months. One year after surgery, contrast-enhanced computed tomography revealed a 15 mm mass in the posterior wall of the gastric body. EUS showed a hypoechoic mass in the muscular layer in the gastric wall, which was diagnosed as adenocarcinoma by FNA. We diagnosed gastric wall recurrence due to needle tract seeding(NTS)following EUS-FNA and performed partial gastrectomy. Histopathological diagnosis was gastric wall recurrence of pancreatic cancer. Since NTS following EUS-FNA can be proven only by the presence of gastric wall recurrence after surgery for pancreatic body or tail cancer, the actual risk of NTS including peritoneal dissemination is not clear and may have been underestimated. In case of resectable pancreatic body or tail cancer, indication for EUS-FNA should be carefully considered.

We have developed a new method to localize a tumor during totally laparoscopic gastrectomy that uses intraoperative laparoscopic ultrasonography combined with preoperative clipping and tattooing. One or 2 days before the surgery, endoscopic clipping was performed just proximal to the tumor, followed by tattooing with India ink at the clipping site. Examination by intraoperative laparoscopic ultrasonography was performed at the tattooed site to detect the clips. The resection line of the stomach was determined with use of the detected clips as a marker of the proximal margin of the tumor. This method was attempted in 14 patients who underwent totally laparoscopic gastrectomy, and the clips were successfully identified in all patients. The clips were visualized as several layers of a hyperechoic bar, which was termed a "ladder sign." The mean time from insertion of the laparoscopic probe to identification of the clips was 2 min. The ladder sign is an important finding in this method.

Background: Splenic flexure mobilization (SFM) is sometimes required for secure and tension-free anastomosis during laparoscopic colorectal surgery. Although several approaches have been used for laparoscopic SFM,1 it is still considered complicated and troublesome because of the lack of a standardized technique. We propose a three-step method for laparoscopic SFM, aimed at providing a simplified and standardized method, which is presented in the video., Method: First, the mesocolon of the transverse and descending colon is dissected from the retroperitoneal tissue using a medial approach. The appropriate plane for dissection can be recognized just beneath the inferior mesenteric vein, and the gauze should be placed in the dissected space. Second, the transverse colon and transverse mesocolon are detached from the pancreas and spleen by means of an anterior approach. The lesser sac is opened, and the attachment to the pancreas or spleen is cut using the inserted gauze as a landmark. Third, the lateral attachment of the descending colon to the left abdominal wall is dissected cranially or caudally., Results: Using this method, we performed laparoscopic SFM for 13 patients with colorectal cancer with no conversion to another approach or to open surgery. No intraoperative complications were reported, including bleeding from the spleen and injury of the pancreas. The mean time for SFM was 55 min., Conclusions: We consider this three-step method as being useful, and it might help the standardization of laparoscopic SFM.

Background: The controversy regarding laparoscopic total gastrectomy (LTG) is mainly due to the difficulty associated with esophagojejunostomy during this procedure. Although several techniques have so far been reported to overcome this issue,1 (-) 4 a reliable technique has not yet been established. We developed intracorporeal esophagojejunostomy using a circular stapler in LTG with a hand-sewn over-and-over suture technique, and have shown its favorable outcomes compared with those of conventional open surgery.5 This technique is presented in the video., Methods: After transection of the esophagus, an over-and-over suture with a 2-0 monofilament is placed counterclockwise from the right to the left side of the cut end in an outside-to-inside direction, and then from the left to the right side in an inside-to-outside direction. After insertion of the anvil head into the esophagus, it was fixed by ligation of the thread. Finally, intracorporeal esophagojejunal anastomosis was performed using a circular stapler., Results: In LTG, reconstruction using this method was performed for 23 consecutive patients with gastric cancer. There were no serious intraoperative complications or need for conversion to open surgery. Anastomotic leakage and stenosis occurred in one case each, respectively. The mean time for fixation of the anvil to the esophagus was 15 min for the last 12 consecutive patients., Conclusions: This method is simple and feasible, and the advantage of this technique is the elimination of the backhand stroke throughout the suturing procedure.

Background: Esophagojejunostomy in laparoscopic total gastrectomy (LTG) is a technically demanding procedure. Although several methods have been reported to date, none is considered consistently reliable. We developed a simple method for intracorporeal circular-stapled esophagojejunostomy using a modified over-and-over suture technique. The surgical outcomes of our technique were evaluated in comparison with those of open total gastrectomy (OTG)., Methods: From April 2012 to August 2014, reconstruction using this method in LTG was performed for 21 consecutive patients with gastric cancer (LTG group). Their surgical outcomes were compared with those of 27 patients with gastric cancer who underwent OTG without splenectomy (OTG group) between January 2011 and April 2014., Results: Estimated blood loss was significantly lower, and the postoperative hospital stay was significantly shorter in the LTG group than in the OTG group. The operating time and the number of harvested lymph nodes were similar between the two groups. The incidence of overall complications did not differ significantly between the two groups. Anastomotic leakage developed in one of the 21 patients in the LTG group and in two of the 27 patients in the OTG group. Anastomotic stenosis was observed in one patient in the LTG group., Conclusions: We consider this method as simple and feasible for most laparoscopic surgeons with basic laparoscopic suturing skills. This method might help LTG to become an accepted standard surgical option for treatment of patients with gastric cancer.

Purpose: Laparoscopic lymph node (LN) dissection around the middle colic vessels is technically demanding, thus raising controversy regarding the role of laparoscopic surgery for transverse colon cancer. We herein describe a cranial approach method to perform radical LN dissection around the middle colic vessels. The key characteristic of this approach is early division of middle colic vessels prior to mobilization of the colon., Methods: From April 2010 to September 2013, 27 patients with colon cancer received laparoscopic LN dissection around the middle colic vessels using this cranial approach. Their surgical and short-term outcomes were reviewed., Results: The mean number of harvested LNs was 29 (range, 6-50). The mean operative time and intraoperative blood loss were 274 min (range, 160-362 min) and 42 mL (range, 3-247 mL), respectively. There were no serious intraoperative complications or conversions to open surgery. There were two patients with stage 0, 7 with stage I, 12 with stage II, and 6 with stage III. No recurrent case was observed with a median follow-up period of 30 months (range, 9-48 months)., Conclusions: We consider this approach feasible and useful for radical LN dissection around the middle colic vessels during laparoscopic colon cancer surgery.