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Although the number of minimally invasive liver resections (MILRs) has been steadily increasing in many institutions, minimally invasive anatomic liver resection (MIALR) remains a complicated procedure that has not been standardized. We present the results of a survey among expert liver surgeons as a benchmark for standardizing MIALR.We administered this survey to 34 expert liver surgeons who routinely perform MIALR. The survey contained questions on personal experience with liver resection, inflow/outflow control methods, and identification techniques of intersegmental/sectional planes (IPs).All 34 participants completed the survey; 24 experts (70%) had more than 11 years of experience with MILR, and over 80% of experts had performed over 100 open resections and MILRs each. Regarding the methods used for laparoscopic or robotic anatomic resection, the Glissonean approach (GA) was a more frequent procedure than the hilar approach (HA). Although hepatic veins were considered essential landmarks, the exposure methods varied. The top three techniques that the experts recommended for identifying IPs were creating a demarcation line, indocyanine green negative staining method, and intraoperative ultrasound.Minimally invasive anatomic liver resection remains a challenging procedure; however, a certain degree of consensus exists among expert liver surgeons.

EUS-guided biliary drainage (EUS-BD) has recently been reported to be a useful salvage technique after ERCP fail. However, data on EUS-BD used for preoperative biliary drainage (PBD) are limited. The aim of this study was to verify the clinical feasibility of EUS-BD for PBD.PBD was performed for malignant biliary obstruction in 318 patients at our institution between July 2014 and April 2022. Fifteen (4.7%) of these patients underwent surgical resection after preoperative EUS-BD (HGS 13; HDS 1; AGS with HGS 1) and were retrospectively analyzed.The stent was successfully placed in all 15 cases with a median procedure time of 15 min (technical success rate 100%). The median total bilirubin value decreased significantly from 3.7 before drainage to 0.9 after surgery (p0.001) and cholangitis was well managed (clinical success rate 100%). Surgery was performed at a median of 22 days after drainage, and there were no stent-related adverse events or recurrences of biliary obstruction. Severe surgery-related adverse events occurred in 3 cases, but none were associated with EUS-BD. The stent was removed during surgery in 12 cases.EUS-BD can be a feasible and safe alternative method of PBD for malignant biliary obstruction after ERCP fail.

BACKGROUND Few reports describe the relationship between preoperative cholangitis and surgical site infections (SSIs) after pancreaticoduodenectomy (PD). We aimed to determine the association between the incidence of preoperative cholangitis and surgical site infection following PD. METHODS The surgical outcomes of 359 patients who underwent PD were compared between patients with (n = 92) and without (n = 267) preoperative cholangitis. Bacterial cultures from the postoperative drainage fluid were examined. Risk factors for postoperative infectious complication were evaluated. RESULTS The incidence of postoperative infectious complications including grade B/C postoperative pancreatic fistula was high among patients with preoperative cholangitis (P

The left renal vein is technically difficult to expose during laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma despite being an important landmark for posterior dissection. We hereby propose a novel technique to safely expose the left renal vein while avoiding the associated anatomical pitfalls. The anatomy of the left renal artery and vein was analyzed using multidetector computed tomography. We initially exposed the left renal vein on the left posterior side of the superior mesenteric artery followed by exposure toward the left kidney. We retrospectively examined the perioperative results of this technique in 33 patients who underwent laparoscopic distal pancreatectomy. 15.7% of the patients had an accessory left renal artery coursing cranial to the vein. In 43.1%, the left renal arterial branch ventrally traversed the vein at the renal hilum, thereby posing a risk for arterial injury. The location of the left renal vein varies cranial (17.6%) or caudal (82.4%) to the pancreas. The left renal vein was exposed without any vascular injury using this technique. The median operative time was 259 min, blood loss was 18 mL, and R0 resection rate was 97.0%. The initial exposure of the left renal vein should, therefore, be on the left posterior side of the superior mesenteric artery.

Background Surgical views with high resolution and magnification have enabled us to recognize the precise anatomical structures that can be used as landmarks during minimally invasive distal pancreatectomy (MIDP). This study aimed to validate the usefulness of anatomy-based approaches for MIDP before and during the Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (February 24, 2021). Methods Twenty-five international MIDP experts developed clinical questions regarding surgical anatomy and approaches for MIDP. Studies identified via a comprehensive literature search were classified using Scottish Intercollegiate Guidelines Network (SIGN) methodology. Online Delphi voting was conducted after experts had drafted the recommendations, with the goal of obtaining >75% consensus. Experts discussed the revised recommendations in front of the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Results Four clinical questions were addressed, resulting in 10 recommendations. All recommendations reached at least a 75% consensus among experts. Conclusions The expert consensus on precision anatomy for MIDP has been presented as a set of recommendations based on available evidence and expert opinions. These recommendations should guide experts and trainees in performing safe MIDP and foster its appropriate dissemination worldwide.

Hand-sewing (HS) and stapling are common parenchymal closure techniques after distal pancreatectomy. However, these methods cannot completely prevent postoperative pancreatic fistula (POPF). The mechanisms of POPF formation after closure are unknown. We performed distal pancreatectomy in mongrel dogs to identify the mechanisms of POPF formation after HS and staple closure. We measured the closed pancreatic duct burst pressures and examined the histology of the remnant pancreas. The after staple-closure burst pressures depended on stapler height; lower pressures were associated with greater stapler heights. Post-HS closure burst pressures were significantly higher than those at each stapler height (P

Clinically relevant postoperative pancreatic fistulas (CR-POPF) occurring after distal pancreatectomy often cause intra-abdominal infections. We monitored the presence of bacterial contamination in the ascitic fluid after distal pancreatectomy to clarify the bacterial origin of intra-abdominal infections associated with CR-POPF. In 176 patients who underwent distal pancreatectomy, ascitic fluid bacterial cultures were performed on postoperative days (POD) 1–4 and when the drainage fluid became turbid. The association between postoperative ascitic bacterial contamination and CR-POPF incidence was investigated. CR-POPF occurred in 18 cases (10.2%). Among the patients with CR-POPF, bacterial contamination was detected in 0% on POD 1, in 38.9% on POD 4, and in 72.2% on the day (median, day 9.5) when the drainage fluid became turbid. A univariate analysis revealed a significant difference in ascitic bacterial contamination on POD 4 (p

Background The anatomical structure around the pancreatic head is very complex, and it is important to understand its precise anatomy and corresponding anatomical approach to safely perform minimally invasive pancreatoduodenectomy (MIPD). This consensus statement aimed to develop recommendations for elucidating the anatomy and surgical approaches to MIPD. Methods Studies identified via a comprehensive literature search were classified using the Scottish Intercollegiate Guidelines Network method. Delphi voting was conducted after experts had drafted recommendations, with a goal of obtaining >75% consensus. Experts discussed the revised recommendations with the validation committee and an international audience of 384 attendees. Finalized recommendations were made after a second round of online Delphi voting. Results Three clinical questions were addressed, providing six recommendations. All recommendations reached at least a consensus of 75%. Preoperatively evaluating the presence of anatomical variations and superior mesenteric artery (SMA) and superior mesenteric vein (SMV) branching patterns was recommended. Moreover, it was recommended to fully understand the anatomical approach to SMA and intraoperatively confirm the SMA course based on each anatomical landmark before initiating dissection. Conclusions MIPD experts suggest to surgical trainees to perform resection based on precise anatomical landmarks for safe and reliable MIPD.

Laparoscopic hepatojejunostomy (HJ) with continuous sutures is commonly performed in laparoscopic pancreaticoduodenectomy (LPD). This study aimed to investigate the long-term surgical outcomes of HJ in LPD. We retrospectively evaluated 103 consecutive patients who underwent pancreaticoduodenectomy via laparoscopic HJ with continuous suturing using multifilament (n = 48) or monofilament-absorbable sutures (n = 47). During follow-up, anastomotic stricture of HJ was identified in 8 (7.8%) patients via balloon enteroscopy-assisted cholangiography. The median time from surgery to confirmation of stricture formation was 7.6 months (range 3.6–19.4). The incidence of HJ stricture was significantly higher in patients with a thin bile duct (diameter

Purpose To evaluate the feasibility of pancreaticoduodenectomy with resection of the second jejunal vein (J2V) for pancreatic ductal adenocarcinoma (PDAC). Methods Among 114 patients with PDAC undergoing pancreaticoduodenectomy with portal-superior mesenteric vein resection (PVR), surgical outcomes, and prognoses of 10 patients with resection of J2V or later branches of the superior mesenteric vein (J2VR) were compared to 104 patients with PVR above J2V (standard PVR). The reconstruction methods in the J2VR group were reviewed. Results There were no significant differences in the operative time (470 vs 435 min), morbidity (30% vs 27%), presence of portal vein stenosis (10% vs 5%) or thrombosis (10% vs 1%), and induction of adjuvant therapy (80% vs 88%) between the J2VR and standard PVR groups, although blood loss was higher in the J2VR group (1184 vs 494 ml; P = .002). R0 proportion and 2-year survival rates were not significantly worse in the J2VR group compared to the standard PVR group (90 and 88%; 67 and 45%, respectively). At least one branch of the superior mesenteric vein was reconstructed in the J2VR group. Conclusion Pancreaticoduodenectomy with J2VR for PDAC can be safely performed with a satisfactory overall survival rate.

Surgery for gastric cancer should be performed as soon as possible after diagnosis. However, sometimes the waiting time for surgery tends to be longer. The relation between the waiting time for surgery and survival in patients with gastric cancer remains to be fully investigated. This retrospective, single-center cohort study evaluated patients with gastric cancer who underwent curative surgery from 2006 through 2012 at Kanagawa Cancer Center in Japan. Patients who received neoadjuvant chemotherapy were excluded. The waiting time for surgery was defined as the time between the first visit and surgery. We investigated whether the waiting time for surgery has a linear negative impact on outcomes by using a Cox regression model with clinical prognostic factors. In total, 801 patients were eligible. The median waiting time was 45 days (range 10–269 days). The restricted cubic spline regression curve showed that the adjusted time-specific hazard ratios of waiting times did not indicate a linear negative trend on survival between 20 and 100 days (p = 0.759). In the Cox model with a quartile of waiting times, waiting times in the 32–44-day group, 43–62-day group, and ≥63 day groups were not associated with poorer overall survival as compared with the ≤31 day group (HR: 1.01, 95% CI 0.63–1.60, p = 0.984, HR: 1.17, 95% CI 0.70–1.94, p = 0.550, HR: 1.06, 95% CI 0.60–1.88, p = 0.831, respectively). There was no negative relation between the waiting time for surgery (within 100 days) and survival in patients with gastric cancer.

The proximal jejunal vein which branches from the dorsal side of the superior mesenteric vein (SMV) usually drains the inferior pancreatoduodenal veins (IPDVs) and contacts the uncinate process of the pancreas. We focused on this vein, termed the proximal dorsal jejunal vein (PDJV), and evaluated the anatomical classification of the PDJV and surgical outcomes in patients with pancreatic ductal adenocarcinoma (PDAC) with PDJV involvement (PDJVI). The jejunal veins that branch from the dorsal side of the SMV above the inferior border of the duodenum are defined as PDJVs. We investigated 121 patients who underwent upfront pancreaticoduodenectomy for PDAC between 2011 and 2017; PDJVs were resected in all patients. The anatomical classification of PDJV was evaluated using multidetector computed tomography. Surgical and prognostic outcomes of pancreticoduodenectomy for PDAC with PDJVI were evaluated. The PDJVs were classified into seven types depending on the position of the first and second jejunal veins relative to the superior mesenteric artery. In all patients, the morbidity and mortality rates were 15.7 and 0.8%, respectively. The rates for parameters including SMV resection, presence of pathological T3–4, R0 resection, and 3-year survival were 46.2, 92.3, 92.3, and 61.1%, respectively, when there was PDJVI (n = 13). When there was no PDJVI (n = 108), the rates were 60.2, 93.5, 86.1, and 58.3%, respectively. Overall, there were no significant differences. Pancreaticoduodenectomy with PDJV resection is feasible for PDAC with PDJVI and satisfactory overall survival rates are achievable. It may be necessary to reconsider the resectability of PDAC with PDJVI.

Although the artery-first approach is widely used in open pancreaticoduodenectomy, it is difficult to laparoscopically expose the origin of the inferior pancreaticoduodenal artery (IPDA) from the left side of the superior mesenteric artery (SMA). By contrast, damaging the inferior pancreaticoduodenal veins (IPDVs) is possible when approaching the IPDA from the right side of the SMA. To facilitate the artery-first approach in laparoscopic pancreaticoduodenectomy (LPD), we focused on the proximal-dorsal jejunal vein (PDJV) that branched from the superior mesenteric vein (SMV) dorsal side and drained the IPDVs. This study aimed to clarify the usefulness of the right SMA approach using the PDJV preisolation method. The PDJV was first isolated, and the IPDVs were divided along the PDJV on the right side of the SMA. Then, the IPDA was divided at the root without first separating the pancreatic head from the portal vein and the SMV. Overall, 21 patients underwent this approach, and the results were retrospectively compared with those of 21 patients who underwent the artery-first approach, which was performed on the left side of the SMA. Anatomical characteristics of the PDJV were evaluated using multidetector computed tomography for the two groups. Operative times and resection times were significantly lower for the PDJV preisolation group than for the conventional LPD group (489.3 vs. 541.7 min, respectively; p = 0.002). During anatomical evaluation, 41 patients (97.6%) had a PDJV that drained from the SMV dorsally and was in contact with the anterior aspect of the uncinate process. The PDJV was confirmed as the first jejunal vein in 31 patients (73.8%) and as the second jejunal vein in 10 patients (23.8%). This approach facilitates dissection of the IPDA on the right side of the SMA, thereby reducing operative times.

BACKGROUND The aim of the present study was to investigate the feasibility of resection based on the nerve and fibrous tissue (NFT) structures around the superior mesenteric artery (SMA) for resectable pancreatic adenocarcinoma (R-PDAC) patients. METHODS NFTs around the SMA were classified into four "intensive NTFs area" with spreading the NFTs around the SMA and three SMA nerve plexus regions without branching nerves according to autopsy findings. Complete dissection of four "intensive NTFs areas" was performed by pre-exposing three SMA nerve plexus regions without branching nerves as "dissection-guiding points" with SMA nerve plexus preservation (NFT-based resection). Among 157 R-PDAC patients undergoing pancreaticoduodenectomy, surgical outcomes of 78 patients with NFT-based resection were compared with 59 patients with half-SMA nerve plexus dissection and 20 patients without NFTs dissection. RESULTS In the NFT-based resection group, 76.5% had tumor involvement and metastasis in each intensive NTFs area. Operative time, blood loss, and postoperative diarrhea rate were significantly lower in NFT-based resection than in half-SMA nerve plexus group (321 vs 390 min; P

The modified Blumgart method for pancreaticojejunostomy has been shown to reduce the rate of postoperative pancreatic fistula (POPF) in open surgery. We describe a modified Blumgart method using LAPRA-TY suture clips to facilitate laparoscopic pancreaticojejunostomy. We prepared a double-armed 4-0 nonabsorbable monofilament, which was ligated using the LAPRA-TY clip at the tail end, 12-cm in length. Next, the U-suture was placed through the pancreatic stump and the seromuscular layer of the jejunum. We performed duct-to-mucosa suturing with a 5-0 absorbable monofilament. After completing the duct-to-mucosa suturing, as a final step we placed the sutures through the seromuscular layer of the jejunum on the ventral side and tightly secured the thread with the LAPRA-TY clips. We performed laparoscopic Blumgart pancreaticojejunostomy during pancreaticoduodenectomy in 39 patients. We compared the surgical outcomes of 19 patients who underwent Blumgart pancreaticojejunostomy using the LAPRA-TY clips (LAPRA-TY group) with 20 patients undergoing surgery not using the LAPRA-TY clips (conventional group). The rate of clinically relevant postoperative pancreatic fistula in the LAPRA-TY group was 21.1%, which did not differ significantly from the rate of the conventional group. However, the mean time of pancreaticojejunostomy in the LAPRA-TY group was 56.2 min (range, 39–79 min), which was significantly shorter than that of the conventional group (69.7 min; range, 53–105 min, P

Neuroendocrine tumors of the pancreas (pNETs) are a rare group of neoplasms that originate from the endocrine portion of the pancreas. Tumors that either secrete or do not secrete compounds, resulting in symptoms, can be classified as functioning and non-functioning pNETs, respectively. The prevalence of such tumors has recently increased due to the use of more sensitive imaging techniques, such as multidetector computed tomography, magnetic resonance imaging and endoscopic ultrasound. The biological behavior of pNETs varies widely from indolent, well-differentiated tumors to those that are far more aggressive. The most effective and radical treatment for pNETs is surgical resection. Over the last decade, minimally invasive surgery has been increasingly used in pancreatectomy, with laparoscopic pancreatic surgery (LPS) emerging as an alternative to open pancreatic surgery (OPS) in patients with pNETs. Non-comparative studies have shown that LPS is safe and effective. In well-selected groups of patients with pancreatic lesions, LPS was found to results in good perioperative outcomes, including reduced intraoperative blood loss, postoperative pain, time to recovery, and length of hospital stay. Despite the encouraging results of studies from highly specialized centers with extensive experience, no randomized trials to date have conclusively validated these findings. Indications for minimally invasive LPS for patients with pNETs remain unclear. This review presents the current state of LPS for pNETs.

Multiplanar reconstruction (MPR) images are used for assessing horizontal and vertical extent of hilar cholangiocarcinoma, while peroral cholangioscopy (POCS) is used for diagnosing ductal spread and mapping biopsy. We fused conventional 3-dimensional computed tomography (3DCT) with MPR images and POCS findings for preoperative assessment of cholangiocarcinoma. The extent of cancer was assessed using MPR images, which were plotted and fused onto 3DCT cholangiography. In addition, the results of mapping biopsy performed under POCS were marked on virtual endoscopic imaging and transferred onto a 3DCT image. Once an angiographic CT image was fused, a multi-3DCT image was created. The incision line was determined based on these images. Multi-3DCT images were created for 13 patients with hilar cholangiocarcinoma. Of 10 patients who underwent POCS, superficial spread was observed in two. Resection was performed in 12 patients. In two cases, the cut end of the intrahepatic bile duct was positive, resulting in 83.3% diagnostic accuracy for horizontal spread. In all patients, the estimated number of bile ducts was the same as the number of the actual resections. R0 resection was achieved in 10 patients (83.3%). Multi-3DCT imaging proved useful in diagnosing longitudinal ductal spread of hilar cholangiocarcinoma.

184 Background: Advanced esophageal cancer patients sometimes have a difficulty to swallow food. On the other hand, standard treatment for resectable advanced esophageal cancer patients is surgery after 2 course preoperative chemotherapy of CDDP-5-FU (JCOG 9907). So we usually use naso-gastric ED tube for patients with difficulty of oral intake during preoperative chemotherapy to administrate adequate nutrition. But there is no report of the safety of this trial. Methods: The aim of this study is to clarify the safety of using ED tube during preoperative chemotherapy and compare the nutritional status between using ED tube or not. From Jan 2012 to June 2017, 122 patients were undergone esophagectomy with 2 course of preoperative chemotherapy, and 14 patients were treated with ED tube for nutrition(Group A) and 108 patients without ED tube(Group B). We evaluated the changes of nutritional status and postoperative complication as an indicator of safety. Results: Changes before and after preoperative chemotherapy(GroupA/B): average of body weight: 53.1→50.8/58.1→57.0, BMI: 20.0→19.2/22.0→21.6, TP: 6.7→6.9/7.3→6.9, alb: 3.5→3.8/4.3→4.2, pre-alb: 20.1→21.7/24.8→23.4, RBP: 2.77→3.33/3.15→3.23. Adverse events during chemotherapy: 1 case of Grade 3 hematologic toxicity and 1 case of Grade 2 non-hematologic toxicity were found at Group A(14.2%), and 11 cases of Grade 3 hematologic toxicity and 8 cases of Grade 2 non-hematologic toxicity were found at Group B(17.61%)(p = 0.758). Postoperative complications (clavien-dindo classification, Grade3 or more): 2 cases were observed at Group A(14.2%), and 21 cases were observed at Group B(19.4%)(p = 0.62). Conclusions: Preoperative chemotherapy with ED tube for nutrition was safe and effective to maintain the preoperative nutritional status.

s / Pancreatology 13 (2013) S1–S80 S63 ml). There was no conversion to open. 2 patients had developed pancreatic fistula (Grade A), which resolved spontaneously. In five of 7 patient (71.4%), R0 resection could be achieved, but the remaining two patients showed R1 resection. The mean numbers of retrieved lymph nodes were 17 (range, 9w40). The average postoperative hospital stay was 17.4 days (range, 7w47 days). Median follow up was 12 months (range, 6w33months). Peritoneal recurrence occurred in 2 patients. One of them died by primary disease. The remaining 5 patients are alive without recurrence. Conclusions: LDP for PDAC can be feasible, safe, and effective in highly selected patients. Clearly, a prospective, randomized study is needed to elucidate appropriate indications and effects of the present procedure.