Standardized single-incision plus one-port laparoscopic left lateral sectionectomy: a safe alternative to the conventional procedure.

PURPOSE: Laparoscopic left lateral sectionectomy (LLLS) is a feasible and safe procedure with a relatively smooth learning curve. However, single-incision LLLS requires extensive surgical experience and advanced techniques. The aim of this study is to report the standardized single-incision plus one-port LLLS (reduced port LLLS, RPLLLS) technique and evaluate its safety, feasibility, and effectiveness for junior surgeons. METHODS: Between January 2008 and November 2020, the clinical records of 49 patients who underwent LLLS, divided into the conventional LLLS (n = 37) and the RPLLLS group (n = 12), were retrospectively reviewed. The patient characteristics, pathologic results, and operative outcomes were evaluated. RESULTS: A history of previous abdominal surgery in the RPLLLS group was significantly high (56.8% vs. 91.7%, p = 0.552). Notably, junior surgeons performed 62.2% of the conventional LLLSs and 58.4% of the standardized RPLLLSs. There were no significant differences between the two groups in terms of median operative time (121.0 vs. 113.5, p = 0.387), median blood loss (13.0 vs. 8.5, p = 0.518), median length of hospital stays (7.0 vs. 7.0, p = 0.408), and morbidity rate (2.7% vs. 0%, p = 0.565), respectively. CONCLUSION: This standardized RPLLLS is a feasible and safe alternative to conventional LLLS and may become the ideal training procedure for both junior surgeons and surgeons aiming to learn more complex procedures.

Pancreatic ductal adenocarcinoma in a patient with pancreas divisum and gastrointestinal duplication cyst: a case report.

BACKGROUND: The complication of duplication of alimentary tracts and pancreas divisum (PD) is a rare malformation and the development of pancreatic ductal adenocarcinoma (PDAC) in this malformation is also extremely rare. There have been some reports of complication of malignancy in a gastric duplication cyst (GDC) and PD. However, there have been no reports of complication of PDAC in cases with GDC and PD. CASE PRESENTATION: A 54-year-old woman was followed up at the previous hospital due to a history of ovarian endometrial adenocarcinoma. She also had a surgical history of partial excision for a GDC and pancreatic tail of PD in her childhood. A gynecological follow-up computed tomography (CT) examination revealed the pancreatic body tumor and the bifurcated main pancreatic duct dilatation. Furthermore, magnetic resonance cholangiopancreatography also revealed that the ventral main pancreatic duct communicated with the GDC. The initial levels of tumor markers were high, but we could not achieve preoperative histopathological diagnosis. The preoperative diagnosis was PDAC occurring in a case with PD and GDC. She received two courses of neoadjuvant chemotherapy with gemcitabine and nab-paclitaxel. A CT examination after neoadjuvant chemotherapy revealed the shrinkage of the tumor, and then we performed distal pancreatectomy with splenectomy and GDC resection. A histopathological examination revealed invasive PDAC and lymph node metastases; pathological staging was T1N1M0, stage III. Furthermore, PD and GDC were also histopathologically detected. The postoperative course was uneventful, and she was discharged on the postoperative day 25. She received S-1 monotherapy for 6 months, and no recurrence has been detected at 1 year after radical resection. CONCLUSIONS: We herein presented an extremely rare combined case of PD, GDC and PDAC. We successfully treated it by neoadjuvant chemotherapy and distal pancreatectomy with GDC resection, and postoperative chemotherapy.

Pure Laparoscopic Living Donor Left Lateral Sectionectomy Using Glissonean Approach and Original Bridging Technique.

BACKGROUND: Living donor liver transplantation (LDLT) is the final treatment for children with end-stage liver disease. Congenital biliary atresia (CBA) is the most common disease requiring LDLT in Japan, and a left lateral sector graft is preferably procured owing to its anatomic predictivity and identical graft volume for preschool recipients. Laparoscopic left lateral sectionectomy (L-LLS) for LDLT has been recently established; however, there is no report about the innovative technique in L-LLS. The aim of this study was to introduce our L-LLS using the Glissonean approach and bridging technique for pediatric LDLT. MATERIALS AND METHODS: From September 2017 to September 2020, 5 cases of L-LLS for pediatric LDLT because of CBA were performed and we performed L-LLS using the original technique on their donors. In this novel procedure, the left Glissonean pedicle was encircled at the parenchymal side of the Laennec capsule after mobilization of the lateral sector and visualization of the left hepatic vein. Then, we passed 2 tapes through the encircled Glissonean pedicle at the hepatic side and the duodenal side, as the caudate lobe branch is enclosed like a bridge. By virtue of this bridging technique, we encircled the caudate lobe branch alone by switching the tape, and we clipped and divided it; this technique secured an adequately long hepatic duct on the graft side to perform a hepaticojejunostomy. The left hepatic duct was divided after indocyanine green fluorescence cholangiography, and the left hepatic artery and portal vein were divided as well. Finally, the left hepatic vein was transected and procured from an extended intraumbilical incision. RESULTS: We achieved L-LLS by using the Glissonean approach and the bridging technique in the 5 donors. The median operating time and blood loss were 282 (268 to 332) minutes and 34 (25 to 75) mL, respectively. There was no conversion to hybrid or open LLS and no postoperative complications. Regarding recipient outcomes, hepatic artery thrombosis occurred on postoperative day 4 in a 5-year-old female. All grafts function well and all recipients are alive after discharge (range of observation period, 3 to 26 mo). CONCLUSIONS: We herein present standardized L-LLS using the Glissonean approach and bridging technique for pediatric LDLT. Our technique can secure a longer margin of the left hepatic duct for recipients' hepaticojejunotomy. Our results have demonstrated the advantage in pediatric LDLT, especially in patients with CBA after the Kasai procedure.

An extremely rare case who underwent total remnant pancreatectomy due to recurrent pancreatic metastasis of intraductal tubulopapillary neoplasm.

We describe a rare case of recurrent pancreatic metastasis of intraductal tubulopapillary neoplasm (ITPN). A 53-year-old woman diagnosed with an intraductal papillary mucinous neoplasm (IPMN) and a pancreatic ductal adenocarcinoma (PDAC) of the pancreatic body underwent a distal pancreatectomy. The tumor was composed of cuboidal, high-grade dysplastic cells proliferating in a tubulopapillary growth pattern without mucin production; hence, the final diagnosis was ITPN. A follow-up computed tomography scan revealed an enhanced 2 cm mass of the pancreatic head 3 years after the surgery. From workup investigations, the patient was diagnosed with PDAC or a recurrent ITPN of the remnant pancreas. A total remnant pancreatectomy was then performed. Histopathological findings revealed that the new ITPN had the same features as the prior ITPN. In IPMNs, the presence of an invasive component and high-grade dysplasia can lead to progression to a recurring IPMN and the development of PDAC. Because there have been few reports of recurrent ITPN developing into PDAC, the risk factors for ITPN have not been investigated. Because of the uncertain clinicopathological characteristics of ITPN, more data should be gathered to assess the long-term outcome and malignant potential of ITPN.

A Rare Case of Intraductal Tubulopapillary Neoplasm of the Pancreas Rupturing and Causing Acute Peritonitis.

An intraductal tubulopapillary neoplasm (ITPN) is a very rare pancreatic tumor. Here we report an extremely rare case of an ITPN rupturing and causing acute peritonitis. A 50-year-old woman presented with left flank pain and vomiting. A computed tomography (CT) scan revealed gigantic multilocular cysts in the pancreatic tail and massive fluid collection in the abdominal cavity. The serum, urine, and abdominal fluid amylase levels were highly elevated, so she was conservatively treated with intraperitoneal drainage and antibiotics for a diagnosis of ruptured pancreatic cysts. After this patient recovered, a CT scan revealed a 2-cm low-density mass located in the body of the pancreas. This was diagnosed as a pancreatic ductal adenocarcinoma of the pancreatic body with an intraductal papillary mucinous neoplasm, and a distal pancreatectomy was performed. The tumor was composed of cuboidal high-grade dysplastic cells proliferating in a tubulopapillary growth pattern without mucin production. An immunohistochemical examination revealed that the tumor cells were positive for MUC1 and CK7, but negative for MUC5AC. These features led to the final diagnosis of ITPN. In this case, the solid ITPN growth obstructed the lumen of the main pancreatic duct, and the intraductal pressure of the distal side rose gradually. Then, pancreatic cysts formed and burst into the abdominal cavity when the intraductal pressure was at its maximum. However, an ITPN consists of high-grade atypical cells derived from the pancreatic ductal epithelium in principle, so the rupture may be an independent risk factor for peritonitis carcinomatosa in the future.

A novel model for prediction of pure laparoscopic liver resection surgical difficulty.

BACKGROUND: Extending the clinical indications for laparoscopic liver resection (LLR) should be carefully considered based on a surgeon's experience and skill. However, objective indexes to help surgeons assess the estimated difficulty of LLR are scarce. The aim of our study was to develop the first objective numerical rating scale to predict the surgical difficulty of various LLR procedures. METHODS: We performed a retrospective review of the operative outcomes of 187 patients who underwent a pure LLR. First, the value of preoperative factors for predicting surgical time was evaluated by multivariate linear regression analyses, and a scoring system was constructed. Next, the integrity of our predictive linear model was evaluated against the documented operative outcomes for patients forming our study group. RESULTS: Four predictive factors were identified and scored based on the weighted contribution of each factor predicting surgical time: extent of resection (scored 0, 2, or 3); location of tumor (scored 0, 1, or 2); obesity (scored 0 or 1); and platelet count (scored 0 or 1). The scores were summed to classify surgical difficulty into three levels: low (total score ≤1); medium (total score 2-3); and high (total score ≥4). Operative outcomes, including surgical time, volume of blood loss, length of hospital stay, and rate of morbidity, were significantly different between the three surgical difficulty levels. CONCLUSION: Our novel model will be useful for surgeons to predict the difficulty of an LLR procedure relative to their own experience and skill.

The First Comparative Study of the Perioperative Outcomes Between Pure Laparoscopic Donor Hepatectomy and Laparoscopy-Assisted Donor Hepatectomy in a Single Institution.

BACKGROUND: In a statement from the second International Consensus Conference for Laparoscopic Liver Resection, adult-to-adult laparoscopic donor surgery was the earliest phase of development. It was recommended that the procedure be performed under institutional ethical approval and a reporting registry. METHOD: At our institute, we started laparoscopy-assisted donor hepatectomy (LADH) in 2007 and changed to pure laparoscopic donor hepatectomy (PLDH) in 2012. This study included 40 living donors who underwent LADH and 14 live donors who underwent PLDH. We describe the technical aspects and outcomes of our donor hepatectomy from assist to pure and examine the liver allograft outcomes of the recipients after LADH and PLDH. RESULTS: There was significantly less blood loss in the PLDH group (81.07 ± 52.78 g) than that in the LADH group (238.50 ± 177.05 g), although the operative time was significantly longer in the PLDH group (454.93 ± 85.60 minutes) than in the LADH group (380.40 ± 44.08 minutes). And there were no significant differences in postoperative complication rate in the 2 groups. The liver allograft outcomes were acceptable and comparable with open living donor hepatectomy. CONCLUSIONS: By changing our routine approach from assist to pure, PLDH can be performed safely, with better exposure due to magnification, and with less blood loss under pneumoperitoneal pressure. PLDH, which has become our promising donor procedure, results in less blood loss, better cosmesis, and the donor's complete rehabilitation without deterioration in donor safety.

Safely extending the indications of laparoscopic liver resection: When should we start laparoscopic major hepatectomy?

BACKGROUND: Laparoscopic major hepatectomy (LMH) is an innovative procedure that is still in the exploration phase. Although new surgical techniques have learning curves, safety should be maintained from the onset. This retrospective study was conducted to evaluate the safe introduction of LMH. METHODS: We retrospectively reviewed data from 245 consecutive patients who underwent pure laparoscopic liver resection. Patients were divided into three groups: Phase I, the first 64 cases, all minor hepatectomies; Phase II, cases from the first LMH case to the midmost of the LMH cases (n = 69, including 22 LMHs); Phase III, the most recent 112 cases, including 22 LMHs. Patient characteristics and surgical results were evaluated, and the learning curve was analysed with the cumulative sum (CUSUM) method. RESULTS: The first LMH was adopted after sufficient preparatory experience was gained from performing 64 minor hepatectomies. In cases of LMH, there were no significant differences in the surgical time between Phases II and III (356 vs. 309 min; P = 0.318), morbidity rate (22.7 vs. 31.8 %; P = 0.736), or major morbidity rate (18.2 vs. 9.1 %; P = 0.664); however, estimated blood loss was significantly reduced from Phase II to Phase III (236 vs. 68 mL; P = 0.018). The CUSUM for morbidity also showed similar outcomes through Phases II and III. CONCLUSION: There is a learning curve associated with laparoscopic liver resection. To maintain a low morbidity rate, 60 laparoscopic minor hepatectomies could provide adequate experience before the adoption of LMH.

Laparoscopic liver resection for hepatocellular carcinoma with cirrhosis in a single institution.

BACKGROUND: In a statement by the second International Consensus Conference for Laparoscopic Liver Resection (LLR), minor LLR was confirmed to be a standard surgical practice, as it has become adopted by an increasing proportion of surgeons. However, it is unclear whether this applies to the more complex group of patients suffering from cirrhosis. Therefore, the aim of this retrospective study was to compare the feasibility and safety of LLR for hepatocellular carcinoma (HCC) between non-liver cirrhosis (NLC) patients and liver cirrhosis (LC) patients at a single high-volume laparoscopy center. METHODS: From the beginning of 2000 to the end of 2013, open liver resection (OLR) was performed in 99 HCC patients, and LLR was in 118. The HCC patients who underwent LLR were divided into NLC-LLR (n=60) and LC-LLR (n=58) groups, and we compare the short-term outcomes between them. RESULTS: There was no significant difference in the incidence of blood loss and transfusion requirements between the NLC-LLR group and the LC-LLR group, although wedge resection was mainly performed in the LC-LLR group. There was no significant difference in the complication rate between the two groups, and the remarkable finding was that there was a significantly lower incidence of postoperative ascites in the LC-LLR group than in the NLC-LLR group. CONCLUSIONS: According to our experience, it appears that LLR for selected HCC patients with cirrhosis is a feasible and promising procedure that is associated with less blood loss and fewer postoperative complications, especially the incidence of postoperative ascites. Further investigations are clearly warranted.

Efficacy of occlusion of hepatic artery and risk of carbon dioxide gas embolism during laparoscopic hepatectomy in a pig model.

BACKGROUND: The important point in safely performing laparoscopic hepatectomy (LH) is to control bleeding. The aims of this study were: (i) to assess the bleeding reduction effect by occlusion of the hepatic artery in LH; and (ii) to evaluate the risk of carbon dioxide (CO2 ) gas embolism (GE) in the case of high pneumoperitoneum (PP). METHODS: Nine piglets underwent laparoscopic left medial lobe and left lateral lobe resection, receiving either occlusion of the hepatic artery (hepatic artery clamping group: HACG, n = 9) or no occlusion (hepatic artery declamping group: HADCG, n = 9) using a PP of 15 mmHg. In addition, we observed changes in hemodynamics induced by PP. The state of GE was observed using transesophageal echocardiography (TEE) during LH (n = 8). GE was graded as grade 0 (none), grade 1 (minor), and grade 2 (major). RESULTS: The HACG had significantly less bleeding compared to the HADCG (P < 0.01). During LH, four animals showed grade 1 (37.5%) and one animal showed grade 2 (12.5%) GE at 15 mmHg. At 20 mmHg, all animals showed grade 2 (100%) GE. CONCLUSION: The occlusion of the hepatic artery in LH reduces blood loss. The control of bleeding from the hepatic vein is feasible with a high PP, but there is a possibility of GE.

[Photodynamic diagnosis and preoperative chemotherapy for biliary tract cancer].

BACKGROUND: Cancer cells synthesize substantial amounts of protoporphyrin IX( PPIX) from aminolevulinic acid( ALA). PPIX emits red fluorescence when illuminated under blue light. Photodynamic diagnosis (PDD), based on this phenomenon, is currently used; however, various microorganisms also show the same fluorescence with ALA when illuminated under blue light, resulting in false-positive PDD results. PURPOSE AND METHODS: To avoid misdiagnosis, we incorporated novel systems into the PDD system. ALA, blue light (wavelength, 380-450 nm), different kinds of cell lines, and bacteria were used in this in vitro study. We used a 70% deacetylated chitosan solution (DAC-70 Sol), developed in-house, as an antibacterial agent and prepared ALA/DAC-70 Sol, used as a novel photoimaging agent. The antibacterial function of ALA/DAC-70 Sol was examined in vitro, and the photodiagnostic effects on using the novel systems were clinically evaluated using bile from patients with biliary tract cancer. RESULTS: DAC-70 Sol demonstrated an effective bactericidal function in vitro. Red fluorescence could clearly be identified, enabling the detection of cancer cells in the bile using ALA/DAC-70 Sol. CONCLUSIONS: Our novel systems have a great potential for use in clinical photodynamic cytodiagnosis( PDCD), which plays an important role in preoperative cancer chemotherapy.