Percutaneous transhepatic gallbladder drainage versus endoscopic gallbladder stenting for managing acute cholecystitis until laparoscopic cholecystectomy.

INTRODUCTION: Gallbladder drainage by methods such as percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic gallbladder stenting (EGBS) is important in the early management of moderate to severe acute cholecystitis. METHODS: In patients undergoing laparoscopic cholecystectomy (LC) for acute cholecystitis after a month or more of gallbladder drainage, the clinical course was compared between patients initially treated with PTGBD or EGBS. RESULTS: Among 331 patients undergoing LC for cholecystitis between 2018 and 2022, 43 first underwent 1 or more months of gallbladder drainage. The median interval between drainage initiation and LC was 89 days (range, 28-261) among 34 patients with PTGBD and 70 days (range, 62-188) among nine with EGBS (p = 0.644). During this waiting period, PTGBD was clamped in six patients and removed in five. Cholecystitis relapsed in three PTGBD patients (9%) and four EGBS patients (44%; p = 0.026). Relapses were managed with medications. Cholecystectomy duration (p = 0.022), intraoperative blood loss (p = 0.026), frequency of abdominal drain insertion (p = 0.023), and resort to bailout surgery such as fundus-first approaches (p = 0.030) were significantly greater in patients with EGBS. Postoperative complications were somewhat likelier (p = 0.095) and postoperative hospital stays were longer (p = 0.007) in the EGBS group. CONCLUSION: Among patients whose LC was performed 1 or more months after initiation of drainage, daily living during the waiting period associated with drainage was well supported by EGBS, but LC and the postoperative course were more complicated than in PTGBD patients.

Full-Circumference Prosthetic Grafts for Replacing a Retrohepatic Inferior Vena Cava Segment During Hepatectomy for Tumor.

BACKGROUND: Although hepatectomy including inferior vena cava (IVC) resection is becoming more common, some details remain uncertain such as use of artificial materials to replace a tumor-involved, damaged, or narrowed retrohepatic IVC segment. METHODS: Surgical outcomes of 12 patients who underwent hepatectomy with IVC resection including reconstruction using synthetic tubular grafts were investigated to clarify safety and feasibility. RESULTS: Operative time (median, 573 min; range, 268 to 774) and the blood loss (1076 mL; 155 to 2960) were acceptable. In-hospital mortality was 8% (1/12), and morbidity was 42% (5/12). Among the 12 patients, 2 were planned to undergo IVC reconstruction without an artificial graft. In one patient, prosthetic repair was adopted because of massive bleeding from the IVC wall during dissection of tumor from the IVC. In the other, severe stricture became evident during attempted direct closure of the partially resected IVC wall. DISCUSSION: Ongoing experience has increased our acceptance of combined liver and IVC resection. We believe that segmental IVC resection and reconstruction with a prosthetic tubular graft could be chosen more frequently in managing liver tumors suspected to involve the IVC.

Prognostic implications of histologic growth patterns and tumor-infiltrating macrophages in colorectal liver metastases.

PURPOSE: Histopathologic patterns at the invasion fronts of tumors predict metastatic potential and prognosis in several cancers. We examined whether such patterns at the interface between colorectal liver metastases and hepatic parenchyma have similar prognostic value. METHODS: Microscopic growth patterns at edges of metastases including desmoplasia, pushing borders, and replacement of hepatocytes were retrospectively analyzed with respect to surgical outcomes in 142 patients who underwent hepatectomy for colorectal metastases. RESULTS: Patterns included desmoplasia in 58 patients (41%), hepatocyte replacement in 41 (29%), and pushing borders in 43 (30%). Maximum metastasis diameter and serum carcinoembryonic antigen concentration in patients showing desmoplastic tumor growth were lower than those in others (P < 0.05 and P < 0.01). Disease-free survival and overall survival were better in patients showing desmoplastic growth, while a non-desmoplastic tumor growth pattern showed a negative influence. More cluster of differentiation (CD) 68-positive M1 macrophages and fewer CD206-positive M2 macrophages were demonstrated at interfaces of tumors with hepatic parenchyma when desmoplasia was present, although markers for proliferative activity (MIB1 index) and metastatic potential (E-cadherin expression) appeared uninfluenced by desmoplasia. CONCLUSION: Better long-term results were associated with metastatic tumors showing desmoplastic growth patterns at invasion fronts, which may reflect local immune state in a prognostically useful manner.

Association between low preoperative skeletal muscle quality and infectious complications following gastrectomy for gastric cancer.

PURPOSE: It is known that sarcopenia affects the overall short- and long-term outcomes of patients with gastric cancer (GC); however, the effect of muscle quality on infectious complications after gastrectomy for GC remains unclear. We investigated the associations between the preoperative quantity and quality of skeletal muscle on infectious complications following gastrectomy for GC. METHODS: The subjects of this retrospective study were 353 GC patients who underwent radical gastrectomy between 2009 and 2018. We examined the relationships between their clinical factors, including skeletal muscle mass index and intramuscular adipose tissue content (IMAC), and infectious complications after gastrectomy. RESULTS: Infectious complications developed in 59 patients (16.7%). The independent risk factors for infectious complications identified by multivariate analysis were male gender (P < 0.001), prognostic nutritional index below 45 (P = 0.006), and high IMAC (P = 0.011). Patients with a high IMAC were older and had a higher body mass index, as well as a greater age-adjusted Charlson comorbidity index, than those with low or normal IMAC. CONCLUSIONS: Low skeletal muscle quality defined by a high IMAC is a risk factor for infectious complications following gastrectomy. When feasible, preoperative nutritional intervention and rehabilitation aiming to improve muscle quality could reduce infectious complications after gastrectomy for GC.

Liver regeneration after performing associating liver partition and portal vein occlusion for staged hepatectomy (ALPPS) is histologically similar to that occurring after liver transplantation using a small-for-size graft.

PURPOSE: Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) can achieve marked future liver remnant (FLR) hypertrophy but this procedure is associated with a risk of mortality due to liver failure because of an insufficient FLR functional increase, a situation comparable to small-for-size syndrome (SFSS) after living-donor liver transplantation (LDLT). METHODS: The clinical data, morphologic volume changes, and histopathologic and immunohistochemical findings in hepatocytes and bile ductules were compared between ALPPS (n = 10) and LDLT with a risk for SFSS (n = 12). RESULTS: Although the patient characteristics and short-term outcome differed between the groups, the mean hypertrophy ratios with respect to liver volume for the FLR after performing the first-stage ALPPS procedures resembled those in small-for-size grafts after similar time intervals: 1.702 ± 0.407 in ALPPS vs. 1.948 ± 0.252 in LDLT (P = 0.205). The histologic grades for sinusoidal dilation (P = 0.896), congestion (P = 0.922), vacuolar change (P = 0.964), hepatocanalicular cholestasis (P = 0.969), and ductular reaction (P = 0.728) within the FLR at the second-stage operation during ALPPS or implanted graft were all similar between the groups. CONCLUSIONS: The hepatic regenerative process may be similar in ALPPS and LDLT using a small-for-size graft. Reducing the hepatic vascular inflow that may be excessive for the FLR volume during the first stage of ALPPS might enhance the functional recovery since measures with a similar effect appear to lessen the likelihood of SFSS.

Body composition as reflected by intramuscular adipose tissue content may influence short- and long-term outcome following 2-stage liver resection for colorectal liver metastases.

INTRODUCTION: For many kinds of cancer, body composition and immunonutritional status have been reported to influence postoperative outcome. We assessed their impact on short- and long-term outcome in patients with colorectal liver metastases who underwent 2-stage liver resections. METHODS: Short- and long-term outcomes for 47 patients with 2-stage hepatectomies were assessed retrospectively in terms of data obtained before preoperative chemotherapy, before the first hepatectomy, and before the second hepatectomy. RESULTS: Although immunonutritional status and body composition did not affect short-term outcome, high intramuscular fat content before the second hepatectomy was a poor prognostic factor for overall survival (HR, 5.829; 95% CI, 1.611-21.090; p = 0.007) and for recurrence-free survival (HR, 2.787; 95% CI, 1.301-5.973; p = 0.008). Patients with high intramuscular fat before the second hepatectomy also showed shorter intervals from recurrence to treatment failure. CONCLUSION: Intramuscular fat before the second hepatectomy is an important negative prognosticator in 2-stage liver resection for colorectal liver metastases.