Benefit of lymph node dissection for perihilar and distal cholangiocarcinoma according to lymph node stations.

BACKGROUND: The benefits of lymph node (LN) dissection at each station have not previously been fully investigated in perihilar cholangiocarcinoma (PHCC) and distal cholangiocarcinoma (DCC). METHODS: The efficacy index (EI) was calculated in patients who underwent surgery for PHCC (n = 134) and DCC (n = 135) by multiplying the frequency of metastasis to the LN station and the 5-year overall survival (OS) rate of patients with metastasis to that station. RESULTS: In PHCC, the frequency of metastasis, 5-year OS rates, and the EI in para-aortic LNs (4.7%, 0%, and 0, respectively) and posterior pancreaticoduodenal LNs (8.1%, 0%, and 0, respectively) were lower than those in hepatoduodenal ligament LNs (30.1%, 24.1%, and 7.25, respectively) and LNs along the common hepatic artery (CHA) (16.2%, 15.0%, and 2.43, respectively). In DCC, these values were lower in LNs along the CHA (6.4%, 0%, and 0, respectively) than in the posterior pancreaticoduodenal LNs (31.2%, 34.5%, and 10.8, respectively), the hepatoduodenal ligament LNs (14.8%, 15.2%, and 2.25, respectively), and para-aortic (4.0%, 25.0%, and 0.99, respectively) LNs. CONCLUSIONS: According to the EI, this study raises concerns about the effectiveness of dissection in the posterior pancreaticoduodenal LNs in PHCC and LNs along the CHA in DCC.

Morbidity after left trisectionectomy for hepato-biliary malignancies: An analysis of the National Clinical Database of Japan.

BACKGROUND: The aim of this study was to analyze the nationwide surgical outcome of a left trisectionectomy (LT) and to identify the perioperative risk factors associated with its morbidity. METHODS: Cases of LT for hepato-biliary malignancies registered at the Japanese National Clinical Database between 2013 and 2019 were retrospectively reviewed. Statistical analyses were performed to identify the perioperative risk factors associated with a morbidity of Clavien-Dindo classification (CD) ≥III. RESULTS: Left trisectionectomy was performed on 473 and 238 cases of biliary and nonbiliary cancers, respectively. Morbidity of CD ≥III and V occurred in 45% and 5% of cases with biliary cancer, respectively, compared with 26% and 2% of cases with nonbiliary cancer, respectively. In multivariable analyses, biliary cancer was significantly associated with a morbidity of CD ≥III (odds ratio, 1.87; p = .018). In subgroup analyses for biliary cancer, classification of American Society of Anesthesiologists physical status (ASA-PS) 2, portal vein resection (PVR), and intraoperative blood loss ≥30 mL/kg were significantly associated with a morbidity of CD ≥III. CONCLUSIONS: Biliary cancer induces severe morbidity after LT. The ASA-PS classification, PVR, and intraoperative blood loss indicate severe morbidity after LT for biliary cancer.

Portal vein thrombosis after right hepatectomy: impact of portal vein resection and morphological changes of the portal vein.

BACKGROUND: Right hepatectomy occasionally requires portal vein resection (PVR) and causes postoperative portal vein thrombosis (PVT). METHODS: A total of 247 patients who underwent right hepatectomy were evaluated using a three-dimensional analyzer to identify the morphologic changes in the portal vein (PV). The patients' characteristics were compared between the PVR group (n = 73) and non-PVR group (n = 174), and risk factors for PVT were investigated. The PVR group were subdivided into the wedge resection (WR) group (n = 38) and segmental resection (SR) group (n= 35). RESULTS: Postoperative PVT occurred in 20 patients (8.1%). Multivariate analyses in all patients revealed that postoperative left PV diameter/main PV diameter (L/M ratio) <0.56 (odds ratio [OR] 4.00, p = 0.009) and PVR (OR 3.31, p = 0.031) were significant risk factors for PVT. In 73 patients who underwent PVR, PVT occurred in 14 (19%) and WR (OR 11.5, p = 0.005) and L/M ratio <0.56 (OR 5.51, p = 0.016) were significant risk factors for PVT. CONCLUSION: PVR was one of the significant risk factors for PVT after right hepatectomy. SR rather than WR may be recommended for preventing PVT.

Systemic immune-inflammation index as a prognostic marker for distal cholangiocarcinoma.

PURPOSE: The systemic immune-inflammation index (SII) is a new marker, defined as the platelet count × neutrophil-to-lymphocyte ratio. This study evaluates the SII as a prognostic marker for the overall survival (OS) of patients who underwent pancreatoduodenectomy (PD) for distal cholangiocarcinoma (DCC). METHODS: One hundred and forty patients who underwent PD for DCC between September, 2002 and December, 2015 at our hospital were divided into a low SII (SII < 1450) group and a high SII (SII ≥ 1450) group. We compared the clinicopathological characteristics and OS of the two groups retrospectively and used multivariate analyses to identify the prognostic factors for OS. RESULTS: The low and high SII groups comprised 119 and 21 patients, respectively. OS was better in the low SII group than in the high SII group, with median survival times of 81 and 26 months, respectively (p < 0.001). Multivariate analyses revealed that portal vein resection (hazard ratio [HR], 9.58; p < 0.001), SII ≥ 1450 (HR, 2.05; p = 0.041), microscopic venous invasion (HR, 2.04; p = 0.005), and pN1 (HR, 1.73; p = 0.034) were independently associated with poor survival. CONCLUSION: The SII may be useful for predicting the long-term survival of patients with DCC after PD.

The impact of standardized methods of hepatic vein reconstruction with an external iliac vein graft.

BACKGROUND: Liver tumors that invade the hepatic vein are surgically challenging, especially in patients with liver dysfunction. Preservation of as much of the parenchyma as possible is important; thus, when feasible, we perform hepatectomy with hepatic vein reconstruction (HVR) using an external iliac vein (EIV) graft. We conducted a retrospective study to investigate the benefit of HVR and to evaluate our procedure. METHODS: The study included patients treated by hepatectomy with HVR using EIV grafts and vascular clips. We reviewed the surgical outcomes, including total operation and HVR times, postoperative complications, and postoperative liver function. RESULTS: The surgeries included right HVR (n=13), left HVR (n=3), and middle HVR (n=1). The total operation time was 277±72 minutes (155-400 minutes), and the HVR time was 27±5 minutes (19-40 minutes). Graft patency was confirmed in 14 (82%) of the patients. One patient who underwent HVR with running sutures required emergency surgery due to graft thrombosis. Clavien-Dindo > grade IIIa postoperative complications occurred in 4 (23.5%) patients, but there were no treatment-related deaths. CONCLUSIONS: In conclusion, our hepatic resections with HVR using the same techniques and graft materials showed acceptable surgical outcomes. From our experience, we believe that preparatory hepatic resection with HVR is an effective treatment, especially for patients with decreased liver function or with a small residual liver parenchyma.

The preoperative controlling nutritional status (CONUT) score is an independent prognostic marker for pancreatic ductal adenocarcinoma.

The controlling nutritional status (CONUT) score was developed as a nutritional score that can be calculated from the serum albumin level, total cholesterol concentration, and total lymphocyte count. The aim of this study was to assess the prognostic factors for the overall survival (OS) of pancreatic cancer patients following a curative resection and to compare the CONUT score with other prognostic factors to demonstrate its utility. Between January 2007 and December 2015, 307 consecutive patients who underwent surgery for pancreatic ductal adenocarcinoma (PDAC) were divided into a low CONUT group (LC; CONUT score ≤ 3) and a high CONUT group (HC; CONUT score ≥ 4) according to the results of their preoperative blood examination. The clinicopathological characteristics and prognosis of the patients were evaluated retrospectively. The prognostic factors of PDAC were detected using multivariate analyses. The LC and HC groups included 279 and 28 patients, respectively. The overall survival of the LC group was better than that of the HC group (LC, median survival time [MST] 27.9 months, 5-year survival rate 33.4%, respectively; HC, 13.9 months, 6.7%, p < 0.001). The multivariate analyses showed that age ≥ 70 years, lymph node metastasis, absence of postoperative adjuvant chemotherapy, CA19-9 ≥ 200 U/ml, and a preoperative CONUT score ≥ 4 were independently associated with poor survival. However, the Glasgow prognostic score, neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and prognostic nutritional index were not significant factors. The CONUT score may be useful for predicting the long-term survival of patients with PDAC.

Analysis of right-sided ligamentum teres: The novel anatomical findings and classification.

BACKGROUND: The true anatomy of right-sided ligamentum teres (RSLT) has not been fully explained for a century. This study aimed to clarify the exact anatomy of RSLT. METHODS: The computed tomography data of 17 651 surgical patients were observed and 76 patients with RSLT, were classified into the bilateral ligamentum teres (LT) group (type A) and three RSLT groups, (B) bifurcation type, (C) trifurcation type, and (D) independent posterior branch type. RESULTS: Type A had double LT that connected to both the right and left sides of the umbilical portion (UP). Types B-D had a P3 + 4 rather than a left UP. Type D was anatomically different from types A-C. Upon comparing types A-C and type D, type D had a significantly smaller volume of segments 3 + 4 (P < .001), and the UP was more often on the left side. The position of the gallbladder fundus in type D was more commonly observed on the right side of the LT compared with that observed in the other types (P = .007). CONCLUSIONS: The change in the volume of segments 3 + 4 and the extent of the RSLT shift create a false perception that the gallbladder changes the position.

Description of the Vascular Anatomy of Livers with Absence of the Portal Bifurcation.

BACKGROUND: The absence of the portal bifurcation (APB) is a rare anatomic variation, in which the horizontal part of the left portal vein (PV) is missing. The aim of this study was to identify the vascular architecture in livers with APB. METHODS: Computed tomography data for 17,651 patients were reviewed; five patients (0.03%) were found to present with APB. The liver volume and anatomy of APB patients were compared with those of 30 patients with normal livers. RESULTS: All the APB patients exhibited an independent posterior branch of the PV. The intrahepatic left PV (LPV) ran through either the ventral (n = 2, 40%) or dorsal side (n = 3, 60%) of the middle hepatic vein. The frequency of medial branches diverging from the LPV was higher in patients with APB than in normal patients (p < 0.001). The left hepatic duct (LHD) ran through the inside of the left lobe along the left PV in 40% of the patients with APB, whereas in the remaining 60% of the patients with APB, the LHD ran on the outside of the liver separately from the left PV and joined the right hepatic duct. The liver volume of the left lateral section was significantly smaller (p = 0.014), and the posterior section was significantly larger (p = 0.014) in patients with APB than in patients with normal livers. CONCLUSION: The unique anatomical characteristics and the positional relation of the vessels should be considered preoperatively in patients with APB.

Use of preoperative controlling nutritional status (CONUT) score as a better prognostic marker for distal cholangiocarcinoma after pancreatoduodenectomy.

PURPOSE: The controlling nutritional status (CONUT) score can be easily calculated from the serum albumin concentration, total cholesterol concentration, and total lymphocyte count. The study aim was to assess the preoperative prognostic factors for the overall survival (OS) of distal cholangiocarcinoma (DCC) following pancreatoduodenectomy (PD) and to demonstrate the utility of the CONUT score. METHODS: A total of 149 consecutive patients who underwent PD for DCC between September 2002 and December 2016 were divided into a low-CONUT (LC) group (CONUT scores ≤ 2) and a high-CONUT (HC) group (CONUT scores ≥ 3). The clinicopathological characteristics and OS of the patients were evaluated retrospectively. Prognostic factors of DCC were identified by multivariate analyses. RESULTS: The LC and HC groups included 113 and 36 patients, respectively. The OS was better in the LC group than in the HC group (median survival time and 5 year survival rate: 82 months and 56.8% vs. 38 months and 27.6%, P = 0.005). Multivariate analyses for the OS in all patients showed that the tumor differentiation, perineural invasion, residual tumor status, portal vein resection, blood transfusion, and preoperative CONUT score ≥ 3 were independently associated with a poor survival. CONCLUSION: The CONUT score may be a useful preoperative factor for predicting the long-term survival in patients with DCC.

Laparoscopic repeat liver resection for hepatic epithelioid hemangioendothelioma.

BACKGROUND: Optimal treatment for patients with hepatic epithelioid hemangioendothelioma (HEHE) remains unclear. Laparoscopic repeat liver resection (LR) is a minimally invasive and potentially effective surgical option for multiple HEHEs. CASE PRESENTATION: A 42-year-old woman with no relevant history was admitted for multiple liver tumors. Six tumors were observed on T2-weighted magnetic resonance imaging (MRI) including one in S2, two in S3, two in S7, and one in S8. Pathological evaluation of percutaneous tumor biopsy tissue suggested a diagnosis of HEHE and laparoscopic LR was planned. The procedure began with partial resection of S7 and partial resection of S8 and left lateral sectionectomy were performed. Another tumor was found intraoperatively on the surface of S6, necessitating removal by partial resection. Pathological evaluation of the resected tumor tissue from all seven tumors concurred with that of the preoperative biopsy. The patient was discharged on postoperative day 6 without any complications. A follow-up MRI 15 months after the primary surgery revealed one tumor each in S4, S6, and S8. Laparoscopic repeat LR was performed. The patient was discharged on postoperative day 5 without any complications. All three recurrent tumors were pathologically confirmed as HEHEs. CONCLUSIONS: We successfully treated primary and recurrent HEHEs with laparoscopic LR, which is a reasonable minimally invasive procedure considering the possibility of multiple courses of liver surgery in patients with HEHE.

Oncological benefit of metformin in patients with pancreatic ductal adenocarcinoma and comorbid diabetes mellitus.

PURPOSE: Some clinical studies have suggested that metformin improved prognoses in several cancers. This study aimed to identify prognostic factors for pancreatic ductal adenocarcinoma (PDAC) and determine the utility of metformin administration. METHODS: Between January 2007 and December 2015, 373 consecutive patients underwent curative surgery for PDAC. Among the patients, 121 were diagnosed as having diabetes mellitus (DM) before surgery. The characteristics and overall survival (OS) between patients with and without DM were compared retrospectively. Based on their metformin intake, patients with DM were divided into two groups. OS rates between patients with and without metformin intake were compared. Univariate and multivariate analyses were performed to identify prognostic factors for OS among all patients and those with PDAC and DM. RESULTS: No significant differences in the 5-year survival rates between patients with and without DM were observed. Among the 121 patients with DM, 18 received metformin and 103 did not (other medications group). The 5-year survival rate was significantly better in the metformin group than in the other medications group (66.7% and 24.4%, respectively; p = 0.034). Multivariate analysis identified pN1 (p = 0.002), metformin administration (p = 0.022), and microvascular invasion (p = 0.023) as independent prognostic factors for OS in the patients with DM. Matched-pair analysis showed that OS tended to be better in the metformin group than in the other medications group (p = 0.067). CONCLUSIONS: History of metformin intake may contribute to favorable prognosis in patients with PDAC and pre-existing DM.

A case of perihilar cholangiocarcinoma with bilateral ligamentum teres hepatis treated with hepatopancreatoduodenectomy.

BACKGROUND: Bilateral ligamentum teres (BLT) hepatis is a very rare anomaly defined as the connection of the bilateral fetal umbilical veins to both sides of the paramedian trunk, and it has never been reported in the English literature. CASE PRESENTATION: A 72-year-old man who presented with obstructive jaundice was referred to our hospital. Contrast-enhanced computed tomography revealed that the patient had right-sided ligamentum teres (RSLT) and left-sided ligamentum teres (LSLT). The umbilical portion of the left portal vein, which the LSLT connected, became relatively atrophic in this patient. The RSLT attached to the tip of the right anterior pedicle and formed the umbilical portion of the right portal vein. The patient was diagnosed with perihilar cholangiocarcinoma which had invaded the root of the posterior branch of the bile duct, LHD, and intrapancreatic bile duct. The central bisectionectomy, in which the liver parenchyma was resected along the RHV on the right side and the LSLT on the left side, and caudate lobectomy combined with pancreatoduodenectomy were performed. The presence of the patient with BLT is important for ascertaining the mechanism of the development of RSLT. Two umbilical veins are present initially during the embryonic stage. In general, the right-sided vein disappears, and the atrophic left-sided vein remains connected to the left portal vein originating from the vitelline vein. Several papers on the mechanism of the development of RSLT have been published. Some authors have mentioned that a residue of the right umbilical vein and the disappearance of the left umbilical vein are the causes of RSLT. On the other hand, some authors have asserted that RSLT is the result of atrophy of the medial liver area. The presence of BLT in patients indicates that the mechanism of the development of RSLT is characterized by a residue of the right umbilical vein and the disappearance of the left umbilical vein. CONCLUSIONS: The mechanism and origin of RSLT can be understood through cases of BLT, and surgeons must pay attention to anomalies of the portal and hepatic veins in patients with abnormal ligamentum teres.

Intraductal papillary neoplasm of the bile duct accompanied by hepatogastric fistula.

Highlight Terasaki and colleagues present images of a rare case of intraductal papillary neoplasm of the bile duct with associated hepatogastric fistula treated with left hepatectomy combined with distal gastrectomy. Laparotomy showed a markedly dilated B3 on the liver surface which continued to the lesser curvature of the stomach.

Laparoscopic left lateral sectionectomy for a patient with right-sided ligamentum teres.

BACKGROUND: A right-sided ligamentum teres (RSLT) is a rare congenital anomaly in which the fetal umbilical vein is connected to the right paramedian trunk. RSLT creates difficulty in liver resection with respect to decision-making regarding the resection line, deviation of the vasculobiliary architecture. We report a case in which laparoscopic left lateral sectionectomy (LLLS) was performed to treat colorectal liver metastasis (CRLM) in a patient with RSLT. CASE PRESENTATION: A 63-year-old man with a past history of rectal cancer presented to our institution due to liver metastasis in the left lateral section from rectal cancer. In this patient, an RSLT was diagnosed and LLLS was planned. The lateral superior branch of the portal vein (P2) branched off behind the bifurcation of the portal vein and running separately from the common branch of the lateral inferior branch (P3) and left paramedian branch (P4) so that stapling could not be performed for liver resection. Frequent intraoperative ultrasonography (IOUS) was necessary to identify the root of P2 and P3. The resection line was distant from the falciform ligament and was carefully decided. The lateral superior branch of Glisson (G2) and lateral inferior branch of Glisson (G3) were separately resected. The patient had a favorable clinical course without any complications. CONCLUSIONS: The resection line of LLLS, which is distant from the falciform ligament, should be carefully identified using IOUS due to the deviation of the umbilical portion and falciform ligament. The recognition of portal vein and hepatic vein anomalies and clear identification of the lateral sectional branches are important to complete LLLS in patients with an RSLT.

Comparison of end-to-end anastomosis and interposition graft during pancreatoduodenectomy with portal vein reconstruction for pancreatic ductal adenocarcinoma.

PURPOSE: Many studies report that pancreatoduodenectomy (PD) with portal-superior mesenteric vein resection and reconstruction (PVR) is not a contraindication to extended tumor resection for pancreatic ductal adenocarcinoma. However, the clinical benefit of an interposition graft for PVR still remains controversial. METHODS: Between January 2001 and December 2017, 199 patients with pancreatic cancer underwent PD either with or without PVR, and their medical records were reviewed retrospectively, paying specific attention to the PVR methods and the long-term outcome. RESULTS: Among the 122 patients with PVR, 97 (79.5%) underwent end-to-end anastomosis and 25 (20.5%) had an interposition graft using the right external iliac vein (REIV). The 2-year and 5-year survival rates of the no-PVR group (54.2% and 30.8%, respectively) were longer than both the end-to-end anastomosis group (24.5% and 13.7%) and the interposition graft group (32% and 10.0%) (p < 0.001). However, there was no significant difference in the survival between the end-to-end anastomosis group and the interposition graft group (p = 0.963). A multivariate analysis indicated that the level of preoperative serum albumin < 3.5 g/dL (risk ratio (RR) 2.08, 95% confidence interval (CI) 1.26 to 3.43; p = 0.004), and postoperative adjuvant chemotherapy (RR 1.82, 95% CI 1.19 to 2.79; p = 0.006) were independently associated with overall survival after PVR. CONCLUSIONS: An interposition graft using the REIV for PVR following PD is safe and effective. There was no significant prognostic difference between PD with end-to-end anastomosis and with an interposition graft in patients with pancreatic ductal adenocarcinoma.