Ponderations around Akamon: from Chinese visiting scholars in the Department of Hepatobiliary-Pancreatic Surgery of Tokyo University Hospital / 中华消化外科杂志

It is well known that Tokyo University Hospital (TUH) is one of the most famous medical centers around the world in Japan. Among several departments in TUH, the Department of Hepatobiliary-Pancreatic Surgery and Artificial Organ and Transplantation Division are representative predominant divisions, which have high-quality diagnostic and treatment service systems being at the leading position in the world. The authors visit the Department of Hepatobiliary-Pancreatic Surgery and Artificial Organ and Transplantation Division in 2022. When studying and working in TUH, the authors make a multi-angle comparisons of the development status and technical levels of hepatobiliary and pancreatic surgery among TUH, western countries and China. It aims to share and exchange with fellow surgeons at home and abroad, and bring benefits or enlightenment to the professional advancement of them.

Difficulties and advances of incisional hernia repair after hepatobiliary and pancreatic surgery / 中华消化外科杂志

Abdominal incisional hernia is caused by poor healing of myofascial layer of abdominal wall and abdominal visceral organs protruding through the defect after abdominal surgery. The incidence of abdominal incisional hernia is 5.0%?20.0%, even higher after hepato-biliary and pancreatic surgery. Although great progress has been made in the methods of abdominal incision closure, hernia repair technology and materials, the overall incidence, repair effect and prognosis of abdominal incisional hernia are still not significantly improved. The incisional hernias after hepatobiliary and pancreatic surgery are relatively more complex, and the difficult problems of surgical repair are more prominent, including effectively controlling basic diseases, choosing a better surgical method, reasonably using a variety of abdominal wall defect closure and reconstruction techniques, and reducing the risk of postoperative complications. Relevant guidelines for abdominal incisional hernia repair and abdominal closure have been issued and updated all over the world. In order to improve the treatment of incisional hernia after hepatobiliary and pancreatic surgery and improve the prognosis of patients, the authors summarize the difficulties and new progress in the repair of incisional hernia after hepatobiliary and pancreatic surgery.

Risk factors for surgical site infection after major hepatobiliary and pancreatic surgery.

Major hepatobiliary and pancreatic (HP) surgeries are complex procedures associated with a high incidence of surgical site infection (SSI) and are commonly performed in patients with cancer in Japan. This study was performed to investigate the risk factors for SSI, including incisional and organ/space SSI, in HP surgery. The following procedures were included in the study: hepatectomy with and without biliary tract resection, pancreatectomy [pancreaticoduodenectomy (PD), others], and open cholecystectomy. In total, 735 patients were analyzed. The incidence of SSI was 17.8% (incisional, 5.2%; organ/space, 15.5%; both 2.9%). The highest incidence of SSI was observed in patients who underwent hepatectomy with biliary tract resection (39.1%), followed by pancreatectomy (PD, 28.8%; others, 29.8%). Almost all SSIs after these three procedures were classified as organ/space (39.1%, 25.0%, and 27.7%, respectively), and these procedures were risk factors for not only total SSI but also organ/space SSI in the multivariate analysis. An American Society of Anesthesiologists physical status of ≥3 was a risk factor for incisional SSI. Preoperative biliary drainage, prolonged surgery, concomitant surgery, and massive intraoperative bleeding were associated with SSI. In conclusion, the main type of SSI was organ/space SSI after HP surgery, and different risk factors were identified between organ/space and incisional SSI. Procedure-related factors and preoperative biliary drainage were independent risk factors for SSI. To prevent SSI, the indication for preoperative biliary drainage should be carefully evaluated in patients undergoing HP surgery.

Epidemiology and risk factors associated with surgical site infection after different types of hepatobiliary and pancreatic surgery.

PURPOSE: Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs); however, SSI after hepatobiliary and pancreatic surgery (HBPS) has not been well investigated in a large cohort of patients. This study analyzed the factors associated with SSI following HBPS in Japan, using a Japanese national database. METHODS: Data on HBPS performed between 2012 and 2014 were extracted from a national monitoring system for HAI: The Japan Nosocomial Infections Surveillance. Using multivariate logistic regression, I assessed the factors associated with SSI. RESULTS: The cumulative incidence of SSI following HBPS was 15.6% (2873/18,398). The incidence of SSI after pancreatoduodenectomy was 28.0%, which was significantly higher than that after liver resection and other types of HBPS (8.8 and 15.5%, respectively). Among the four traditional risk factors, the American Society of Anesthesiologists score was ineffective for predicting SSI in the final model of all three types of surgery. Additional risk factors were identified, including age and male gender. CONCLUSIONS: The incidence of and factors associated with SSI after the three types of HBPS analyzed differed significantly. To accurately compare hospital performance in relation to SSI following HBPS, the operative procedure category in the surveillance system must be divided into three types.

A brief analysis of hepatobiliary and pancreatic surgery in the era of precise medicine / 中华肝胆外科杂志

Hepatobiliary and pancreatic surgery in the 21st century is undergoing major changes based on the concepts of precision surgery,minimally invasive treatment,information technology,and individualized and integrated management.These changes have been brought about by new developments in electrosurgical instruments and surgical equipments,advances in medical imaging and 3D reconstruction technique,digital technology,artificial intelligence,machine vision,and regeneration medicine.All these new advances make hepatobiliary surgery in the era of precision medicine to focus on the development of precision surgery,minimally invasive treatment,repair and regenerative medicine,and individualized treatment,with the ultimate aims to improve patient survival and quality of life.

Three-dimensional imaging identified the accessory bile duct in a patient with cholangiocarcinoma.

The development of diagnostic imaging technology, such as multidetector computed tomography (MDCT) and magnetic resonance cholangiopancreatography (MRCP), has made it possible to obtain detailed images of the bile duct. Recent reports have indicated that a 3-dimensional (3D) reconstructed imaging system would be useful for understanding the liver anatomy before surgery. We have investigated a novel method that fuses MDCT and MRCP images. This novel system easily made it possible to detect the anatomical relationship between the vessels and bile duct in the portal hepatis. In this report, we describe a very rare case of extrahepatic cholangiocarcinoma associated with an accessory bile duct from the caudate lobe connecting with the intrapancreatic bile duct. We were unable to preoperatively detect this accessory bile duct using MDCT and MRCP. However, prior to the second operation, we were able to clearly visualise the injured accessory bile duct using our novel 3D imaging modality. In this report, we suggest that this imaging technique can be considered a novel and useful modality for understanding the anatomy of the portal hepatis, including the hilar bile duct.

Robot-assisted whipple's operation for solid pseudopapillary tumour of pancreas.

Solid pseudopapillary tumor is a rare tumor of the pancreas. They are slow growing with low malignant potential. The prognosis is excellent after surgical resection. Here we report a case of solid pseudopapillary tumor of the pancreas at the uncinate process. There are increasing interests about minimal access surgery for pancreatic lesion. However conventional laparoscopic Whipple's operation is technically difficult. With the benign characteristic of this tumor, as well as the advance in robotic surgery, robot assisted approach is an ideal alternative for this case. The operation was performed with a five-port approach with the use of da Vinci S Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA). The operative time was 420 min and operative blood loss was 100 ml. The post operative course was uneventful and the patient was discharged on post operative day 10. This case demonstrates the feasibility of robot assisted Whipple's operation, which has not been extensively reported in the literature.