堀口 明彦

BACKGROUND: This study aimed to investigate the effect of the use of new lithotomy stirrups-2 on the pressure dispersal on lower limbs, which may lead to the prevention of well-leg compartment syndrome (WLCS) and deep venous thrombosis (DVT), which are the most commonly associated adverse events with laparoscopic and robot-assisted rectal surgery. METHODS: A total of 30 healthy participants were included in this study. The pressure (mmHg) applied on various lower limb muscles when using conventional lithotomy stirrups-1 and new type stirrups-2 was recorded in various lithotomy positions; 1) neutral position, 2) Trendelenburg position (15°) with a 0° right inferior tilt, and 3) Trendelenburg position (15°) with a 10° right inferior tilt. Using a special sensor pad named Palm Q®, and the average values were compared between two types of stirrups. RESULTS: The use of new lithotomy stirrups-2 significantly reduced the pressure applied on the lower limb muscles in various lithotomy positions compared with the use of lithotomy stirrups-1. The most pressured lower limb muscle when using both lithotomy stirrups was the central soleus muscle, which is the most common site for the development of WLCS and DVT. In addition, when using the conventional lithotomy stirrups-1, the pressure was predominantly applied to the proximal soleus muscle; however, when using lithotomy stirrups-2, the pressure was shifted to the more distal soleus muscle. CONCLUSION: These results suggest that the new lithotomy stirrups-2 is useful in reducing the pressure load on leg muscles, especially on the proximal to central soleus, and may reduce the incidence of WLCS and DVT after rectal surgery performed in the lithotomy position. Further clinical studies are needed to determine whether the use of lithotomy stirrups-2 prevents these complications in various clinical settings.

In this review article, we focus on recent papers on organ-preserving pancreatectomy procedures published since 2010. When comparing central pancreatectomy (CP) and distal pancreatectomy (DP), most studies have concluded that the CP group exhibited significantly lower incidence of new-onset diabetes or diabetes exacerbation than the DP group postoperatively. However, because of increased incidence of morbidities such as pancreatic fistula, the surgeon faces a considerable trade-off between increased short-term morbidity and long-term preservation of endocrine function. When the outcomes of two types of spleen-preserving DP (Kimura and Warshaw procedures) are compared, most studies mentioned the low incidence of postoperative gastric varices and splenic infarction with the Kimura procedure. Although there are several reports regarding the effect of spleen preservation on prevention of postoperative infections, no report on the contribution of spleen preservation to the prevention of overwhelming post-splenectomy infection is seen. The advantages of duodenum-preserving pancreatic head resection (DPPHR) concerning endocrine and exocrine functions continue to be subjects of discussion, mainly due to the limited number of institutions that have adopted this approach; however, DPPHR should be presented as an option for patients due to its low incidence of postoperative cholangitis. Organ-preserving pancreatectomy requires meticulous surgical techniques, and postoperative complications may increase with this surgery compared with standard pancreatectomy, which may be influenced by the surgeon's skill and the surgical facility where the procedure is performed. Nonetheless, this technique has significant long-term advantages in terms of endocrine and exocrine functions and its wider adoption in the future is expected.

Purpose: The present study aimed to determine whether concomitant extrahepatic bile duct resection (EHBDR) improves the prognosis of patients with T2 gallbladder cancer (GBC). Methods: Between 2014 and 2018, 4947 patients with GBC were registered in the National Biliary Tract Cancer Registry in Japan. This included 3804 patients (76.9%) who underwent curative-intent surgical resection; 1609 of these patients had pT2 GBC with no distant metastasis. Of the 1609 patients with GBC, 520 underwent EHBDR and 1089 did not. We compared the patients' backgrounds and disease-specific survival rates between the groups. Results: The frequency of lymph node metastasis was significantly higher in the EHBDR group than in the non-EHBDR group (38.2% vs. 20.7%, p <.001). In the entire cohort, however, there was no significant difference in disease-specific survival between the two groups (76% vs. 79%, p =.410). The EHBDR group had a significantly higher incidence of postoperative complications (Clavien–Dindo classification grade = 3) (32.4% vs. 11.7%, p <.001). When we focused on the survival of only T2N1 patients who underwent gallbladder bed resection, the prognosis was significantly improved for the EHBDR group (5-year survival rate: 64% vs. 54%, p =.017). The non-EHBDR group was subcategorized into two groups: D2 dissection and D1 dissection or sampling, and survival curves were compared between these subgroups. Although the EHBDR group tended to have a favorable prognosis compared to the D2 group, this difference was not significant (p =.167). However, the EHBDR group had a significantly greater prognosis than the D1 dissection or sampling group (5 year-survival rate: 64 vs. 49%, p =.027). Conclusions: The EHBDR may improve the prognosis of patients with T2 gall bladder cancer with lymph node metastases; however, its indication should be carefully determined because of the increased risk of postoperative complications.

BACKGROUND/PURPOSE: The aim of this study was to clarify the clinical characteristics of acute cholangitis (AC) after bilioenteric anastomosis and stent-related AC in a multi-institutional retrospective study, and validate the TG18 diagnostic performance for various type of cholangitis. METHODS: We retrospectively reviewed 1079 AC patients during 2020, at 16 Tokyo Guidelines 18 (TG 18) Core Meeting institutions. Of these, the post-biliary reconstruction associated AC (PBR-AC), stent-associated AC (S-AC) and common AC (C-AC) were 228, 307, and 544, respectively. The characteristics of each AC were compared, and the TG18 diagnostic performance of each was evaluated. RESULTS: The PBR-AC group showed significantly milder biliary stasis compared to the C-AC group. Using TG18 criteria, definitive diagnosis rate in the PBR-AC group was significantly lower than that in the C-AC group (59.6% vs. 79.6%, p < .001) because of significantly lower prevalence of TG 18 imaging findings and milder bile stasis. In the S-AC group, the bile stasis was also milder, but definitive-diagnostic rate was significantly higher (95.1%) compared to the C-AC group. The incidence of transient hepatic attenuation difference (THAD) and pneumobilia were more frequent in PBR-AC than that in C-AC. The definitive-diagnostic rate of PBR-AC (59.6%-78.1%) and total cohort (79.6%-85.3%) were significantly improved when newly adding these items to TG18 diagnostic imaging findings. CONCLUSIONS: The diagnostic rate of PBR-AC using TG18 is low, but adding THAD and pneumobilia to TG imaging criteria may improve TG diagnostic performance.

局所進行切除不能膵癌に対してFOLFIRINOX+放射線療法を行った後,conversion surgeryを施行した1例について報告する。症例は70歳代,女性。食後の腹痛を主訴に近医を受診し,腹部造影CTを撮影したところ,膵鉤部に上腸間膜動脈,第1空腸動脈,第2空腸動脈浸潤(>180°)を伴う不整形腫瘤を認めた。画像上,UR-LA(sm),cT4N0M0,cStage IIIの膵癌と診断され,mFOLFIRINOX 5コース施行した。その後,局所制御を目的として,放射線療法50.4Gy(三次元原体照射)を追加した。CA19-9は394.1U/mLから10.5U/mLへ低下した。治療効果はRECIST:partial responseと判定した。この後,根治術可能と判断し,初回治療から8ヵ月後に亜全胃温存膵頭十二指腸切除術を施行した。腫瘍は3×2mm相当とごくわずかな範囲に認められ,pStage IA,R0,術前化学療法の治療効果判定はEvans Grade IIIであった。患者は術後5ヵ月無再発生存中である。(著者抄録)

S状結腸癌および多発肝転移に対して化学療法後,肝切除術を施行し病理結果で完全寛解を得たが,化学療法中止後肝局所再発を来したため再肝切除を行った1例を報告する。下腹部痛で当院救急外来を受診した。大腸内視鏡では全周性のII型腫瘍を認め生検にて高分化型腺癌と診断された。根治目的にて腹腔鏡下S状結腸切除+D3リンパ節郭清を施行した。術後CTにてS5,S7,S8に肝転移を認め,Bev+modified FOLFOX(mFOLFOX)を11サイクル施行した。肝転移はいずれの部位でも縮小し肝右葉切除術を施行した。切除標本からはviableな癌組織は認めず完全寛解と考えられた。術後Bev+mFOLFOXを6サイクル再開し寛解を維持していたが,化学療法を中止した3ヵ月後,肝切除後1年6ヵ月後のフォローアップCTにて肝断端の局所再発を認め,肝転移局所再発と診断し開腹肝部分切除を行った。患者は術後9ヵ月現在,無再発生存中でありmFOLFOXを再開している。(著者抄録)

We report a case of a woman in her 70s who underwent conversion surgery after FOLFIRINOX, followed by radiation therapy for initially locally advanced unresectable pancreatic cancer. She visited her local doctor with a chief complaint of upper abdominal pain. Contrast-enhanced CT scan of the abdomen revealed an irregular mass invading the superior mesenteric artery, and the first and second jejunal arteries(>180°)in the pancreatic uncinate region. Based on imaging, she was diagnosed as UR-LA(sm), cT4N0M0, cStage Ⅲ pancreatic cancer, and underwent 5 courses of modified FOLFIRINOX. Radiation therapy of 50.4 Gy was added for local control, and CA19-9 decreased from 394.1 U/mL to 10.5 U/mL. The treatment effect was judged as RECIST: partial response. The tumor was considered to be potentially curative, and a subtotal stomach preserving pancreaticoduodenectomy was performed 8 months after the initial treatment. The tumor was found to be 3× 2 mm in size, pStage ⅠA, R0, and the response to preoperative chemotherapy: Evans Grade Ⅲ. The patient is alive at 5 months postoperatively without recurrence.

We report a case of a patient with sigmoid colon cancer and multiple liver metastases who underwent hepatectomy after chemotherapy and pathological results showed complete remission. However, after chemotherapy was discontinued, the patient developed a local recurrence of the liver metastasis and underwent rehepatectomy. The patient came to our hospital with lower abdominal pain. Colonoscopy revealed a circumferential type Ⅱ, well-differentiated adenocarcinoma. Laparoscopic sigmoidectomy with lymph node dissection was performed. Postoperative CT scan showed multiple liver metastases at S5, S7, and S8. 11 cycles of bevacizumab plus modified FOLFOX(mFOLFOX)were subsequently performed. The liver metastases shrank at all sites, and the patient underwent right hepatectomy. The resected specimen was considered to be in complete remission, with no evidence of viable malignant cells. Postoperatively, bevacizumab plus mFOLFOX was resumed for 6 cycles and the patient remained in remission. However, 3 months after stopping chemotherapy and 1 year and 6 months after hepatectomy, a follow-up CT scan showed local recurrence of the liver edge, and a diagnosis of local recurrence of liver metastasis was made, and a partial hepatectomy was performed. The patient is recurrence-free and resuming modified FOLFOX 9 months after surgery.

59歳の男性で,左下腹部痛と発熱を認めたため当院を受診した.下腹部に限局した圧痛と筋性防御を認めたが,反跳痛は認めなかった.白血球数16,200/μl,CRP5.29mg/dlを認め,腹部CT検査ではS状結腸の壁肥厚を認め,周囲に遊離ガス像を認めた.S状結腸穿孔,限局性腹膜炎と診断し,手術を勧めたが患者の同意が得られず絶食と抗生剤による治療を行った.全身状態は改善したのちに精査を行いS状結腸癌と診断した.腹部CT検査で腫瘍は左骨盤壁への近接が予測され,麻酔導入後に蛍光尿管ステントを留置した.腹腔鏡下に手術を行い,術中所見で腫瘍は尿管に近接していたが,近赤外光で尿管を視認し,尿管への浸潤は認めなかった.しかし精管への癒着浸潤が疑われ,腹腔鏡下S状結腸切除術,精管合併切除術を行った.術前に尿管損傷を危惧する際において蛍光尿管ステントは術中に尿管の位置を把握するために有用であると考えられた.(著者抄録)

Recurrence of liver cancers after liver resection (LR), such as recurrences of hepatocellular carcinoma and colorectal liver metastases, is often treated with repeat LR (RLR) as the only curative treatment. However, RLR is associated with an increased risk of complications. The indications for the currently emerging laparoscopic LR and its advantages and disadvantages for repeat treatment are still under discussion. Our multi-institutional propensity-score matched analyses of laparoscopic vs. open RLRs for hepatocellular carcinoma showed the feasibility of laparoscopic RLR with comparable short- and long-term outcomes. Small blood loss and low morbidity was observed in selected patients treated using laparoscopic RLR in which total adhesiolysis can be dodged, with speculations that laparoscopic minor repeated LR can minimize functional deterioration of the liver. However, there are several disadvantages, such as easily occurring disorientation and difficulty in repeated wide-range dissection of Glissonian pedicles. Recently emerging small anatomical resection, indocyanine green fluorescence-guided surgery, and robot-assisted surgery are promising tools for the further development of laparoscopic RLR. This review discusses how laparoscopic RLR, as a powerful unique local therapy causing less damage to the residual liver and surrounding structures, could contribute to the outcomes of repeated treatments for cancers and its future perspectives.

INTRODUCTION: Non-technical skills are essential for surgical patient safety and are implemented in clinical practice. However, training for non-technical skills has not been thoroughly investigated. This study aimed to evaluate the learning curve for non-technical skill-based education in herniorrhaphy. METHODS: Quality improvement initiatives, including non-technical skill-based intervention, were performed in the department of surgery. The intervention included declaring the patient safety policy, briefing and debriefing, and criterion for the switching of places of the trainee and instructor as defined by the department. Patients who underwent herniorrhaphy from April 2014 to September 2017 were included. RESULTS: A total of 14 trainees and nine instructors in the pre-intervention period and 14 trainees and seven instructors in the intervention period were included in this study. The median experience of each trainee was 28 and 15 cases in the pre-intervention and intervention groups, respectively. A total of 749 patients were included: 473 in the pre-intervention period and 328 in the intervention period. Demographics and hernia types were mostly similar between groups, and morbidity was not statistically different between the two groups (3.4 vs. 1.2%, p = 0.054). The nonlinear regression model showed an early decline and deep plateau phase of the learning curve in the intervention group. A significant difference was observed in the plateau operation time (61 min in the pre-intervention group and 52 min in the intervention group). CONCLUSION: This study demonstrated the effectiveness of non-technical skill-based intervention for surgical training. An early decline and deep plateau of the learning curve can be achieved with well-implemented quality improvement initiatives. Nonetheless, further studies are needed to establish a training program for non-technical skill-based learning.

目的:肛門部扁平上皮癌(SCC)に対する化学放射線療法(CRT)の治療効果を検討した.対象と方法:CRTが施行された肛門部SCC15例を対象とし,その治療成績を後方視的に検討した.結果:全例が放射線治療を完遂しえたが,Grade 3以上の副作用を3例に認め,6例は化学療法を減量投与した.局所の治療効果は全例がCRであったが,4例(26.7%)に再発を認めた.化学療法の非減量例の再発は1例(10%)で,T2以下の非減量例では再発を認めなかった.再発部位はいずれも局所であった.再発までの期間が1年以内であった3例はいずれも化学療法の減量例であった.予後は原癌死を3例,他病死を3例に認めたが,再発手術後の1例を含む9例が無病生存中である.結語:肛門部SCCに対するCRTは安全に施行が可能で,根治が期待されるが,化学療法の減量例では早期の局所再発に配慮したフォローアップが必要と考えられた.(著者抄録)

The natural history of intracholecystic papillary neoplasm (ICPN), especially the speed of growth from small benign to a carcinomatous lesion, is quite unrevealed. Here, we report an extremely rare case of ICPN, in which the papillary lesion was observed transforming from small and benign to malignant using abdominal ultrasound (AUS) over 2 years during routine health checks. A 44-year-old man underwent a routine health check-up. The initial AUS showed a small sessile polyp in the gallbladder, which enlarged slightly at the next AUS, a year later. In the third year, the polypoid lesion enlarged markedly, with a maximum diameter of 10 × 9 × 7 mm. Therefore, a laparoscopic cholecystectomy was performed. Microscopically, the 10 mm tumor had intracytoplasmic mucus, and a clear cytoplasm compatible with gastric-type features. Immunohistochemical analysis showed positive staining of atypical cells for MUC6 and PAS. These findings led to the diagnosis of ICPN with high-grade intraepithelial neoplasia of the gastric type. In conclusion, sessile polyps with rapid growth might be a crucial finding in the early stage of ICPN.

A 49-year-old female was underwent laparoscopic right hemicolectomy for ascending colon cancer and liver metastasis. Then, she was underwent laparoscopic hepatectomy. She received BEV plus mFOLFOX6 therapy as postoperative adjuvant chemotherapy, but she had liver recurrence. She received FOLFOXIRI therapy. Although tumor tended to progressive, it was localized, so laparoscopic hepatectomy was performed again. She received AFL plus FOLFIRI therapy. Fourteen months after hepatic resection, disseminated nodules and lung metastases were found. However, both of peritoneal dissemination, and lung metastasis were localized, so it was judged that peritoneal dissemination and lung metastasis could be resectable. Then, peritoneal dissemination resection and sigmoid colectomy were performed, and then lung resection was performed to perform R0 resection. R0 resection and multimodal therapy for simultaneous and heterotopic metastases of colorectal cancer can contribute to provide a long-term prognosis.

根治度A手術が施行された下部直腸T2癌88例(T2)の治療成績をT3またはT4a癌(T3/T4a)340例,T1癌(T1)51例と比較した。T2の全リンパ節(LN)転移率,腸管傍LN転移率,中間および主LN転移率,側方LN転移率はいずれもT1と差がなかった。T2の再発率は15.9%で,T1は差がなかった。T2はT1に比べて肺再発の頻度が有意に高率であった。T2再発例の50%は術後30ヵ月以降に認められ,T3/T4aに比して有意に高率で,T1とは差がなかった。LN転移陰性T2における多変量解析で術前血清CA19-9高値が再発危険因子であった。T2の5年生存率,再発後5年生存率はT3/T4aに比べて有意に高率で,T1と差がなかった。下部直腸T2ではT1と同様なLN郭清が適当で,術前血清CA19-9高値は再発危険因子であり,術後30ヵ月以降の肺再発に配慮したフォローアップが必要と考えられた。(著者抄録)

The outcomes of 88 patients with lower rectal T2 cancer who underwent radical A surgery(T2)were compared with those of 340 patients with T3 or T4a cancer(T3/T4a)and 51 patients with T1 cancer(T1). The rates of all lymph node(LN) metastasis, paraintestinal LN metastasis, intermediate and main LN metastasis, and lateral LN metastasis in T2 were all significantly lower than in T3/T4a and not different from those in T1. The recurrence rate of T2 was 15.9%, significantly lower than that of T3/T4a and not different from that of T1. Fifty percent of T2 recurrences were observed after 30 months postoperatively, significantly higher than that of T3/T4a and not different from that of T1. The 5-year survival rate of T2 was significantly higher than that of T3/T4a and did not differ from that of T1. In lower rectal T2, cancer LN dissection similar to that in T1 is appropriate, and high preoperative serum CA19-9 level is a risk factor for recurrence, suggesting the need for follow-up after 30 months postoperatively to take recurrence into consideration.

Purpose: To establish the best treatment strategy for acute appendicitis. Methods: We collected data on 2142 appendectomies performed in 2017 and compared the backgrounds and surgical outcomes of patients who underwent early surgery (ES) (< 48 h) with those managed with non-ES (> 48 h). We performed a risk factor analysis to predict postoperative complications and subgroup analysis to propose a standard treatment strategy. Results: The incidence of postoperative complications was significantly higher in the ES group than in the non-ES group, and significantly lower in the laparoscopic surgery group than in the laparotomy group. Surgical outcomes, including the incidence of postoperative complications, were comparable after acute surgery (< 12 h) and subacute surgery (12–48 h), following antibiotic treatment. The risk factors for postoperative complications in the ES group were a higher age, history of abdominal surgery, perforation, high C-reactive protein level, histological evidence of gangrenous or perforated appendicitis, a long operation time, and intraoperative complications. The risk factors for postoperative complications in the non-ES group were perforation and unsuccessful conservative treatment. Conclusions: Non-early appendectomy is feasible for acute appendicitis but should be applied with care in patients with risk factors for postoperative complications or failure of pretreatment, including diabetes mellitus, abscess formation, and perforation.

AIM: This study aimed to compare the incidence of postoperative nonalcoholic fatty liver disease (NAFLD), postoperative cholangitis, and fibrosis-4 (FIB)-4 index in patients who underwent duodenum-preserving pancreatic head resection (DPPHR) and pancreaticoduodenectomy (PD) for low-grade malignant tumors and verify the usefulness of DPPHR in preventing the occurrence of these disorders. METHODS: This retrospective study included 70 patients who underwent PD (n = 39) and DPPHR (n = 31) between 2006 and 2018 for benign or low-grade malignant tumors. The present study compared the preoperative background, cumulative incidence of postoperative NAFLD and cholangitis, and other biochemical markers, including the FIB-4 index. Subanalysis by propensity score matching (PSM) analysis was conducted to minimize treatment selection bias. RESULTS: In terms of the cumulative incidence of NAFLD, the 5-y incidence was significantly lower in the DPPHR group than in the PD group both before (10% vs 38%, P = .002) and after (13% vs 38%, P = .008) matching. Multivariate analyses identified DPPHR as the only independent preventive factor for postoperative NAFLD (hazard ratio: 0.160, 95% confidence intervals: 0.034-0.76, P = .021). The 5-y cumulative incidence of postoperative cholangitis was significantly higher in the PD group than in the DPPHR group before (51% vs 3%, P < .001) and after (49% vs 4%, P < .001) matching. The FIB-4 index at 12 mo postoperatively was significantly better in the DPPHR group than in the PD group (1.45 vs 2.35, P = .006) before matching. CONCLUSION: Preservation of the duodenum and bile duct may contribute to preventing long-term postoperative NAFLD and cholangitis, and liver fibrosis for benign or low-grade malignant pancreatic head tumors.

Herein, we report an extremely rare case of intraductal tubulopapillary carcinoma (ITPC) that was detected due to the pancreatic duct dilatation newly appeared on CT after surgery for gallbladder cancer associated with pancreaticobiliary maljunction. Present case: a 77-year-old female. Extended cholecystectomy, extra-bile duct resection, and hepaticojejunostomy was performed and resected specimen showed that this gallbladder tumor was papillary adenocarcinoma, pT2(ss), pN0, pDM0, pHM0, pEM0. Thereafter, the follow-up CT scan 2 years after surgery detected the dilatation of main pancreatic duct (MPD) and the elevation of carcinoembryonic antigen (CEA) level was pointed out (4.9 to 5.9 ng/ml). Moreover, pancreatic juice cytology revealed adenocarcinoma cells. Thus, distal pancreatectomy was performed based on the diagnosis of pancreatic adenocarcinoma associated with pancreaticobiliary maljunction (PBM). Histologically, proliferation of highly columnar atypical cells in the dilated main pancreatic duct with marked papillary and irregular tubular structures is seen. No mucus production is observed. Based on immunohistochemistry, Mucin (MUC) 1, 2 and 5AC were focal weak positive, negative and negative, respectively. Taken together of these findings, we could diagnose this tumor with ITPC without invasive component. The patient is alive without any recurrence for 36 months after a second surgery. In conclusion, it is essential to be fully aware that PBM is a disease in which there is still a possibility that pancreatic or biliary tract cancer may occur in the future, and that careful routine follow-up for a long period after diversion surgery may lead to early detection of complicated cancers.

A 50-year-old woman was hospitalized for fainting caused by hypoglycemia. Her blood glucose level was low (40 mg/dL), immunoreactive insulin was 16.9 μU/mL, and C-peptide level was high (4.8 ng/mL). Computed tomography and magnetic resonance imaging revealed a 7-mm tumor in the uncinate process of the pancreas. A selective arterial calcium injection test indicated an increase in the superior mesenteric artery. Insulinoma of the uncinate process of the pancreas was diagnosed, and tumor enucleation was planned using an artificial pancreas for intraoperative and postoperative blood glucose control. Hypoglycemia (blood glucose, 38 mg/dL) was observed from the onset of surgery. An artificial pancreas cannot be used if the blood glucose level is ≤ 70 mg/dL; thus, continuous glucose infusion was administered. The sudden rise in blood glucose prompted insulin infusion from the device, causing hypoglycemia. Controlling blood glucose levels is challenging when introducing the artificial pancreas. However, altering the device’s blood glucose control algorithm controlled the fluctuating blood glucose level, and, intraoperative average blood glucose was raised to 94.8 ± 21.1 mg/dL, thereby avoiding hypoglycemia, that is, a blood glucose level of ≤ 70 mg/dL. We report a case in which an artificial pancreas was used for glycemic control during surgery for an insulinoma.

In this report, we describe a case of highly advanced hepatocellular carcinoma with tumor thrombosis extending into the main portal vein of the pancreas that was successfully treated with adjuvant lenvatinib after right hepatic resection with thrombectomy. A 70-year-old woman was referred from the clinic because of elevated hepatobiliary enzymes. The patient was positive for the hepatitis B virus antigen at our hospital. The tumor markers were highly elevated with alpha-fetoprotein (14.5 U/mL) and protein induced by vitamin K absence (PIVKAII) (1545 ng/mL), suggesting hepatocellular carcinoma. Dynamic abdominal computed tomography showed an early enhanced tumor approximately 6 cm in size and portal vein tumor thrombosis filling the main portal vein, but not extending into the splenic or superior mesenteric vein (SMV). On magnetic resonance imaging 1 week after CT, portal vein tumor thrombosis had extended to the confluence of the splenic vein with the SMV, indicating rapid tumor growth. Thus, we performed emergent right hepatectomy with tumor thrombectomy. Postoperatively, we treated the patient with lenvatinib for a tumor reduction surgery. Fortunately, the patient was alive 2 years postoperatively without recurrence. This case report suggests that a favorable outcome may be achieved with multidisciplinary treatment including resection and postoperative treatment with lenvatinib.

We had reported the novel concept of “caudal approach in laparoscopic liver resection” in 2013. In the first report, the caudal approach of laparoscopic transection–first posterior sectionectomy without prior mobilization of the liver in the left lateral position was described. Thereafter, 10 complex laparoscopic extended posterior sectionectomies with combined resection of the right hepatic vein or diaphragm were performed using the same approach. In the present study, the short-term outcomes of these cases and 42 cases of laparoscopic sectionectomies or hemi-hepatectomies (excluding left lateral sectionectomy) were compared. There was no statistically significant difference between the groups in terms of patients’ backgrounds, diseases for resection, preoperative liver function, tumor number and size, as well as outcomes, operation time, intraoperative blood loss, morbidity, conversion to laparotomy, and post-operative hospital stay. Even complex laparoscopic extended posterior sectionectomy was safely performed using this procedure. This approach has the technical benefits of acquiring a well-opened transection plane between the resected liver fixed to the retroperitoneum and the residual liver sinking to the left with the force of gravity during parenchymal transection, and less bleeding from the right hepatic vein due to its higher position than the inferior vena cava. Furthermore, it has an oncological benefit similar to that of the anterior approach in open liver resection, even in posterior sectionectomy. The detailed procedure and general conceptual benefits of the caudal approach to laparoscopic liver resection for repeated multimodal treatment for hepatocellular carcinoma are described.

BACKGROUND: Socratic method, which is an educational method to promote critical thinking through a dialogue, has never been practiced in a large number of people at the academic societies. METHODS: Modified Socratic method was performed for the first time as an educational seminar using an example case of moderate acute cholecystitis based on the evidence described in Tokyo Guidelines 2018. We adopted a method that Takada had been modifying for many years: the instructor first knows the degree of recognition of the audience, then the instructor gives a lecture in an easy-to-understand manner and receives questions from the audience, followed by repeated questions and answers toward a common recognition. RESULTS: Using slides, video, and an answer pad, 281 participants including the audience, instructors and moderators came together to repeatedly ask and answer questions in the five sessions related to the case scenario. The recognition rate of the topic of Critical View of Safety increased significantly before vs after this method (53.0% vs 90.3%). The seminar had been successfully performed by receiving a lot of praise from the participants. CONCLUSION: This educational method is considered to be adopted by many academic societies in the future as an effective educational method.

BACKGROUND: The association between pancreatic fistula (PF) after pancreaticoduodenectomy (PD) and preoperative exocrine function is yet to be elucidated. This study aimed to evaluate the association between the preoperative results of the 13C-trioctanoin breath test and the occurrence of PF, showing the clinical relevance of the breath test in predicting PF. METHOD: A total of 80 patients who underwent 13C-trioctanoin breath tests prior to PD from 2006 to 2018 were included in this study. Univariate and multivariate analyses were conducted to reveal the preoperative predictors of PF, showing the association between 13C-trioctanoin absorption and PF incidence. RESULTS: Among 80 patients (age, 68.0 ± 11.9 years, 46 males and 34 females; 30 pancreatic ductal adenocarcinoma [PDAC]/50 non-PDAC patients), the incidence of PF was 12.5% (10/80). Logistic regression analysis results revealed that the frequency of PF increased significantly as the 13C-trioctanoin breath test value (Aa% dose/h) increased (odd's ratio: 1.082, 95% confidence interval: 1.007-1.162, p = 0.032). Moreover, the optimal cutoff value of the preoperative fat absorption level to predict PF was 38.0 (sensitivity, 90%; specificity, 74%; area under the curve, 0.78; p = 0.005). Indeed, the incidence of PF was extremely higher in patients whose breath test value was greater than 38.0 (33%, 9/27) compared with that in patients with values less than 38.0 (1.8%, 1/53). CONCLUSIONS: Favorable preoperative fat absorption evaluated using the 13C-trioctanoin breath test is a feasible and objective predictor of PF after PD.

The two patterns of pathogenesis for pancreatic colloid carcinoma are reported; (1) progression from ordinary ductal adenocarcinoma, a subtype of invasive pancreatic ductal carcinoma, and (2) progression from papillary adenocarcinoma derived from intraductal papillary mucinous neoplasm (IPMN) or mucinous cystic neoplasm (MCN). Whether these two conditions are the same disease remains controversial. Case Report 1. An 81-year-old woman was evaluated for an increased carbohydrate antigen 19-9 (CA19-9) value (130 U/mL) detected at 4-year follow-up after distal pancreatectomy for IPMN. Based on the image findings, a local recurrence of IPMN was diagnosed, and the patient underwent a remnant total pancreatectomy. Histopathologic findings showed marked mucus production from the tumor, also noteworthy because mucous nodule formation occurs in more than 80% of tumor. Fibrosis around the mucous cavity was noted, and a low papillary lesion was found in part of the cyst wall, which was contiguous to a flat, basal area; its nucleus was enlarged and heterogeneous in size, which is considered to be a component of intraductal papillary mucinous (IPMC). Therefore, the patient was diagnosed with pancreatic colloid carcinoma derived from IPMN. Case report 2 a 71-year-old man was evaluated for jaundice. Based on the image findings, a diagnosis of pancreatic head cancer was made, and a substomach preserving pancreaticoduodenectomy was performed. Histologically, marked mucus production and floating cuboidal masses of atypical cells without mucinous nodules were seen. Mucinous nodule formation is observed in more than 80% of tumor, but there was no IPMN component, which led to the diagnosis of pancreatic colloid carcinoma. In conclusion, there might be two types of colloid carcinoma of the pancreas, and further study is needed to determine whether these diseases are truly the same or not.

BACKGROUND: Performing major hepatectomy for patients with marginal hepatic function is challenging. In some cases, the procedure is contraindicated owing to the threat of postoperative liver failure. In this case report, we present the first case of marginal liver function (indocyanine green clearance retention rate at 15 min [ICGR15]: 28%) successfully treated with right hepatectomy, resulting in total caudate lobe preservation. CASE PRESENTATION: A 71-year-old man was diagnosed with sigmoid colon cancer with three liver metastases (S5, S7, and S8). All of metastatic lesions shrunk after chemotherapy, but his ICGR15 and indocyanine green clearance rate (ICGK) were 21% and 0.12, respectively. Moreover, the remnant liver volume was only 39%. Therefore, portal venous embolism (PVE) of the right portal vein was suggested. Portography showed divergence of the considerably preserved right caudate lobe branch (PV1R) from the root of the right portal vein. The liver function was reevaluated 18 days after PVE was suggested. During this time, the ICGR15 (21-28%) and ICGK rate (0.12-0.10) deteriorated. The right caudate lobe was significantly enlarged; thus, a total caudate lobe-preserving hepatectomy (TCPRx) was performed. Patients eligible for TCPRx included those with (1) hepatocellular carcinoma or metastatic liver cancer, (2) no tumor in the caudate lobe, (3) marginal liver function (ICG Krem greater than 0.05 if TCPRx was adapted; otherwise, less than 0.05) and Child-Pugh classification category A, and (4) preserved PV1R and right caudate bile duct branch. The procedure was performed through (A) precise estimation of the remnant liver volume preoperatively, (B) repeated intraoperative cholangiography to confirm the biliary branch of the right caudate lobe (B1R) conservation, and (C) stapler division of posterior and anterior Glisson's pedicles laterally to avoid injuries to the PV1R and B1R. CONCLUSIONS: Right hepatectomy with total caudate lobe preservation, following PVE, was a safe and viable surgical technique for patients with marginal liver function.

We had reported the novel concept of "caudal approach in laparoscopic liver resection" in 2013. In the first report, the caudal approach of laparoscopic transection-first posterior sectionectomy without prior mobilization of the liver in the left lateral position was described. Thereafter, 10 complex laparoscopic extended posterior sectionectomies with combined resection of the right hepatic vein or diaphragm were performed using the same approach. In the present study, the short-term outcomes of these cases and 42 cases of laparoscopic sectionectomies or hemi-hepatectomies (excluding left lateral sectionectomy) were compared. There was no statistically significant difference between the groups in terms of patients' backgrounds, diseases for resection, preoperative liver function, tumor number and size, as well as outcomes, operation time, intraoperative blood loss, morbidity, conversion to laparotomy, and post-operative hospital stay. Even complex laparoscopic extended posterior sectionectomy was safely performed using this procedure. This approach has the technical benefits of acquiring a well-opened transection plane between the resected liver fixed to the retroperitoneum and the residual liver sinking to the left with the force of gravity during parenchymal transection, and less bleeding from the right hepatic vein due to its higher position than the inferior vena cava. Furthermore, it has an oncological benefit similar to that of the anterior approach in open liver resection, even in posterior sectionectomy. The detailed procedure and general conceptual benefits of the caudal approach to laparoscopic liver resection for repeated multimodal treatment for hepatocellular carcinoma are described.

PURPOSE: The aim of this study was to elucidate the association between pancreatic fistula (PF) and the sequential changes in the perioperative exocrine function after pancreatectomy. METHODS: The subjects were 96 patients who underwent a 13C-trioctanoin breath test before and 1 month after pancreatectomy, between 2006 and 2018. We retrospectively compared the pre- and postoperative fat absorption levels between patients with PF (PF group; n = 17) and without PF (non-PF group; n = 79) using the breath test. RESULTS: The preoperative level of 13C-trioctanoin absorption (%dose/h) was comparable between the non-PF and PF groups (36.5 vs. 36.9). In the non-PF group, 13C-trioctanoin absorption was significantly decreased after surgery in comparison to the preoperative setting (post-operative 28.5; pre-operative 36.5; p < 0.0001), whereas these values were comparable (post-operative 36.9; pre-operative 34.5; p = 0.129) in the PF group. Moreover, postoperative absorption in the PF group was significantly better than that in the non-PF group (34.5 vs. 28.5%, p = 0.0003). The maximum drain amylase level was significantly higher in patients with a 13C-trioctanoin absorption level (%dose/h) of ≥ 30 in comparison to patients with levels of < 30 (2502 vs. 398 U/L, p = 0.001). CONCLUSION: PF did not exacerbate the pancreatic exocrine function in the early postoperative period, and the acceleration or preservation of the exocrine function after surgery may be an important cause of PF.

BACKGROUND: We aimed to present the 2019 annual report of the gastroenterological section of the National Clinical Database (NCD). METHODS: We reviewed 609,589 cases recorded in 2019 and 5,029,764 cases registered from 2011 to 2019 for the 115 selected gastroenterological surgical procedures. RESULTS: The main features of gastroenterological surgery in Japan were similar to those described in the 2018 annual report, namely, that 1) operative numbers gradually increased in all procedures, except gastrectomy and hepatectomy, which decreased in these years; 2) in all eight major gastroenterological surgeries, the age distribution tended toward older patients; 3) the morbidity of esophagectomy, hepatectomy, and pancreaticoduodenectomy increased, but mortality was minimized in all procedures; 4) all eight major gastroenterological procedures have increasingly been performed under laparoscopy; and 5) board-certified surgeons were increasingly involved. These trends in recent years were more prominent in 2019. CONCLUSIONS: Thanks to the continuous cooperation and dedication of the surgeons, medical staff, and surgical clinical reviewers who registered the clinical data into the NCD, it is possible to understand the comprehensive landscape of surgery in Japan and to disclose new evidence in this field. The Japanese Society of Gastroenterological Surgery will continue to promote the value of this database and encourage the use of feedback and clinical studies using the NCD, now and in the future. Generating further approaches to surgical quality improvement are important directions for future research.

The spread of the new coronavirus (COVID-19) infection in 2020 has had a significant impact on the treatment of cancer worldwide. During the COVID-19 pandemic, the biggest challenge for pancreatic surgeons is the difficulty in providing oncological care. In this review article, from the standpoint of surgeons, we explain the concept of triaging of patients with pancreatic tumors under the COVID-19 pandemic, and the actual impact of COVID-19 on the treatment of patients with pancreatic tumors. The most vital points in selecting the best therapeutic approach for patients with pancreatic tumors during this pandemic are (1) Oncologists need to tailor the treatment plan based on the COVID-19 phase, tumor malignant potential, and patients' comorbidities; and (2) Optimal treatment for pancreatic cancer should be planned according to the condition of each patient and tumor resectability based on national comprehensive cancer network resectability criteria. To choose the best therapeutic approach for patients with pancreatic tumors during this pandemic, we need to tailor the treatment plan based on elective surgery acuity scale (ESAS). Newly established ESAS for pancreatic tumor and flowchart indicating the treatment strategy of pancreatic cancer, are feasible to overcome this situation.

BACKGROUND: The high operative mortality rate after hepatopancreatoduodenectomy (HPD) is still a major issue. The present study explored why operative mortality differs significantly due to hospital volume. METHOD: Surgical case data were extracted from the National Clinical Database (NCD) in Japan from 2011 to 2014. Surgical procedures were categorized as major (≥2 sections) and minor (<2 sections) hepatectomy. Hospitals were categorized according to the certification system by the Japanese Society of Hepato-Biliary-Pancreatic Surgery (JSHBPS) based on the number of major hepato-biliary-pancreatic surgeries performed per year. The FTR rate was defined as death in a patient with at least one postoperative complication. RESULTS: A total of 422 patients who underwent HPD were analyzed. The operative mortality rates in board-certified A training institutions, board-certified B training institutions, and non-certified institution were 7.2%, 11.6%, and 21.4%, respectively. Multiple logistic regression showed that certified A institutions, major hepatectomy, and blood transfusion were the predictors of operative mortality. Failure to rescue rates were lowest in certified A institutions (9.3%, 17.0%, and 33.3% in certified A, certified B, and non-certified, respectively). CONCLUSIONS: To reduce operative mortality after HPD, further centralization of this procedure is desirable. Future studies should clarify specific ways to improve the failure-to-rescue rates in certified institutions.

81歳男性.発熱,黄疸の精査のため紹介となり,造影CTで遠位胆管に狭窄を認めた.ERC時に行った腫瘍生検で遠位胆管癌と診断し,膵頭十二指腸切除術を施行した.病理標本では腫瘍部位に腺癌の他,浸潤部位の免疫染色ではchromogranin A,synaptophysin及びCD56が陽性,MIB-1 index 80%と神経内分泌癌も認め,混在した腺癌成分と神経内分泌癌成分とが各々30%以上を占めており,Mixed neuroendocrine-non-neuroendocrine neoplasm(MiNEN)と診断した.その後肝転移を認め,化学療法を開始したがその20ヵ月後に死亡した.胆管原発MiNENの術前診断は,画像診断や胆管生検では困難であり,その治療方針は手術療法だけでなく術前化学療法など集学的治療も考慮されているが,未だ確立されていない.今回稀な胆管MiNENを経験したため報告する.(著者抄録)

Overall survival of patients with localized pancreatic ductal adenocarcinoma (PDAC) is extremely poor. Therefore, the establishment of multimodal treatment strategies is indispensable for PDAC patients because surgical treatment alone could not contribute to the improvement of survival. In this review article, we focus on the current topics and advancement of the treatments for localized PDAC including resectable, borderline resectable, and locally advanced PDAC in accordance with the articles mainly published from 2019 to 2020. Reviewing the articles, the recent progress of multimodal treatments notably improves the prognosis of patients with localized PDAC. For resectable PDAC, neoadjuvant chemo or chemoradiation therapy, rather than upfront surgery, plays a key role, especially in patients with a large tumor, poor performance status, high tumor marker levels, peripancreatic lymph nodes metastasis, or neural invasion suspected on preoperative imaging. For borderline resectable PDAC, neoadjuvant treatments followed by surgery is a desirable approach, and maintenance of immunonutritional status during the treatments are also important. For locally advanced disease, conversion surgery has a central role in improving a survival outcome; however, its indication should be standardized.

OBJECTIVES: We evaluated the clinical outcomes of transumbilical single-incision laparoscopic appendectomy with extracorporeal hand-sewn stump closure in adults. METHODS: One-hundred-and-thirty-one consecutive adults with acute appendicitis were treated with the intention of performing transumbilical single-incision laparoscopic appendectomy with extracorporeal hand-sewn stump closure from July 2012 to December 2017. The procedure completion rate and outcomes were examined. To evaluate the risk factors for conversion, the background data were compared between the patients in whom the procedure was completed versus those in whom the procedure was uncompleted. RESULTS: The procedure was completed in 113 of 131 patients (86.3%). Single-site surgery was completed in 117 patients (89.3%). The median operation time was 79 (range 30-270) minutes and median intraoperative blood loss was 10 (range 0-394) ml. Postoperative complications occurred in 17 patients (13.0%). Postoperative hospital stay was 6 (range 1-27) days. The 18 patients in whom the procedure could not be completed comprised four patients in whom the stapler was used for intraabdominal stump closure, and 14 patients who were converted to multiport laparoscopic surgery or open surgery. Multivariate analysis showed that the independent risk factors for conversion were age, preoperative abscess, and peri-appendiceal fat density. Receiver operating characteristic curve analysis showed that the cutoff value of peri-appendiceal fat density for conversion was -40.51 Hounsfield units. CONCLUSIONS: Transumbilical single-incision laparoscopic appendectomy with extracorporeal hand-sewn stump closure was safe in adults with acute appendicitis. The risk factors for conversion were age ≥60 years, preoperative abscess, and peri-appendiceal fat density ≥-40.51 Hounsfield units.

We present the case of a 66-year-old female diagnosed with gallbladder cancer that was initially discovered with contrast enhanced computed tomography. The primary gall bladder tumor displayed heterogeneous enhancement. The patient underwent cholecystectomy with full-thickness excision of the gallbladder cancer. After 3 rounds of adjuvant chemotherapy with the oral fluoropyrimidine derivative, S-1(administered for 4 weeks at 120 mg/day and then stopped for 2 weeks), a metastasis measuring 15 mm in diameter emerged within hepatic segment 5. The chemotherapy regimen was altered to include 6 months of combination therapy with gemcitabine(1,000 mg/m2)and cisplatin(25 mg/m2)given once every week for 2 weeks and then stopped for 1 week. The hepatic metastasis decreased in size to 8 mm in diameter, and a partial liver resection was performed. After hepatectomy, the patient remains alive and without disease recurrence.

The National Clinical Database (NCD) of Japan was established in 2010 with the board certification system. A joint committee of 16 gastroenterological surgery database-affiliated organizations has been nurturing this nationwide database and utilizing its data for various analyses. Stepwise board certification systems have been validated by the NCD and are used to improve the surgical outcomes of patients. The use of risk calculators based on risk models can be particularly helpful for establishing appropriate and less invasive surgical treatments for individual patients. Data obtained from the NCD reflect current developments in the surgical approaches used in hospitals, which have progressed from open surgery to endoscopic and robot-assisted procedures. An investigation of the data acquired by the NCD could answer some relevant clinical questions and lead to better surgical management of patients. Furthermore, excellent surgical outcomes can be achieved through international comparisons of the national databases worldwide. This review examines what we have learned from the NCD of gastroenterological surgery and discusses what future developments we can expect.

BACKGROUND: Lymph node metastasis is an important prognostic factor for distal bile duct cancer. The number of lymph node metastases was adopted for nodal classification. However, different cutoff values have been proposed, ranging from two to five. METHODS: A total of 1748 cases who underwent curative surgery with pancreatoduodenectomy for distal bile duct cancer registered in the nationwide biliary tract cancer registry in Japan from 2008 to 2013 were included. Univariate Cox regression was performed to assess the effect of prognostic lymph node metastasis counts on mortality and to determine cutoff values. RESULTS: The overall survival rate after resection was 47.4% at 5 years. Univariate and multivariate analysis found prognostic factors to include lymph node metastasis. The cutoff point was set to two lymph node metastases using the Cox model. There were significant differences in pairwise comparisons between three groups by the number of metastatic lymph node (P < .001 for 0 vs 1-2 and P = .003 for 1-2 vs ≥3). CONCLUSION: Our data suggest lymph node classification as N0 (patients without lymph node metastases), N1 (metastasis in 1-2 regional lymph nodes), and N2 (metastases in ≥3 regional lymph nodes).