Publications by authors named "Junichi Kaneko"

255 Publications

Endoscopic duodenal stent placement versus gastrojejunostomy for unresectable pancreatic cancer patients with duodenal stenosis before introduction of initial chemotherapy (GASPACHO study): a multicenter retrospective study.

Jpn J Clin Oncol 2021 Dec 29. Epub 2021 Dec 29.

Department of Medical Oncology, Kyorin University Faculty of Medicine, Tokyo, Japan.

Background: Endoscopic duodenal stent placement is an alternative technique to gastrojejunostomy for gastric outlet obstruction due to pancreatic cancer. We compared the efficacy of endoscopic duodenal stent placement with that of gastrojejunostomy for treating patients with pancreatic cancer who are candidates for intensive combination chemotherapies as the first line of treatment.

Methods: This retrospective observational study included 100 patients from 18 institutions in Japan. Inclusion criteria were as follows: (1) cytologically or histologically confirmed adenocarcinoma of the pancreas, (2) good performance status, (3) gastric outlet obstruction scoring system score of 0-1 and (4) no history of treatment for pancreatic cancer.

Results: There was no significant difference in the background characteristics of patients in the endoscopic duodenal stent placement (n = 57) and gastrojejunostomy (n = 43) groups. The median overall survival in the endoscopic duodenal stent placement and gastrojejunostomy groups was 5.9 and 6.0 months, respectively. Clinical success was achieved in 93 cases; the median time to food intake resumption was significantly shorter in the endoscopic duodenal stent placement group (median: 3 days, n = 54) than in the gastrojejunostomy group (median: 5 days, n = 43). Chemotherapy was introduced in 63% of the patients in both groups after endoscopic duodenal stent placement or gastrojejunostomy. Chemotherapy was started earlier in the endoscopic duodenal stent placement group (median: 14 days) than in the gastrojejunostomy (median: 32 days) group.

Conclusions: Endoscopic duodenal stent placement showed similar or better clinical outcomes than gastrojejunostomy. Thus, it might be a promising option in patients with good performance status.
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http://dx.doi.org/10.1093/jjco/hyab194DOI Listing
December 2021

Artificial intelligence enhances the accuracy of portal and hepatic vein extraction in computed tomography for virtual hepatectomy.

J Hepatobiliary Pancreat Sci 2021 Nov 14. Epub 2021 Nov 14.

Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.

Background/purpose: Current conventional algorithms used for 3-dimensional simulation in virtual hepatectomy still have difficulties distinguishing the portal vein (PV) and hepatic vein (HV). The accuracy of these algorithms was compared with a new deep-learning based algorithm (DLA) using artificial intelligence.

Methods: A total of 110 living liver donor candidates until 2017, and 46 donor candidates until 2019 were allocated to the training group and validation groups for the DLA, respectively. All PV or HV branches were labeled based on Couinaud's segment classification and the Brisbane 2000 Terminology by hepato-biliary surgeons. Misclassified and missing branches were compared between a conventional tracking-based algorithm (TA) and DLA in the validation group.

Results: The sensitivity, specificity, and Dice coefficient for the PV were 0.58, 0.98, and 0.69 using the TA; and 0.84, 0.97, and 0.90 using the DLA (P < .001, excluding specificity); and for the HV, 0.81, 087, and 0.83 using the TA; and 0.93, 0.94 and 0.94 using the DLA (P < .001 to P = .001). The DLA exhibited greater accuracy than the TA.

Conclusion: Compared with the TA, artificial intelligence enhanced the accuracy of extraction of the PV and HVs in computed tomography.
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http://dx.doi.org/10.1002/jhbp.1080DOI Listing
November 2021

National survey of hepatobiliary and pancreatic surgery in hemophilia patients in Japan.

J Hepatobiliary Pancreat Sci 2021 Nov 2. Epub 2021 Nov 2.

Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.

Background: Approximately 8300 hemophiliacs are registered in Japan, but no comprehensive reports on hepatobiliary and pancreatic surgery (HBPS) have been conducted. This report investigates the current status of HPBS in hemophilia patients in Japan.

Methods: The subjects were hemophiliac patients seen between January 1 2007, and December 31 2017, at facilities participating in this study among the facilities for performing high-difficulty cases nationwide designated by the Japanese Society for HBPS. A retrospective examination of short-term outcomes in 49 cases was conducted to assess patient background, disease, surgical procedure, and complications.

Results: The types of hemophilia were A: 43 cases, B: four cases, and von Willebrand disease: two cases (hemophilia severity: mild 32, moderate seven, severe 10). The target malignant diseases for surgery were hepatocellular carcinoma (HCC) in 20 cases, intrahepatic cholangiocellular carcinoma (CCC) in four cases, combined HCC-CCC in two cases, hilar CCC in two cases, and pancreatic cancer in four cases. As for the surgical procedure, limited resection (subsegmentectomy and partial hepatectomy) was performed in 16 cases of HCC even with normal liver function tests. Pancreaticoduodenectomy and distal pacreatectomy were performed for pancreatic cancers as in the standard procedure. Postoperative complications were postoperative bleeding in two cases after hepatectomy and one after pancreatectomy in one case. When compared with Japanese National Clinical Data base, the complication rates after hepatectomy and pancreatectomy were not conspicuous in hemophilic patients.

Conclusions: As long as they are performed in qualified centers, complication rate is not increased in hemophilic patients undergoing HBPS.
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http://dx.doi.org/10.1002/jhbp.1073DOI Listing
November 2021

Macroscopic visible core length can predict the histological sample quantity in endoscopic ultrasound-guided tissue acquisition: Multicenter prospective study.

Dig Endosc 2021 Aug 26. Epub 2021 Aug 26.

Division of, Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan.

Objectives: Measurement of the macroscopic visible core (MVC) length during macroscopic on-site quality evaluation (MOSE) may allow estimation of sample adequacy for next-generation sequencing (NGS), and prediction of correct diagnosis in endoscopic ultrasound-guided tissue acquisition (EUS-TA) of pancreatic masses.

Methods: This multicenter prospective study included consecutive patients who underwent EUS-TA for pancreatic masses using a 22-G Franseen needle. MVC length and pathological samples obtained from two needle passes were analyzed on a per-pass basis. Outcome measures included respective correlations of MVC length with histological sample quantity and diagnostic yields.

Results: The analysis included 204 passes from 102 EUS-TAs. MVC length correlated positively with histological sample quantity (P < 0.01). On the receiver operating characteristic curve for MVC length, the cut-off value and area under the curve for obtaining a candidate sample for NGS were 30 mm and 0.74 (95% confidence interval [CI] 0.65-0.83), respectively. On multivariate analysis, MVC length ≥30 mm was a significant factor affecting suitability for NGS (odds ratio 6.19; 95% CI 2.72-14.10). Histologic diagnostic yield correlated positively with MVC length (P = 0.01); however, there was no positive correlation between MVC length and overall (histology plus cytology) diagnostic yield.

Conclusions: Measuring MVC length to predict histological sample quantity on MOSE may be of clinical significance during EUS-TA using a 22-G Franseen needle. It may be an effective method, particularly while submitting samples for NGS. Registration: University Hospital Medical Information Network Trials Registry (UMIN000036528).
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http://dx.doi.org/10.1111/den.14116DOI Listing
August 2021

Understanding conditional cumulative incidence of complications following liver resection to optimize hospital stay.

HPB (Oxford) 2021 Jul 8. Epub 2021 Jul 8.

Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan. Electronic address:

Background: After liver resection, the in-hospital observation periods associated with minimal risks for complications and unplanned readmission remains unclear. This study aimed to assess changes in risks of complications over time.

Methods: Surgical complexity of liver resection was stratified into grades I (low complexity), II (intermediate), and III (high). The cumulative incidence rate and risk factors for complication ≥ Clavien-Dindo grade II (defined as treatment-requiring complications) were assessed.

Results: Of 581 patients, grade I, II, and III resections were performed in 81 (13.9%), 119 (20.5%), and 381 patients (65.6%). Complexity grades (I vs. III, hazard ratio [HR] 0.45, P = 0.007; II vs. III, HR 0.60, P = 0.011) and background liver status (HR 1.76, P = 0.004) were risk factors for treatment-requiring complications. The cumulative incidence rate of treatment-requiring complications was higher after grade III resection than grade I resection (38.1% vs. 16.1%, P < 0.001) or grade II resection (38.1% vs. 25.2%, P = 0.019). Without cirrhosis/chronic hepatitis, the cumulative incidence rate of treatment-requiring complications decreased to less than 10% on postoperative day (POD) 3 after grade I resection, POD 5 after grade II resection, and POD 10 after grade III resection.

Conclusion: Conditional complication risk analysis stratified by surgical complexity may be useful for optimizing in-hospital observation.
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http://dx.doi.org/10.1016/j.hpb.2021.06.419DOI Listing
July 2021

Can regular follow-up imaging contribute to the determination of appropriate timing of surgery in patients with undiagnosed mucinous cystic neoplasm? A multicenter retrospective study.

Jpn J Clin Oncol 2021 Aug;51(9):1423-1429

Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan.

Objective: Guidelines suggest that patients with undiagnosed pancreatic cystic lesions should be monitored despite a lack of evidence supporting surveillance for undiagnosed mucinous cystic neoplasms (MCNs). We aimed to investigate the pre- and post-operative clinical course of patients with MCN and the utility of follow-up for patients who were not diagnosed with MCN at initial examination.

Patients And Methods: This multicenter retrospective study enrolled 28 patients with resected pathology-proven MCN; 12 and 16 patients underwent surgery within and after 6 months from the initial examination (Groups A and B, respectively). Outcome measures included changes in imaging findings until surgery in Group B, pathological findings between both groups and differences in pathological findings between patients with and without regular follow-up imaging in Group B.

Results: In Group B, the median cyst size was 30 and 48 mm at the initial examination and immediately before surgery, respectively. The incidence of mural cysts, thickened walls and mural nodules were 25, 19 and 0%, respectively, at the initial examination and 69, 56 and 31%, respectively, immediately before surgery. There were no significant differences in the invasive carcinoma rates between Groups A and B (13 vs. 17%). Regular follow-up imaging was offered to Group B. Among these, invasive carcinoma was found in one patient exhibiting no recurrence. One patient without follow-up imaging had invasive carcinoma recurrence post-operatively.

Conclusions: MCNs increased in size, and typical imaging findings appeared over time. For undiagnosed MCN, regular follow-up examination contributed to the determination of the appropriate surgical timing.
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http://dx.doi.org/10.1093/jjco/hyab103DOI Listing
August 2021

A safe sequential treatment approach for patients who have acute cholecystitis with severe inflammation: Transmural gallbladder drainage followed by laparoscopic cholecystectomy under the guidance of fluorescence imaging.

Asian J Endosc Surg 2022 Jan 30;15(1):230-234. Epub 2021 May 30.

Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan.

Introduction: For patients who have acute severe cholecystitis, urgent/early biliary drainage followed by delayed/elective laparoscopic cholecystectomy is recommended according to the Tokyo Guidelines 2018. Percutaneous transhepatic gallbladder drainage is an established technique. Recently, transmural gallbladder drainage under the guidance of endoscopic ultrasonography (EUS-GBD) was reported as a safe alternative. During surgery, fluorescence imaging using indocyanine green (ICG) has been increasingly used for visualizing the bile ducts. Herein, we report a sequential treatment approach which ensures safety without impairing normal activities before cholecystectomy: EUS-GBD followed by laparoscopic cholecystectomy using ICG fluorescence imaging.

Materials And Surgical Technique: A 66-year-old man with acute cholecystitis underwent urgent EUS-GBD and had the drainage tube placement through the duodenum into the gallbladder. During 2.5 months of the waiting period, he had no clinical troubles. After insertion of a laparoscope, we found a structure between the gallbladder and the duodenum. We injected 0.025 mg/mL of ICG into the nasobiliary drainage tube (placed in the gallbladder through the duodenum) and confirmed that the structure was a fistula. After removing the tube, the fistula was divided using a surgical stapler under the guidance of fluorescence imaging. The cystic and common bile ducts were also clearly visualized as fluorescence.

Discussion: We reported a safe sequential treatment approach for the patient who required biliary drainage: EUS-GBD followed by laparoscopic cholecystectomy under the guidance of ICG fluorescence imaging. This sequential approach may improve patients' satisfaction with respect to quality of life during the waiting period and may ensure the safety of laparoscopic cholecystectomy.
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http://dx.doi.org/10.1111/ases.12955DOI Listing
January 2022

Open and/or laparoscopic one-stage resections of primary colorectal cancer and synchronous liver metastases: An observational study.

Medicine (Baltimore) 2021 Mar;100(11):e25205

Department of Surgical Oncology.

Abstract: One-stage resections of primary colorectal cancer and liver metastases have been reported to be feasible and safe. Minimally invasive approaches have become more common for both colorectal and hepatic surgeries. This study aimed to investigate outcomes of these combined surgical procedures among different approaches.We retrospectively analyzed patients diagnosed as having primary colorectal cancer with synchronous liver metastases and who underwent 1-stage primary resection and hepatectomy with curative intent in our hospital. According to the surgical approach for the primary tumor and hepatic lesions, namely open laparotomy (Op) or laparoscopic approach (Lap), patients were classified into Op-Op, Lap-Op (laparoscopic colorectal resection plus open hepatectomy), and Lap-Lap groups, respectively. Clinicopathological factors were reviewed, and short- and long-term outcomes were compared among the groups.The Op-Op, Lap-Op, and Lap-Lap groups comprised 36, 18, and 17 patients, respectively. The superior/posterior hepatic segments were more frequently resected via an open approach. There was no laparoscopic major hepatectomy. The median volume of intraoperative blood loss was smaller in the Lap-Lap and Lap-Op groups (290 and 270 mL) than in the Op-Op group (575 mL, P = .008). The hospital stay after surgery was shorter in the Lap-Lap and Lap-Op groups (median: 17 days and 15 days, vs 19 days for the Op-Op group, P = .033). The postoperative complication rates and survivals were similar among the groups.Application of laparoscopy to 1-stage resections of primary colorectal cancer and liver metastases may offer advantages of enhanced recovery from surgical treatment, given appropriate patient selection.
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http://dx.doi.org/10.1097/MD.0000000000025205DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982201PMC
March 2021

A new rapid diagnostic system with ambient mass spectrometry and machine learning for colorectal liver metastasis.

BMC Cancer 2021 Mar 10;21(1):262. Epub 2021 Mar 10.

Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.

Background: Probe electrospray ionization-mass spectrometry (PESI-MS) can rapidly visualize mass spectra of small, surgically obtained tissue samples, and is a promising novel diagnostic tool when combined with machine learning which discriminates malignant spectrum patterns from others. The present study was performed to evaluate the utility of this device for rapid diagnosis of colorectal liver metastasis (CRLM).

Methods: A prospectively planned study using retrospectively obtained tissues was performed. In total, 103 CRLM samples and 80 non-cancer liver tissues cut from surgically extracted specimens were analyzed using PESI-MS. Mass spectra obtained by PESI-MS were classified into cancer or non-cancer groups by using logistic regression, a kind of machine learning. Next, to identify the exact molecules responsible for the difference between CRLM and non-cancerous tissues, we performed liquid chromatography-electrospray ionization-MS (LC-ESI-MS), which visualizes sample molecular composition in more detail.

Results: This diagnostic system distinguished CRLM from non-cancer liver parenchyma with an accuracy rate of 99.5%. The area under the receiver operating characteristic curve reached 0.9999. LC-ESI-MS analysis showed higher ion intensities of phosphatidylcholine and phosphatidylethanolamine in CRLM than in non-cancer liver parenchyma (P < 0.01, respectively). The proportion of phospholipids categorized as monounsaturated fatty acids was higher in CRLM (37.2%) than in non-cancer liver parenchyma (10.7%; P < 0.01).

Conclusion: The combination of PESI-MS and machine learning distinguished CRLM from non-cancer tissue with high accuracy. Phospholipids categorized as monounsaturated fatty acids contributed to the difference between CRLM and normal parenchyma and might also be a useful diagnostic biomarker and therapeutic target for CRLM.
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http://dx.doi.org/10.1186/s12885-021-08001-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7945316PMC
March 2021

Detectability on Plain CT is an Effective Discriminator between Carcinoma and Benign Disorder for a Polyp >10 mm in the Gallbladder.

Diagnostics (Basel) 2021 Feb 25;11(3). Epub 2021 Feb 25.

Division of Endoscopy, Shizuoka Cancer Center, Shizuoka 411-8777, Japan.

An appropriate diagnosis is required to avoid unnecessary surgery for gallbladder cholesterol polyps (GChPs) and to appropriately treat pedunculated gallbladder carcinomas (GCs). Generally, polyps >10 mm are regarded as surgical candidates. We retrospectively evaluated plain and contrast-enhanced (CE) computed tomography (CT) findings and histopathological features of 11 early GCs and 10 GChPs sized 10-30 mm to differentiate between GC and GChP >10 mm and determine their histopathological background. Patient characteristics, including polyp size, did not significantly differ between groups. All GCs and GChPs were detected on CE-CT; GCs were detected more often than GChPs on plain CT (73% vs 9%; < 0.01). Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy for GCs were 73%, 90%, 89%, 75%, and 81%, respectively. On multivariate analysis, lesion detectability on plain CT was independently associated with GCs (odds ratio, 27.1; = 0.044). Histopathologically, GChPs consisted of adipose tissue. Although larger vessel areas in GCs than in GChPs was not significant (52,737 μm vs 31,906 μm; = 0.51), cell densities were significantly greater in GCs (0.015/μm vs 0.0080/μm; < 0.01). Among GPs larger than 10 mm, plain CT could contribute to differentiating GCs from GChPs.
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http://dx.doi.org/10.3390/diagnostics11030388DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7996218PMC
February 2021

Impact of Abdominal Incision Type on Postoperative Pain and Quality of Life Following Hepatectomy.

World J Surg 2021 06 17;45(6):1887-1896. Epub 2021 Feb 17.

Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.

Background: The aim of this prospective study was to analyze the impact of abdominal incision type on postoperative pain and quality of life (QOL) in hepatectomy.

Methods: In patients undergoing hepatectomy by open, hybrid, or pure laparoscopic approaches, we classified abdominal incisions as: pure laparoscopic (LAP), midline (MID), J-shaped (J), and J-shaped incision plus thoracotomy (TRC). Postoperative pain was measured on postoperative day (POD) 3, 7, 30, and 90 using a visual analog scale (VAS). QOL was evaluated using the short-form-36 questionnaire preoperatively and on POD 30 and 90.

Results: We categorized 165 patients into LAP (n = 9, 5%), MID (n = 21, 13%), J (n = 95, 58%), and TRC (n = 40, 24%) groups. Median VAS scores on PODs 3/7/30/90 were: LAP, 27.5/7.5/10/10; MID, 30/10/15/5; J, 50/27.5/20/10, and TRC, 50/30/30/19. The J and TRC groups had significantly higher VAS scores vs. MID on PODs 3 and 7; the LAP and MID groups did not differ significantly. No significant positive correlations were observed between incision length and postoperative VAS, when we stratified patients into two groups according to the presence or absence of a transverse incision. Physical QOL summary scores did not return to preoperative levels even on POD 90, in patients with an additional transverse incision. Mental QOL summary scores worsened with postoperative complications rather than with abdominal incision type.

Conclusions: Transverse incisions, rather than incision length, led to worse midline incision pain and poorer QOL recovery post-hepatectomy. A hybrid approach may be a considerable option when pure laparoscopic hepatectomy is technically difficult.

Trial Registration: This study was registered in the UMIN Clinical Trials Registry (registration number: UMIN000017467; http://www.umin.ac.jp/ctr/index.htm ).
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http://dx.doi.org/10.1007/s00268-021-05992-xDOI Listing
June 2021

Comparing the 14-mm uncovered and 10-mm covered metal stents in patients with distal biliary obstruction caused by unresectable pancreatic cancer: a multicenter retrospective study.

Surg Endosc 2022 Jan 16;36(1):736-744. Epub 2021 Feb 16.

Department of Gastroenterological Internal Medicine, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.

Background: Endoscopic biliary drainage using metal stent (MSs) is an established palliative treatment for patients with unresectable malignant distal biliary obstruction (MDBO). However, a major drawback of MS is recurrent biliary obstruction (RBO). Uncovered MSs with a diameter of 14 mm (UMS-14) were developed to overcome this. We aimed to compare the clinical outcomes of UMS-14 with those of conventional covered MSs having a diameter of 10 mm (CMS-10).

Methods: Consecutive patients with MDBO caused by unresectable pancreatic cancer, who underwent UMS-14 or CMS-10 placement at two tertiary-care centers, were retrospectively examined according to the Tokyo Criteria 2014.

Results: Two hundred and thirty-eight patients who underwent UMS-14 (the UMS-14 group, n = 80) or CMS-10 (the CMS-10 group, n = 158) over a 62-month period were included. The technical and clinical success rates were similar between the two groups. RBO occurred in 20 (25%) and 59 (37%) patients of the UMS-14 and CMS-10 groups, respectively (p = 0.06). Median time till RBO was significantly longer in the UMS-14 group than in the CMS-10 group (not reached vs. 290 days, p = 0.04). Multivariate analysis revealed that CMS-10 placement was an independent risk factor for RBO (hazard ratio: 1.66, 95% confidence interval: 1.00-2.76). The incidence of early complications, including pancreatitis, and the overall survival (UMS-14 vs. CMS-10: 169 vs. 167 days, p = 0.83) were comparable between the two groups.

Conclusions: UMS-14 stents were safe and effective for treating patients with MDBO secondary to unresectable pancreatic cancer. The insertion of UMS-14 is recommended, because it is less likely to get occluded as compared to CMS-10.
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http://dx.doi.org/10.1007/s00464-021-08342-zDOI Listing
January 2022

An aberrant right hepatic artery arising from the gastroduodenal artery: a pitfall encountered during pancreaticoduodenectomy.

Surg Today 2021 Oct 11;51(10):1577-1582. Epub 2021 Feb 11.

Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.

Purpose: Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt.

Methods: A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes.

Results: Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases.

Conclusions: We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.
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http://dx.doi.org/10.1007/s00595-021-02242-4DOI Listing
October 2021

Bile aspiration during EUS-guided hepaticogastrostomy is associated with lower risk of postprocedural adverse events: a retrospective single-center study.

Surg Endosc 2021 12 4;35(12):6836-6845. Epub 2021 Jan 4.

Division of Endoscopy, Shizuoka Cancer Center, 1007 Shimonagakubo Nagaizumi-cho, Sunto-gun, Shizuoka, Japan.

Background: In endoscopic retrograde cholangiopancreatography (ERCP), reduction of pressure inside of the bile duct by bile aspiration is a well-known method to lower the rate of adverse events (AEs) including cholangitis. Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) has been introduced as an alternative to ERCP. The use of self-expandable metallic stents is recommended in EUS-HGS to reduce bile leak; however, other methods to reduce the rate of AEs including bile leak, abdominal pain, fever, and sepsis, have not been elucidated yet. This study investigated whether bile aspiration during EUS-HGS decreased the rate of postprocedural AEs.

Methods: Consecutive patients who underwent EUS-HGS between July 2016 and April 2020 were retrospectively evaluated in this study. EUS-HGS was performed at a tertiary cancer center. Patient characteristics, site of biliary obstruction, the quantity of bile aspirated during EUS-HGS, type of stent, whether or not antegrade stenting (AS) was performed, procedure time, and AEs were assessed based on a prospectively recorded institutional endoscopy database. Logistic regression analysis was performed to identify factors affecting postprocedural AEs.

Results: Ninety-six patients were included in the study. EUS-guided HGS with and without AS was performed in 45 and 51 patients, respectively. Bile was aspirated in 71 patients (74%). The quantity of bile aspirated was 0-10 mL and > 10 mL in 40 and 56 patients, respectively. AEs including fever, abdominal pain, postprocedural cholangitis, sepsis, acute pancreatitis, and bleeding occurred in 45 patients (47%). The AE rates were 65% (26/40) and 34% (19/56), for 0-10 mL and > 10 mL bile, respectively (p = 0.004). Using multivariate analysis, the only independent factor affecting the occurrence of AEs was found to be an aspirated bile amount of 0-10 mL (odds ratio: 4.16; 95% CI 1.6-10.8).

Conclusions: Bile aspiration of more than 10 mL during EUS-HGS contributes to reducing the rate of postprocedural AEs.
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http://dx.doi.org/10.1007/s00464-020-08189-wDOI Listing
December 2021

Identification of Glisson's Capsule Invasion During Hepatectomy for Colorectal Liver Metastasis by Contrast-Enhanced Ultrasonography Using Perflubutane.

World J Surg 2021 Apr 3;45(4):1168-1177. Epub 2021 Jan 3.

Department of Surgery, Graduate School of Medicine, Hepato-Biliary-Pancreatic Surgery Division, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.

Background: Glisson invasion by CLM is associated with a risk of margin-positive resection, leading to poor long-term outcomes after hepatectomy. This study was performed to evaluate the efficacy of intraoperative ultrasonography (IOUS) for the diagnosis of Glisson's capsule invasion by colorectal liver metastasis (CLM).

Methods: This prospective study involved 50 consecutive patients undergoing hepatectomy for CLM. Preoperatively, all patients had undergone gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOB-MRI). During hepatectomy, a contrast agent (perflubutane) was intravenously injected and Glisson invasion was estimated based on three characteristic findings: a tumor thrombus, peripheral dilatation, and border irregularity/caliber change. The diagnostic abilities of the preoperative and intraoperative imaging studies were evaluated based on pathological examinations of resected specimens.

Results: Among 187 CLMs resected, pathological examinations proved Glisson invasion in 24 tumors (13%). IOUS revealed a tumor thrombus in 3 tumors (1.6%), peripheral dilatation in 4 (2.1%), and border irregularity and/or caliber change in 24 (12.8%). The sensitivity and specificity of IOUS with any of the above three findings for diagnosis of Glisson invasion was 79% and 96%, respectively, while preoperative EOB-MRI detected Glisson invasion in only four tumors (sensitivity/specificity, 17%/100%). The cutoff value of caliber change for diagnosis of Glisson invasion was set at 140% by receiver operating characteristic analysis. The R0 resection rates were not significantly different between patients with (82%) and without (85%) Glisson invasion.

Conclusions: Identification of characteristic findings (tumor thrombus, peripheral dilatation, and border irregularity/caliber change) by contrast-enhanced IOUS is useful for the prediction of Glisson invasion by CLM.
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http://dx.doi.org/10.1007/s00268-020-05883-7DOI Listing
April 2021

Intestinal-type histology is associated with better prognosis in patients undergoing liver resection for gastric/esophagogastric-junction liver metastasis.

Glob Health Med 2019 Dec;1(2):101-109

Gastrointestinal Surgery Division, Department of Surgery, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan.

The indication for resection of gastric/esophagogastric-junction liver metastasis (GELM) has yet to be established. This study aimed to investigate prognostic factors in patients undergoing GELM resection. From 2001 to 2015, 31 consecutive patients underwent resection for GELM; and factors for poor prognosis were evaluated. Of the 31 patients, 23 (74.2%) developed multiple liver metastases. The histology of gastric cancer was intestinal-type adenocarcinoma in 21 patients (67.7%). Median overall survival (OS) was 3.2 years. The 1-, 3-, and 5-year OS rates were 92.8%, 56.2%, and 42.2%, respectively. The 1-, 3-, and 5-year recurrence-free survival (RFS) rates were 58.5%, 31.3%, and 31.3%, respectively. Multivariate analysis indicated that intestinal-type adenocarcinoma was associated with a significantly lower risk of OS (hazard ratio [HR], 0.26; =0.022) and RFS (HR, 0.25; = 0.008). In multiple logistic regression analysis, intestinal-type adenocarcinoma (odds ratio, 0.14; = 0.012) reduced incidence of extra-hepatic recurrence after GELM resection. In conclusion, GELM resection in patients with intestinal-type histology is preferable because intestinal-type adenocarcinoma is associated with better prognosis and a lower incidence of extra-hepatic recurrence than diffuse/other-type adenocarcinoma.
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http://dx.doi.org/10.35772/ghm.2019.01012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7731421PMC
December 2019

Silk fibroin vascular graft: a promising tissue-engineered scaffold material for abdominal venous system replacement.

Sci Rep 2020 12 3;10(1):21041. Epub 2020 Dec 3.

Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.

No alternative tissue-engineered vascular grafts for the abdominal venous system are reported. The present study focused on the development of new tissue-engineered vascular graft using a silk-based scaffold material for abdominal venous system replacement. A rat vein, the inferior vena cava, was replaced by a silk fibroin (SF, a biocompatible natural insoluble protein present in silk thread), tissue-engineered vascular graft (10 mm long, 3 mm diameter, n = 19, SF group). The 1 and 4 -week patency rates and histologic reactions were compared with those of expanded polytetrafluoroethylene vascular grafts (n = 10, ePTFE group). The patency rate at 1 and 4 weeks after replacement in the SF group was 100.0% and 94.7%, and that in the ePTFE group was 100.0% and 80.0%, respectively. There was no significant difference between groups (p = 0.36). Unlike the ePTFE graft, CD31-positive endothelial cells covered the whole luminal surface of the SF vascular graft at 4 weeks, indicating better endothelialization. SF vascular grafts may be a promising tissue-engineered scaffold material for abdominal venous system replacement.
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http://dx.doi.org/10.1038/s41598-020-78020-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713399PMC
December 2020

Risk factors for hepatitis B virus recurrence after living donor liver transplantation: A 22-year experience at a single center.

Biosci Trends 2021 Jan 25;14(6):443-449. Epub 2020 Nov 25.

Organ Transplantation Service, The University of Tokyo Hospital, Tokyo, Japan.

The factors associated with hepatitis B virus (HBV) recurrence after living donor liver transplantation (LDLT) have not been fully clarified. The aim of this study was to determine the risk factors associated with HBV recurrence after LDLT. From January 1996 to December 2018, a total of 609 LDLT operations were performed at our center. A retrospective review was performed of 70 patients (male, n = 59; female, n = 11; median age = 54 years) who underwent LDLT for HBV-related liver disease. The virologic and biochemical data, tumor burden, antiviral and immunosuppressive therapy were evaluated and compared between the HBV recurrence and non-recurrence groups. Eleven of 70 patients (16%) developed post-LDLT HBV recurrence. The overall actuarial rates of HBV recurrence at 1, 3, 5, 10, and 20 years were 0%, 13%, 16.7%, 18.8%, and 18.8%, respectively. The median interval between LDLT and HBV recurrence was 57 months (range, 18-124 months). Based on the univariate and multivariate analyses, a serum HBV DNA level of ≥ 4 log copies/mL (hazard ratio [HR], 4.861; 95% confidence interval [95% CI], 1.172-20.165; P = 0.029), and hepatocellular carcinoma (HCC) beyond the Milan criteria (HR, 10.083; 95% CI, 2.749-36.982; P < 0.001) were independent risk factors for HBV recurrence after LDLT. In LDLT patients, high pre-LT HBV DNA levels and HCC beyond the Milan criteria were risk factors for HBV recurrence. With the current expansion of the LT criteria for HCC, we should remain cautious regarding the risk of HBV recurrence, particularly in these groups.
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http://dx.doi.org/10.5582/bst.2020.03336DOI Listing
January 2021

Indocyanine green administration a day before surgery may increase bile duct detectability on fluorescence cholangiography during laparoscopic cholecystectomy.

J Hepatobiliary Pancreat Sci 2021 Feb 17;28(2):202-210. Epub 2020 Nov 17.

Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.

Background: The optimal indocyanine green (ICG) administration protocol for fluorescence cholangiography during laparoscopic cholecystectomy (LC) has yet to be determined.

Methods: A prospective study including 20 cases of ICG fluorescence-navigated LC was conducted. Accordingly, the first 10 patients were administered 2.5 mg of ICG on the day of surgery after intubation (surgery-day group), while the remaining 10 consecutive patients were administered 0.25 mg/kg of ICG on the evening before surgery (one-day-before group). Fluorescence intensity (FI) of each tissue and FI ratios were then compared between both groups.

Results: The median interval between observation and ICG administration was 27 minutes and 16 hours 24 minutes in the surgery-day and one-day-before group, respectively. Although FI values for the common bile duct (CBD), liver, and hepatoduodenal ligament (HDL) were significantly lower in the one-day-before group than in the surgery-day group, CBD- , 0.6-1.2 vs 2.5, 0.9 = -4.8; P < .001), and CBD-HDL contrast (1.7, 1.4-2.4 vs 2.3, 1.5-13.3; P = .038) were significantly higher in the one-day-before group than in the surgery-day group.

Conclusion: ICG administration a day before LC may offer better CBD background contrast compared to administration just prior to surgery.
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http://dx.doi.org/10.1002/jhbp.855DOI Listing
February 2021

Type 1 Autoimmune Pancreatitis Extending along the Main Pancreatic Duct: IgG4-related Pancreatic Periductitis.

Intern Med 2021 Mar 30;60(5):739-744. Epub 2020 Sep 30.

Division of Endoscopy, Shizuoka Cancer Center, Japan.

We herein report a unique form of autoimmune pancreatitis (AIP) spreading along the main pancreatic duct (MPD). A 70-year-old man was referred for a small lesion at the pancreatic neck, accompanying an adjacent cyst and dilated upstream MPD. Four years earlier, health checkup images had shown a pancreatic cyst but no mass lesion. Endoscopic ultrasonography showed a contrast-enhanced, tumorous lesion, mainly occupying the MPD. With a preoperative diagnosis of ductal neoplasms mainly spreading in the MPD, Whipple's resection was performed. The resected specimens showed MPD periductitis with IgG4-related pathology, indicating type 1 AIP. Clinicians should practice caution concerning the various AIP forms.
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http://dx.doi.org/10.2169/internalmedicine.5754-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7990648PMC
March 2021

Pulse oximetry-based capillary refilling evaluation predicts postoperative outcomes in liver transplantation: a prospective observational cohort study.

BMC Anesthesiol 2020 09 29;20(1):251. Epub 2020 Sep 29.

Department of Acute Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.

Background: Capillary refill time (CRT) is a non-invasive technique to evaluate tissue perfusion, and quantitative CRT (Q-CRT) adapted to pulse oximetry was developed with patients with sepsis and compared to blood lactate and sepsis scores. In post liver transplantation, large amounts of fluid administration are necessary for maintaining tissue perfusion to grafted liver against intravascular hypovolemia. This study aimed to evaluate whether Q-CRT can predict poor outcomes by detecting peripheral tissue perfusion abnormality in patients with liver transplantations who were treated with massive fluid administration.

Methods: In this single-center prospective cohort study, we enrolled adult patients with liver transplantations between June 2018 and July 2019. Measurement of Q-CRT was conducted at intensive care units (ICU) admission and postoperative day 1 (POD1).

Results: A total of 33 patients with liver transplantations were enrolled. Significant correlations of Q-CRT and ΔA, a tissue oxygen delivery parameter calculated by pulse oximetry data, at ICU admission with the postoperative outcomes such as length of ICU and hospital stay and total amount of ascitic fluid discharge were observed. Quantitative CRT and ΔA at ICU admission were significantly associated with these postoperative outcomes, even after adjusting preoperative and operative factors (MELD score and bleeding volume, respectively). However, quantitative CRT and ΔA at POD1 and changes from ICU admission to POD1 failed to show significant associations.

Conclusions: Q-CRT values were significantly associated with postoperative outcomes in liver transplantation. Although the mechanisms of this association need to be clarified further, Q-CRT may enable identification of high-risk patients that need intensive postoperative managements.
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http://dx.doi.org/10.1186/s12871-020-01171-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523076PMC
September 2020

Microvascular Hepatic Artery Anastomosis in Living Donor Liver Transplantation for Erythropoietic Protoporphyria.

Plast Reconstr Surg Glob Open 2020 Aug 17;8(8):e3066. Epub 2020 Aug 17.

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.

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http://dx.doi.org/10.1097/GOX.0000000000003066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489609PMC
August 2020

Macroscopic on-site evaluation of biopsy specimens for accurate pathological diagnosis during EUS-guided fine needle biopsy using 22-G Franseen needle.

Endosc Ultrasound 2020 Nov-Dec;9(6):385-391

Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan.

Background And Objectives: Measuring a visible core length during macroscopic on-site evaluation (MOSE) can be useful for accurate diagnoses during an EUS-guided fine needle biopsy (EUS-FNB). We aimed to estimate visible core cutoff lengths predictive of a correct diagnosis when using 22-gauge Franseen needles for biopsies from pancreatic masses.

Materials And Methods: We assessed 77 consecutive patients who underwent EUS-FNB using 22-gauge Franseen needles for pancreatic masses between March 2018 and October 2018. At least two needle passes were performed in all patients, irrespective of the findings on MOSE. The endoscopists measured the visible cores using a ruler during MOSE. The first two passes were analyzed on a per pass basis, and the correlation between visible core lengths and diagnostic accuracy was evaluated.

Results: We evaluated 150 needle passes of 75 patients. The accuracy per pass was 92% (138/150). The median length of the visible cores was 15 (range: 0-60) mm and they were significantly longer in the correct diagnosis group than in the incorrect diagnosis group. The accuracy correlated positively with the visible core length. Receiver-operating characteristic curve analysis of the visible core length for accuracy demonstrated an optimal cutoff value of 10 mm. On multivariate logistic regression, visible core lengths >10 mm independently affected the correct diagnosis (odds ratio: 5.1, P= 0.02).

Conclusions: Visible cores exceeding 10 mm may be useful for correct diagnosis while using a 22-gauge Franseen needle for EUS-FNB from pancreatic masses.
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http://dx.doi.org/10.4103/eus.eus_49_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811705PMC
September 2020

Identification of liver lesions using fluorescence imaging: comparison of methods for administering indocyanine green.

HPB (Oxford) 2021 02 13;23(2):262-269. Epub 2020 Jul 13.

Hepato-Pancreatico-Biliary Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Japan. Electronic address:

Background: Fluorescence imaging using indocyanine green (ICG) enables intraoperatively visualizing liver tumors as fluorescent. This study evaluated the doses and timing of ICG administration for visualizing tumors via fluorescence using near-infrared light camera systems.

Methods: Consecutive patients who underwent open liver resection for liver tumors from 2016 to 2017 were included. ICG was intravenously injected one-day before surgery at 0.25 mg-intravenous injection (IV), 1.25 mg-IV, 2.5 mg-IV, or 3.75 mg-IV. No additional ICG was administered when patients underwent ICG (0.5 mg/kg) retention test within 10 preoperative days. The ability of fluorescence imaging to enable identifying liver tumors was compared using the PDE-NEO and PINPOINT.

Results: 154 lesions in 82 patients were assessed. The tumor identification rate of PDE-NEO did not differ significantly among dosages. The positive predictive values of PDE-NEO were significantly lower at 3.75 mg-IV (69.0%) than in the control group (92.0%) (p = 0.036) and at 1.25 mg-IV (88.9%) (p = 0.033). The tumor identification rate of PINPOINT was significantly higher at 3.75 mg-IV (82.4%) than at 1.25 mg-IV (60.0%) (p = 0.035). The positive predictive values of PINPOINT did not significantly differ among dosages.

Conclusion: Administering 2.5 mg of ICG one-day before surgery can enable identifying tumors via fluorescence imaging when the ICG test was not performed within 10 preoperative days.
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http://dx.doi.org/10.1016/j.hpb.2020.06.006DOI Listing
February 2021

Therapeutic effect of portal vein stenting for portal vein stenosis after upper-abdominal surgery.

HPB (Oxford) 2021 02 27;23(2):238-244. Epub 2020 Jun 27.

Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan. Electronic address:

Background: The therapeutic effect of portal vein (PV) stenting for PV stenosis following nontransplant hepato-pancreato-biliary (HPB) surgery has not been fully investigated.

Methods: Changes in portal venous pressure (PVP) gradient before and after stenting, complications, symptomatic improvement, and stent patency were evaluated.

Results: We identified 14 consecutive patients undergoing PV stenting for malignant (n = 8) and benign (n = 6) PV stenosis. Signs of PV stenosis were composed of refractory ascites in 6 patients, varices with hemorrhagic tendencies in 5, and abnormal liver function in 5. The median PVP gradient after PV stenting was 3.0 cm HO (range, 1.5-3.0), which was significantly smaller than that before PV stenting (median, 15 cm HO [range, 2.5-25]; P < 0.01). Thirteen out of 14 (93%) achieved clinical success with symptomatic improvement, except one patient with sustained refractory ascites because of peritoneal seeding. During the median follow-up time of 7.3 months (range, 1.0-87), stent occlusion occurred in two patients (14%) because of intrastent tumor growth. The 1-year cumulative stent patency rate was 76% in the entire cohort.

Conclusions: Based on durable effect on patency, we deemed PV stenting for PV stenosis after HPB surgery to be safe and beneficial for improving symptoms.
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http://dx.doi.org/10.1016/j.hpb.2020.06.003DOI Listing
February 2021

Sex differences in postsurgical skeletal muscle depletion after donation of living-donor liver transplantation, although minimal, should not be ignored.

BMC Surg 2020 Jun 3;20(1):119. Epub 2020 Jun 3.

Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.

Background: Donor safety is the top priority in living-donor liver transplantation. Splenic hypertrophy and platelet count decrease after donor surgery are reported to correlate with the extent of hepatectomy, but other aftereffects of donor surgeries are unclear. In this study, we evaluated the surgical effects of donor hepatectomy on skeletal muscle depletion and their potential sex differences.

Methods: Among a total of 450 consecutive donor hepatectomies performed from April 2001 through March 2017, 277 donors who completed both preoperative and postoperative (60-119 days postsurgery) evaluation by computed tomography were the subjects of this study. Donors aged 45 years or older were considered elderly donors. Postoperative skeletal muscle depletion was assessed on the basis of the cross-sectional area of the psoas major muscle. Postoperative changes in the spleen volume and platelet count ratios were also analysed to evaluate the effects of major hepatectomy.

Results: The decrease in the postoperative skeletal muscle mass in the overall donor population was slight (99.4 ± 6.3%). Of the 277 donors, 59 (21.3%) exhibited skeletal muscle depletion (i.e., < 95% of the preoperative value). Multivariate analysis revealed that elderly donor (OR:2.30, 95% C.I.: 1.27-4.24) and female donor (OR: 1.94, 95% C.I. 1.04-3.59) were independent risk factors for postoperative skeletal muscle depletion. Stratification of the subjects into four groups by age and sex revealed that the elderly female donor group had significantly less skeletal muscle mass postoperatively compared with the preoperative values (95.6 ± 6.8%), while the other three groups showed no significant decrease. Due to their smaller physical characteristics, right liver donation was significantly more prevalent in the female groups than in the male groups (112/144, 77.8% vs 65/133, 48.9%; p < 0.001). The estimated liver resection rate correlated significantly with the splenic hypertrophy ratio (r = 0.528, p < 0.001) and the extent of the platelet count decrease (r = - 0.314, p < 0.001), but donor age and sex did not affect these parameters.

Conclusion: Elderly female donors have a higher risk of postoperative skeletal muscle depletion. Additionally, female donors are more likely to donate a right liver graft, whose potential subclinical risks include postoperative splenic enlargement and a platelet count decrease.
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http://dx.doi.org/10.1186/s12893-020-00781-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7268651PMC
June 2020

Clinical Significance of Spontaneous Portosystemic Shunts in Living Donor Liver Transplantation.

Liver Transpl 2021 01 14;27(1):77-87. Epub 2020 Jul 14.

Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.

Spontaneous portosystemic shunts (SPSS) are commonly observed in patients undergoing living donor liver transplantation (LDLT); however, their impact on the outcome after transplantation is unclear. We aimed to assess the type, size, and the effects of SPSS on outcomes after LDLT. A total of 339 LDLT recipients in a single institution were included. The type and diameter of the SPSS (splenorenal shunt [SRS], oesogastric shunt, and umbilical shunt) were retrospectively analyzed. A large shunt was defined as having a diameter ≤7 mm. No portal flow modulation was attempted over time. Portal complications were defined as stenosis, thrombosis, or hepatofugal flow requiring any treatment after transplantation. There were 202 (59.0%) patients who exhibited at least 1 large SPSS. Neither the size nor type of SPSS was associated with mortality, morbidity, or liver function recovery. However, the incidence of portal complications was significantly higher in patients with a large SRS (8.6% versus 2.9%; P = 0.04). Multivariate analysis of portal complications revealed 2 independent predictors: pre-LT portal vein thrombosis (PVT) and SRS size. The observed risk among recipients with pre-LT PVT was 8.3% when the SRS was ≤7 mm, but increased to 38.5% when the SRS was >15 mm. The present study suggests that large SPSS do not negatively affect the outcomes after LDLT. However, a large SRS is associated with a higher risk of portal complications, particularly in recipients with pre-LT PVT, for whom intraoperative intervention for SRS should be considered. Otherwise, a conservative approach to SPSS during LDLT seems reasonable.
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http://dx.doi.org/10.1002/lt.25798DOI Listing
January 2021

Timing for removing prophylactic drains after liver resection: an evaluation of drain removal on the third and first postoperative days.

Ann Transl Med 2020 Apr;8(7):454

Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.

Background: Conventionally, drains are removed from postoperative day (POD) 7 to POD 14 at our institute after hepatectomy (control group). This study was conducted to evaluate the outcomes of drain removal in the early postoperative period.

Methods: Recently, we defined criteria for the early removal of drains: (I) a drain-fluid bilirubin level of below 3 mg/dL; (II) a drain discharge volume of less than 500 mL/day; and (III) no macroscopic signs of bleeding or infection. For patients meeting these criteria, drains were removed on POD 3 between January 2012 and February 2013 (POD 3 group) and on POD 1 between February and December 2013 (POD 1 group). The outcomes of these groups were then retrospectively compared.

Results: The median duration of the postoperative hospital stay was shorter in the POD 3 group (11 days) than in the control group (14 days) (P<0.0001). The incidence of drain infection was lower in the POD 3 group (1.2%) than in the control group (5.7%). Meanwhile, the incidences of bile leakage and complications were higher in the POD 1 group than in the POD 3 group. However, the incidences were almost the same when patients whose drains were actually removed on the predefined POD were compared. The intraoperative findings were also considered when removing the drains.

Conclusions: Drain removal on POD 3 may reduce the length of the postoperative hospital stay and the incidence of drain infection without impairing safety. To remove drains safely on POD 1, however, the intraoperative findings should also be considered.
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http://dx.doi.org/10.21037/atm.2020.04.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7210192PMC
April 2020
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