Background/Aim: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is a precursor lesion with variable malignant potential. Due to its heterogeneity, optimal treatment strategies remain controversial, especially regarding surgical resection and surveillance indications. We reviewed our institutional outcomes to reassess the current postoperative strategy and refine management guidelines. Patients and Methods: This study retrospectively and consecutively analyzed the data of 49 IPMN patients who underwent pancreatectomy at an academic institution from 2015 to May 2025. Results: Diagnostic mismatch between preoperative and final pathological findings was observed in 39% of cases, with overdiagnosis (downgrade group) being more common than underdiagnosis. Overdiagnosed cases were significantly associated with main pancreatic duct dilation (>5 mm) (p=0.012) and elevated amylase levels (p=0.031), while the only upgraded case involved invasive carcinoma with mural nodule and Sonazoid enhancement. Histological grade strongly influenced prognosis: Patients with adenoma or carcinoma in situ showed favorable outcomes (5-year OS ≥89%), whereas those with invasive IPMN had markedly worse survival (5-year OS 36%; p<0.001). Elevated CA19-9 was a significant negative prognostic factor (p=0.031), while lymph node metastasis (p=0.035) and advanced tumor stage (p=0.0014) were also associated with poor outcomes. Tumors located in the pancreatic tail and those classified as mixed-type IPMN tended to have inferior survival, though without statistical significance. Cancer recurrence occurred in 18% of patients, primarily via peritoneal and hepatic routes. Conclusion: Preoperative diagnostic inaccuracies remain common in IPMN, and invasive transformation, elevated CA19-9, lymph node metastasis, and tumor stage are key prognostic factors. A multimodal diagnostic approach is needed to improve risk stratification and guide appropriate surgical management.

BACKGROUND:Pancreaticoduodenectomy (PD) in dialysis patients is rare but carries a high risk of complications and mortality. This study aimed to identify preoperative factors associated with severe postoperative complications and mortality. METHODS:Using the Japanese National Clinical Database, 329 dialysis patients undergoing PD between 2016 and 2020 were retrospectively analyzed. Multivariable penalized logistic regression identified preoperative risk factors for Clavien-Dindo classification (CDC) grade ≥ 4 complications, 30-day mortality, operative mortality, postoperative sepsis, and postoperative pancreatic fistula (POPF) (grade B or C). RESULTS:CDC grade ≥ 4 complications, 30-day mortality, and operative mortality occurred in 10.3%, 5.5%, and 11.2%, respectively. Diet- or oral medication-treated diabetes (Odds ratio 5.19, 95% confidence interval 1.19-22.66) and insulin-treated diabetes (7.50, 1.61-34.93) independently predicted 30-day mortality. Serum albumin levels < 3.0 g/dL independently predicted operative mortality (2.72, 1.05-7.02), while cardiovascular disease showed a borderline association (2.15, 0.95-4.85). Elevated CRP was significantly associated with postoperative sepsis (2.47, 1.07-5.67), and pancreatic cancer was associated with a lower risk of POPF (grade B or C) (0.59, 0.37-0.94). CONCLUSIONS:Dialysis patients undergoing PD face perioperative risks. Early mortality is driven by acute metabolic and infectious vulnerability, whereas operative mortality reflects diminished physiologic reserve related to malnutrition and cardiovascular comorbidity.

ABSTRACT Aim We examine the impact of interferon (IFN)‐based and IFN‐free treatment on the prognosis of hepatocellular carcinoma (HCC) after hepatitis C virus (HCV) sustained virological response (SVR). Methods Clinical information was collected on 311 cases of HCC after HCV‐SVR from 16 facilities affiliated with the Kyushu Liver Surgery Study Group. Clinical factors and the tumor microenvironment of HCC after SVR treatment with IFN‐based and IFN‐free treatments were analyzed. Results No statistically significant differences were observed in the recurrence rate and overall survival (OS) between the two groups. Propensity score–matched analysis similarly showed no statistically significant differences in recurrence and OS. In the IFN‐based treatment group, OS time was significantly shorter for the programmed death‐ligand 1(PD‐L1)‐positive HCC than the PD‐L1‐negative HCC group (p = 0.0183). No significant difference was observed in the recurrence rate between PD‐L1‐positive and PD‐L1‐negative HCC groups. In the IFN‐based treatment group, the recurrence rate in the cluster of differentiation (CD) 8‐positive group was significantly lower than in the CD8‐negative group (p = 0.0292). There was no difference in OS time between the CD8‐positive and CD8‐negative groups. In the IFN‐free treatment group, PD‐L1 and CD8 were not associated with recurrence rate or OS. Conclusions No statistically significant differences were observed in recurrence or OS rate after HCC resection in the IFN‐free treatment group compared with the IFN‐based treatment group. In the IFN‐based treatment group, PD‐L1 and CD8 expression on cancer cells might be prognostic factors.

Virtual Reality (VR) is increasingly used in surgical education. This study examines the impact of VR-integrated training on learning, memory, and psychological responses. A prototype VR system with immersive OR views was tested on 67 clinical clerkship students. OR experiences followed the simulation. Thirty-two questionnaires covered surgical procedures and systems. Mood and personality were assessed using POMS-2, focusing on Total Mood Disturbance (TMD), fatigue-inertia (FI), vigor-activity (VA), and friendliness (F). VR modestly increased interest in surgery (~3.4/5) but training confidence stayed low (2.2/5). Understanding of abdominal surgery improved (2.6/5), with 96% correctly identifying the sterile field. Robotic roles were partially grasped; DCS understanding remained low (2.3/5). VR users better located OR equipment but 22% experienced nausea and 46% disliked the design. Compared to non-VR peers, they had lower procedural knowledge (p<0.01), but reported less stress and improved teamwork awareness (p<0.01). Mood analysis showed increased TMD and FI, decreased VA and F (all p<0.01), and reduced anxiety (TA). Personality traits (low neuroticism, high extraversion) were linked to stronger emotional reactions. VR sickness (51%) correlated with cognitive confusion and higher TMD (p<0.01). This VR approach enhances surgical understanding and team role awareness, offering experiential value in preclinical training.

Peritoneal dissemination remains a critical factor associated with a poor prognosis in gastric cancer. Blue light irradiation has recently been reported to exert wavelength-specific cytotoxic effects on cancer cells. This study evaluated the feasibility, safety, and antitumor efficacy of intraoperative intraperitoneal blue LED (IPBL) irradiation using a murine gastric cancer peritoneal dissemination model. BALB/c nude mice were intraperitoneally inoculated with HGC27 cells and treated with IPBL irradiation via a cylindrical fiber-optic diffuser. Tumor burden was quantitatively assessed by total tumor weight and peritoneal carcinomatosis index (PCI), and perioperative safety was evaluated by clinical findings, serum biochemistry, histopathology, and scanning electron microscopy. The total PCI was markedly reduced in the IPBL group in comparison to the control group (7.2 ± 6.9 vs. 21.3 ± 3.1, P < 0.01). No procedure-related mortality, ascites formation, or macroscopic peritoneal damage was observed. Histological analyses demonstrated preservation of the mesothelial layer, although mild submesothelial collagen deposition and mesothelial flattening were noted. These results indicate that IPBL irradiation is a feasible and well-tolerated intraoperative intervention that significantly suppresses peritoneal dissemination in a murine gastric cancer model and may serve as a promising surgical adjunct to reduce postoperative peritoneal recurrence.

Background: Hepatolithiasis is a life-threatening condition, and the incidence of secondary hepatolithiasis has increased in patients with a history of choledochoenterostomy who underwent pancreaticoduodenectomy (PD). In this study, we aimed to evaluate the risk factors and confirm the appropriate treatment for hepatolithiasis after PD. Materials and methods: Between January 2010 and December 2022, 314 patients who underwent PD were evaluated using a cross-sectional study. Eight patients who underwent PD with hepatectomy were excluded, leaving 306 patients for analysis. Patient demographics, surgical factors, and clinical and biochemical parameters were assessed to determine the predictive factors of hepatolithiasis after PD. Results: Among the 306 patients, 21 (6.9%) developed hepatolithiasis after PD. Of these, 17 patients (81.0%) experienced cholangitis, while 4 (19.0%) were asymptomatic. Cholangitis occurred on average 33.4 ± 10.3 months postsurgery. Fifteen patients received treatment (13 with cholangitis, two without). Fourteen underwent balloon enteroscopy-assisted endoscopic retrograde cholangioscopy (BE-ERC), with 100% scope insertion and 87.5% stone removal success rates. Univariate analysis revealed several risk factors for hepatolithiasis after PD, including heavy body weight ( P = 0.0096), high body mass index ( P = 0.0508), benign disease ( P = 0.0109), preoperative drainage ( P = 0.0680), and hepaticojejunostomy suture pitch greater than 2 mm ( P = 0.0222). Multivariate analysis indicated that only a suture pitch greater than 2 mm ( P = 0.0367) was a risk factor for hepatolithiasis after PD. Conclusion: BE-ERC is an effective treatment for hepatolithiasis after PD. For hepaticojejunostomy, the suture pitch should not exceed 2 mm to prevent hepatolithiasis after PD.

BACKGROUND/PURPOSE:This study evaluated the association between institutional advanced hepatobiliary-pancreatic (HBP) surgical volume and operative mortality for pancreaticoduodenectomy (PD) and advanced hepatectomy using data from the Japanese National Clinical Database. METHODS:Patients undergoing PD or advanced hepatectomy between 2018 and 2021 were identified. Hospital volume was defined as the mean annual number of advanced HBP procedures performed at each institution. Volume-mortality associations were assessed using thin-plate spline regression with hospital volume as a continuous variable, followed by categorical analyses using four predefined groups (≤ 19, 20-29, 30-49, and ≥ 50 cases/year). The primary outcome was the operative mortality. RESULTS:We analyzed 47 088 patients undergoing PD and 27 358 undergoing hepatectomy. Mortality decreased with increasing institutional advanced HBP surgical volume for both procedures and plateaued at approximately 50 annual procedures. Compared with 30-49-case institutions, ≤ 19-case hospitals had significantly higher adjusted mortality for PD and hepatectomy, whereas ≥ 50-case hospitals had significantly lower mortality. CONCLUSIONS:Higher institutional advanced HBP surgical volume was associated with lower operative mortality for both procedures. Although both procedures appeared to achieve stable outcomes at similarly high institutional volumes, their volume-mortality curves differed in shape, suggesting the value of incorporating procedure-specific considerations into future quality assessment frameworks.

Background/Aim:Pancreatic neuroendocrine tumors (PanNETs) are heterogeneous neoplasms for which surgical resection remains the only potentially curative therapy. However, preoperative diagnostic accuracy - particularly tumor grading - often varies, complicating treatment decisions. This study evaluated diagnostic concordance between preoperative assessments and postoperative pathology, as well as surgical outcomes and prognostic factors in patients undergoing pancreatectomy for PanNETs. Patients and Methods:We retrospectively reviewed the clinical records of 32 patients who underwent surgical resection for PanNETs. Patient demographics, tumor characteristics, surgical procedures, and postoperative outcomes were analyzed. Preoperative imaging and cytology-based diagnoses were compared with final pathological findings to evaluate diagnostic concordance. Prognostic factors were assessed using Kaplan-Meier survival analysis. Results:Histological grading of resected specimens showed G1 in 53%, G2 in 41%, and G3/NEC in 6%, with a 38% discordance rate from preoperative biopsy. Lymphatic, venous, and perineural invasions were identified in 16%, 44%, and 13% of cases. Lymph node metastasis occurred in 22%. Among 30 patients with follow-up >12 months, eight developed recurrence, most commonly in the liver. The 3-year and 5-year disease-free survival (DFS) rates were 78% and 69%, while overall survival (OS) rates were 96% and 91%. Tumor number >2 and histologic grade G3 were significantly associated with reduced DFS (p<0.05). Lymphatic invasion and metachronous liver metastasis were significantly associated with reduced OS (p<0.01 and p<0.05, respectively). Histological grading mismatch was not associated with survival outcomes. Conclusion:Pancreatectomy for PanNETs is a safe and effective treatment with favorable long-term outcomes. Histological factors such as tumor grade, lymphatic invasion, and tumor number significantly predict recurrence and survival.

INTRODUCTION:Pelvic arteriovenous malformations (AVMs) are rare vascular anomalies that may cause marked venous engorgement and increase the risk of massive hemorrhage during pelvic surgery. When rectal cancer coexists with a pelvic AVM, achieving oncological radicality while maintaining surgical safety becomes particularly challenging. CASE PRESENTATION:A patient with rectal cancer complicated by a pelvic AVM was referred for surgical treatment. Preoperative imaging demonstrated a pelvic AVM supplied by branches of the internal iliac artery with venous drainage into the rectal venous plexus. Selective preoperative coil embolization was performed to treat the AVM while rectal arterial perfusion was preserved. Robotic-assisted total mesorectal excision (TME) was subsequently undertaken. Despite residual presacral venous dilatation related to chronic hemodynamic changes, robotic-assisted TME was completed without hemorrhagic complications. Intraoperative indocyanine green fluorescence angiography confirmed adequate perfusion of both the proximal colon and the distal rectal stump, allowing safe primary anastomosis without a diverting stoma. The postoperative course was uneventful. CONCLUSIONS:Rectal cancer associated with a pelvic AVM presents unique surgical challenges due to altered pelvic vascular anatomy. This case suggests that careful preoperative planning, selective embolization, and appropriate integration of advanced surgical techniques may facilitate safe radical resection in similarly complex pelvic conditions.

INTRODUCTION:Esophageal penetration due to accidental foreign body ingestion is relatively rare but has a poor prognosis. Penetration into the left atrium is extremely rare, and only a few cases have been reported. A case of foreign body penetration into the left atrium is reported. CASE PRESENTATION:The patient was a 75-year-old woman who was transferred to our hospital for surgery due to fish bone perforation from the lower esophagus into the left atrium on CT. Urgent surgery was performed with the diagnosis of sepsis due to a mediastinal abscess and esophageal penetration into the left atrium caused by accidental fish bone ingestion. At surgery, only the fistula of the penetration wound in the esophagus and the left atrium could be detected, but not the fish bone. On CT after surgery, a folded fish bone was seen at the pericardium close to the left atrium. It was considered unlikely that the heart would again be perforated due to the fish bone's length, and it was decided to follow up with continued antimicrobial therapy. CONCLUSIONS:A rare, successfully rescued case of esophageal penetration of an accidentally ingested fish bone into the left atrium by urgent surgery, with collaboration between gastrointestinal and cardiovascular surgeons, is reported.

BACKGROUND:Although portal vein (PV) contact ≤ 180° in pancreatic body/tail ductal adenocarcinoma (PbtCa) is a criterion for resectable, adequate evidence has not been established yet. METHODS:This retrospective study analyzed 1693 patients with PbtCa who underwent distal pancreatectomy across 31 institutions in Japan. Clinicopathological factors, survival, and recurrence pattern were compared among non-PV contact, PV contact, and celiac axis (CeA) contact groups. RESULTS:Overall survival (MST: 28.3 months) and the positive surgical margin rate (23%) in the PV contact (n = 168) were worse than those of non-PV contact (n = 1353, 47.9 months [p < 0.001], 13% [p = 0.001]), and were comparable with CeA contact (n = 172, 26.4 months [p = 0.136], 26% [p = 0.447]). Incidence of local recurrence (26%) and peritoneal recurrence (20%) in the PV contact were comparable to those in the CeA contact (21%, p = 0.309, and 19%, p = 0.915). Cox proportional hazards analysis revealed PV contact (hazard ratio, 1.295; p = 0.003) as independent prognostic factors for overall survival. CONCLUSIONS:PbtCa with PV contact should be considered borderline resectable because of a high positive surgical margin rate and poor survival, similar to those in PbtCa with CeA contact. TRIAL REGISTRATION:This study was registered in the UMIN Clinical Trial Registry (UMIN-CTR: UMIN000041642).

Introduction: The main text introduction expands on the initial introduction by providing a more detailed discussion of massive bleeding in elective surgeries and its challenges. It describes how traditional hemostatic procedures are essential but may not always be sufficient, especially in uncontrolled coagulopathy despite aggressive transfusion. It then introduces DCS as a well-established approach in trauma surgery, emphasizing its role in stabilizing patients with hemorrhagic shock, coagulopathy, hypothermia, and acidosis. It highlights that DCS can be a lifesaving intervention when unexpected massive bleeding occurs and justifies its use in patients with unstable vital signs or increased intra-abdominal pressure by our two experienced cases presentation. Case 1. A 76-year-old obese male diagnosed with advanced transverse colon cancer with regional balky lymph node metastasis was identified at the root of the regional colic vein trunk. A robotic surgical approach was changed to open laparotomy because of bleeding tendency due to fatty mesentery. During the balky node dissection, the root of the vein was injured and induced massive bleeding during the compressive hemostatic procedure. As the hypotensive control rapidly became quite tricky, DCS by gauze packing and covered by the commercial dressing kit with open abdominal management (OAM). The second look operation, by supporting the Restrictive Endovascular Balloon Occlusion of the Aorta, repaired the superior mesenteric vein's injured parts. He survived for nine months. Case 2. The 72-year-old male patient was diagnosed as solitary 3 cm of hepatocellular carcinoma at S6 with alcoholic liver cirrhosis. The laparoscopic limited hepatic resection was changed to the open laparotomy due to the bleeding tendency at the transected parenchyma. After accomplishing limited resection, massive hepatic venous bleeding occurred; DCS was decided due to continuing hypotension, oozed hemorrhage, and low platelet level with metabolic acidosis by peri-hepatic gauze packing around the right liver. The second look operation for remnant hemostasis and the de-packing with abdominal closure could be achieved without severe events. The postoperative course showed no hepatic failure, and they recovered during a hospital stay. Discussion: It describes how conventional hemostatic procedures are essential but may not always be sufficient, especially in uncontrolled coagulopathy despite aggressive transfusion. DCS is a well-established approach in trauma surgery, emphasizing its role in stabilizing patients with hemorrhagic shock, coagulopathy, hypothermia, and acidosis. The role of DCS is well known even in elective surgery in unforeseen emergency situations such as hemodynamic instability, severe coagulopathy, and prolonged surgery over 24 h. It highlights that DCS can be a lifesaving intervention when unexpected massive bleeding occurs and justifies its use in patients with unstable vital signs or increased intra-abdominal pressure, where prolonged surgery is not feasible. It reinforces that DCS was successfully utilized in the reported cases, leading to favorable second-look operations. Conclusion: The main text introduction is a more comprehensive and structured expansion of the initial introduction. While the initial version introduces the problem concisely, the revised introduction elaborates on the challenges of massive bleeding, the principles of DCS, and its potential role in elective surgeries before transitioning into the case reports.

SET domain bifurcated 1 (SETDB1), a histone H3K9-specific methyltransferase, is crucial for heterochromatin formation and intestinal homeostasis, but its role in intestinal ischemia-reperfusion injury (IRI) remains unclear. This study investigated changes in SETDB1-mediated nuclear chromatin regulation in intestinal epithelial cells (IECs) using an IRI mouse model. Jejunal samples were collected after 75 min of ischemia followed by 24 hr of reperfusion. Sinefungin was administered as a histone methyltransferase inhibitor. Morphologic changes were evaluated using hematoxylin-eosin staining and electron microscopy, and cell-adhesion molecule expression, including ZO-1, E-cadherin, integrin-β4, and laminin, was evaluated using immunohistochemistry. Super-resolution microscopy analyzed intranuclear SETDB1 localization and heterochromatin formation in IECs. IRI-affected jejunum exhibited massive IEC detachment, dilated intercellular spaces, basement membrane damage, and decreased expression of E-cadherin and integrin-β4. Sinefungin prevented these changes, however. The proportion of IECs expressing nuclear SETDB1 throughout the euchromatin was significantly higher in IRI-affected jejunum (77.8%) than sham-treated (3.0%) or sinefungin-treated, IRI-affected jejunum (2.7%). The proportion of IECs with decreased heterochromatin was significantly higher in sinefungin-treated, IRI-affected jejunum (84.3%) than untreated IRI-affected jejunum (15.6%). These findings suggest that SETDB1-mediated chromatin regulation is pivotal in intestinal IRI and represents a potential therapeutic target.

Background:The underlying etiology of liver disease, such as metabolic dysfunction-associated steatotic liver diseases (MASLDs) or alcohol-related liver injury, significantly affects liver function and regenerative capacity. In hepatocellular carcinoma (HCC) patients undergoing hepatectomy, these background factors may influence postoperative outcomes and long-term survival. This study aimed to evaluate the impact of different etiologies of liver disease on survival outcomes following curative hepatectomy in patients with HCC. Methods:We retrospectively analyzed patients with HCC who underwent curative hepatectomy at two academic institutions. Background liver disease was classified according to etiology, including viral liver disease (VLD), alcohol-related liver disease (ALD), MASLD, and others. Survival outcomes were evaluated and compared across etiological groups at two institutions from 1994 to 2023. Results:Patients with VLD, ALD, and MASLD exhibited significantly elevated rates of advanced liver fibrosis (P<0.001), while vascular involvement was less frequent in MASLD cases. No significant differences in tumor stage, tumor markers, or postoperative complications were found among the etiologies. However, tumor recurrence was significantly more common in the VLD and ALD groups (P<0.001), and HCC-related deaths were most frequent in the VLD and other/unknown groups. MASLD patients presented the most favorable outcomes, with a 5-year recurrence-free survival (RFS) of 54% and a 10-year overall survival (OS) of 100%, significantly better than VLD (RFS 31%, OS 49%; P<0.01). Multivariate analysis revealed that VLD, vascular invasion, R1 margin, and poor liver function were independent predictors of recurrence and poor OS. Conversely, MASLD was not a significant risk factor for recurrence and was independently associated with better survival (P<0.05). Conclusions:MASLD-related HCC represents a distinct clinical entity with relatively indolent tumor behavior and better-preserved liver function. Recognizing the prognostic implications of MASLD-related HCC is essential for optimizing surgical indications and developing etiology-specific treatment strategies.

INTRODUCTION:Achalasia is a primary esophageal motility disorder of unknown origin. The clinical manifestations are caused by the loss of peristalsis of the esophagus and functional obstruction at the esophagogastric junction. There are several treatment strategies for esophageal achalasia, such as medications, endoscopic treatment, and surgery. The successful treatment of a case of jejunal interposition surgery with overlap esophago-jejunal anastomosis for an esophageal stricture due to repeated endoscopic dilation for esophageal achalasia is reported. CASE PRESENTATION:The patient was a 67-year-old man who was diagnosed with esophageal achalasia 13 years earlier. Partial esophagectomy of the portion with the stricture and esophago-jejunal anastomosis using the overlap method were performed for the esophageal stricture due to rupture during endoscopic balloon dilatation. The patient's postoperative recovery was unremarkable, and the dysphagia due to esophageal stricture disappeared. CONCLUSIONS:The overlap technique in esophago-jejunal anastomosis after partial esophagectomy was very effective for an esophageal stricture in a patient with achalasia because it made possible the additional resection of endoluminal muscle.

Background:Neoadjuvant chemotherapy (NAC) has been increasingly used in recent years in patients with pancreatic ductal adenocarcinoma (PDAC). This has forced a change in the practice of preoperative biliary drainage (PBD) is performed in PDAC patients scheduled for pancreatoduodenectomy (PD). What has changed in the NAC era and what is the appropriate method of PBD? To address this question, this study retrospectively reviewed the surgical outcomes and details of PBD in NAC and upfront surgery (US) patients. Methods:The study included consecutive PDAC patients who underwent PD from 2013 to 2021 during the transition from US to NAC, when outcomes were comparable. Clinical factors such as patient background, preoperative examination, surgical procedure, and postoperative complications were compared between the NAC group (40 patients) and the US group (59 patients), and details of PBD such as PBD procedure and adverse events were compared between the NAC and US groups who received PBD (27 NAC patients, 33 US patients). In the comparison test between groups, Fisher's exact test and Mann-Whitney U test were mainly used. In addition, the outcomes and patency periods of each of the 128 PBD procedures were examined for the 60 patients who underwent PBD. The log-rank test was performed using the Kaplan-Meier method to compare patency period by PBD procedure. Results:There were no differences in patient background between the NAC and US groups. Compared with the US group, the NAC group had higher preoperative albumin (ALB) levels and less blood loss, but there was no difference of postoperative complications (NAC vs. US, 35% vs. 46%, respectively, P=0.29). With respect to PBD, the NAC group had more initial metallic stent (MS) placement (NAC vs. US, 52% vs. 15%, respectively, P=0.009), and fewer PBD-related adverse events (NAC vs. US, 33% vs. 61%, respectively, P=0.04). In a comparison of outcomes by drainage method, the duration of patency was significantly longer with MS placement than plastic stent (PS) placement (median days of patency, MS vs. PS, 68 vs. 15 days, respectively, P<0.001). However, MS placement and PS placement were equally likely to require a delay in the surgical schedule due to PBD-related adverse events (MS vs. PS, 6% vs. 6%, respectively, P>0.99). Conclusions:Prolonged PBD with NAC did not adversely affect surgical outcomes. MS placement provides a long patency period and is currently useful in PBD for PDAC patients undergoing PD after NAC, which requires a prolonged preoperative period. However, MS placement also has adverse events, and further studies are needed.

INTRODUCTION:In hepatobiliary surgery, bile exposure (BE) may cause complications such as bile peritonitis, slow postoperative recovery, and peritoneal dissemination of cancer cells in adult patients. We investigated the effect of BE on postoperative recovery and complications in pediatric patients with choledochal cysts (CCs) who underwent laparoscopic treatment. METHODS:We reviewed the medical records of patients with CCs who underwent laparoscopic surgery at our institution and associated institutions between April 2016 and April 2024. Patients were divided into two groups according to the presence (BE group) or absence (control group) of BE during surgery. RESULTS:Forty-three patients were enrolled in this study (control group, n = 25; BE group, n = 18). Patient background characteristics, operative results, and postoperative complications were compared between the two groups. There were no significant differences in the patients' background characteristics and operative results between the two groups. The incidence of postoperative cholangitis was significantly higher in the BE group than in the control group (n = 1 [4.0%] vs. n = 6 [33.3%], p = 0.003). However, the incidence of stenosis at the anastomotic site and intrahepatic stones was not significantly different. CONCLUSION:BE during surgery did not affect the postoperative recovery of patients with CCs treated by laparoscopic surgery. However, this did affect the rate of postoperative cholangitis. BE may be a factor contributing to the onset of postoperative cholangitis. Further investigations are necessary to clarify the mechanisms underlying the development of postoperative cholangitis in pediatric patients with CC.

Objective:To elucidate surgical strategies for patients undergoing radical resection, in cases where solitary distant lymph node metastasis is identified intraoperatively, we investigated the prognostic significance of para-aortic lymph node (PALN) metastases and other regional lymph node (RLN) metastases in pancreatic carcinomas (PC) and biliary duct cancers (BDC). Material and Methods:This study retrospectively analyzed data from 181 PC patients and 116 BDC patients who underwent radical resections at two institutions between 1994 and 2021. Results:Among PC patients, metastases were observed in RLN and PALN in 54% and 9% of cases, respectively. Similarly, RLN and PALN metastases were present among BDC patients in 39% and 9% of cases, respectively. Survival analysis revealed that patients with BDC and PALN metastases exhibited significantly reduced disease-free (DFS) and overall survival (OS) compared to those without PALN involvement. Multivariate analysis identified PALN metastasis as an independent predictor of OS in BDC patients (p<0.05), while RLN metastasis was independently associated with DFS (p<0.05). Additional clinicopathological factors associated with PALN and RLN metastases were also identified. Preoperative serum levels of Duke Pancreas II monoclonal antibody were significantly elevated in patients with PALN metastases. Histological findings of lymphatic or perineural infiltration and hepatic or pancreatic invasion were independently associated with RLN metastases. Conclusion:Based on these findings, radical resection may be considered for PC patients with isolated PALN metastases only in the absence of additional adverse prognostic factors. Prospective clinical trials are warranted to further refine the criteria for surgical intervention when solitary PALN metastases are detected intraoperatively.

Background:Pancreatic anastomosis has been developed, and each anastomosis has its pros and cons. This study investigated the prevalence of postoperative complications, particularly pancreatic fistula (POPF), among five types of pancreatoenteric anastomoses to determine the optimal anastomosis for patients undergoing pancreatectomy. Methods:This study retrospectively and consecutively analyzed the data of 365 patients who underwent pancreatectomy with pancreaticoenteral anastomosis at two academic institutions from 1994 to 2024. Pancreaticogastrostomy via invagination was performed in 24 patients (group PG). For pancreaticojejunal anastomosis, we performed an end-to-end invagination procedure on eight patients (group PJI), two-layer suturing procedure on 96 patients (group PJT), Kakita procedure on 55 patients (group K), and modified Blumgart procedure on 182 patients (group B). Results:Group B had the shortest hospital stay and fastest resumption of oral intake. Groups PG and PJI exhibited higher grade B/C POPF rates and prolonged ascites. The potential benefits of group B included reduced hospitalization period and enhanced recovery owing to decreased POPF rates. Habitual alcohol consumption and high preoperative creatinine levels increased the risk of POPF, whereas external drainage issues and blood loss contributed to prolonged ascites. In particular, habitual alcohol consumption [relative risk (RR) =2.42], group K anastomosis (RR =2.79), soft pancreatic texture (RR =2.48), delayed oral intake (≥4 days; RR =2.78), and complete external drainage (RR =8.68) were independent predictors of POPF. Conclusions:Modified Blumgart procedure is an optimal pancreaticoenteral anastomosis technique for avoiding POPF. Early oral intake has emerged as a protective factor, highlighting its role in improving postoperative outcomes. Surgeons should prioritize intraoperative blood conservation, perioperative nutritional support, and appropriate anastomotic selection to enhance surgical success.