Background/PurposeThe 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.MethodsWe 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.ResultsThe 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.ConclusionsThe diagnostic rate of PBR-AC using TG18 is low, but adding THAD and pneumobilia to TG imaging criteria may improve TG diagnostic performance.

To ensure that highly advanced hepatobiliary‐pancreatic surgery (HBPS) is performed safely, the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery (JSHBPS) board certification system for expert surgeons established a safety committee to monitor surgical safety.

1960年代半ばに医師となった主筆(高田)の時代での医療systemは,過去の経験則に基づいていた.1983年日本腹部救急医学会を創立し,1990年から膵炎診療の診療ガイドライン作成の模索を始めた.2003年にevidence -based medicineを基に,致命率が高く難治性疾患とされていた急性膵炎を焦点に第1版を出版した(日本で初めての診療ガイドライン).ひきつづいて,2007年,2010年,2015年と,その時代での工夫を凝らし出版を続け,2014年には難治性疾患からは外れることができた.しかし,2016年の全国調査結果から問題点が残っていることが分かった.対応として,ガイドラインのさらなる普及に力を入れる重要性を強く感じた.2021年版では,「やさしい解説」を取り入れ,参考資料とともにQRコード(QRコードは株式会社デンソーウェーブの登録商標です)で読み取れるように工夫した.さらに,モバイルアプリでQRコードから無料でダウンロードができる使い勝手がよい形を取り入れた.実臨床の場で,医師が患者ならびに家族に説明する時にこの資料を用いていただけることを望んでいる.

Background/Purpose Whether organ-preserving pancreatic surgery has an advantage in postoperative short- and long-term outcomes or not is still unknown because only small case series studies have been available to date. In this multicenter retrospective study, we aimed to elucidate the clinical advantage and disadvantage of organ-preserving pancreatectomy among patients with low-grade malignant pancreatic tumors and benign pancreatic diseases. Methods We included patients diagnosed with benign or low-malignant pancreatic tumor who underwent pancreaticoduodenectomy (PD) in 621 cases, duodenum-preserving pancreatic head resection (DPPHR) in 31 cases, middle pancreatectomy (MP) in 148 cases, distal pancreatectomy (DP) in 814 cases, and spleen-preserving distal pancreatectomy (SPDP) in 259 cases between January 1, 2013, and December 31, 2017. Preoperative backgrounds, surgical outcomes and pre- and postoperative (3, 6, 12, 24, and 36 months) nutritional status were compared between these procedures. Results In terms of short-term outcomes, the incidence of pancreatic fistula in patients who underwent MP was significantly higher than in patients with standard pancreatectomy. As for the long-term pancreatic functions in the cases of head or body lesion, both exocrine and endocrine functions after MP were significantly favorable compared with the PD group from 3 to 36 months after surgery. In pancreatic body or tail lesion, significant advantage of endocrine function, but not exocrine function, was found in the MP group compared to standard DP at all time points. Conclusions MP may contribute to the improvement of postoperative quality of life for patients with pancreatic body low-malignant tumors, rather than PD or DP; however, reducing the incidence of short-term complications such as pancreatic fistula is a future challenge.

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 In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan. Method In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system. Results Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Based on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced computed tomography (CT) grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which were shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 h of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics are administered in mild pancreatitis. Conclusion All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.

本邦初のEBMの手法を用いて作成され,2003年に刊行された『急性膵炎診療ガイドライン』は,その後も常に最新の手法に則って作成されてきた.第5版は全国調査で明らかになった知見を基に2021年に改訂された.早期経腸栄養の促進,予防的抗菌薬の投与不要が強調され,ステップアップ・アプローチの内容がより具体的に記述された.ガイドラインの遵守を願いpancreatitis bundlesも改訂され,bundlesフローチャートも作成され,無料で入手でき診断,重症度判定が可能なモバイルアプリもup dateされた.参考資料は二次元バーコードで閲覧できるようにし,冊子を薄くした.特筆すべき点は,「やさしい解説」を新設し,コメディカルや患者・家族にも理解していただけるようにしたことである.

Background We re-analyzed data on cholangio-venous reflux from a clinical study conducted prospectively on 22 patients in 1974. Method Direct cholangiography was performed with indocyanine green (ICG) mixed into Urographin(R) under monitoring of intrabiliary pressure, and the participants were allocated to three groups according to whether ICG leakage into the blood, signs of infection, or both, were present. Results The intrabiliary pressure of six patients negative for both ICG leakage and signs of infection was approximately 19.5 (median, [range 18-22]) cmH(2)O. In contrast, for the five patients positive for ICG leakage but negative for signs of infection, the intrabiliary pressure was higher (median 32.0 [range 27-41) cmH(2)O]. The 11 patients positive for both ICG leakage and signs of infection had the highest intrabiliary pressure (median 48.0 [range 33-77] cmH(2)O). Our analyses revealed that, as the intrabiliary pressure increased, the status of ICG leakage and signs of infection appeared in a stepwise fashion. Conclusion Our findings suggest that the tight junctions sealing the bile canaliculi deteriorated with increasing intrabiliary pressure, resulting in reflux of the biliary contents into the vascular system via paracellular pathways between hepatocytes.

BACKGROUND:Hepatectomy is standard treatment for colorectal liver metastases; however, it is unclear whether liver metastases from other primary cancers should be resected or not. The Japanese Society of Hepato-Biliary-Pancreatic Surgery therefore created clinical practice guidelines for the management of metastatic liver tumors.METHODS:Eight primary diseases were selected based on the number of hepatectomies performed for each malignancy per year. Clinical questions were structured in the population, intervention, comparison, and outcomes (PICO) format. Systematic reviews were performed, and the strength of recommendations and the level of quality of evidence for each clinical question were discussed and determined. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.RESULTS:The eight primary sites were grouped into five categories based on suggested indications for hepatectomy and consensus of the guidelines committee. Fourteen clinical questions were devised, covering five topics: (1) diagnosis, (2) operative treatment, (3) ablation therapy, (4) the eight primary diseases, and (5) systemic therapies. The grade of recommendation was strong for one clinical question and weak for the other 13 clinical questions. The quality of the evidence was moderate for two questions, low for 10, and very low for two. A flowchart was made to summarize the outcomes of the guidelines for the indications of hepatectomy and systemic therapy.CONCLUSIONS:These guidelines were developed to provide useful information based on evidence in the published literature for the clinical management of liver metastases, and they could be helpful for conducting future clinical trials to provide higher-quality evidence.

BACKGROUND:Prevention of bile duct injury and vasculo-biliary injury while performing laparoscopic cholecystectomy (LC) is an unsolved problem. Clarifying the surgical difficulty using intraoperative findings can greatly contribute to the pursuit of best practices for acute cholecystitis. In this study, multiple evaluators assessed surgical difficulty items in unedited videos and then constructed a proposed surgical difficulty grading. METHODS:We previously assembled a library of typical video clips of the intraoperative findings for all LC surgical difficulty items in acute cholecystitis. Fifty-one experts on LC assessed unedited surgical videos. Inter-rater agreement was assessed by Fleiss's κ and Gwet's agreement coefficient (AC). RESULTS:Except for one item ("edematous change"), κ or AC exceeded 0.5, so the typical videos were judged to be applicable. The conceivable surgical difficulty gradings were analyzed. According to the assessment of difficulty factors, we created a surgical difficulty grading system (agreement probability = 0.923, κ = 0.712, 90% CI: 0.587-0.837; AC2  = 0.870, 90% CI: 0.768-0.972). CONCLUSION:The previously published video clip library and our novel surgical difficulty grading system should serve as a universal objective tool to assess surgical difficulty in LC.

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo‐biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail‐out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail‐out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47 . Related clinical questions and references are also included.

Microwave coagulation therapy (MCT) for liver tumors had initially developed in Japan and now is spreading worldwide. Microwave thermosphere ablation is a new concept using cooling antenna to create a larger spherical necrotic area. Recently, the indications of MCT is spreading from hepatocellular carcinoma to liver metastases. MCT is recommended only for patients with unresectable colorectal liver metastases (CRLM); ≤ 3cm and ≤ 3 nodules in combination with systemic chemotherapy. MCT has some benefits compared with radiofrequency ablation: 1) Shorter ablation time; 2) Lower local recurrence rate; 3) better disease-free and overall survival; 4) Complete necrosis even for the tumor adjacent to the large vessels; and 5) Similar complication rates. In summary, MCT is evolving as one of the promising local treatments for liver metastases; however, a randomized control trial is required to create solid evidences.

Alonso-Lej classified extrahepatic bile duct cystic dilatation into three types. Type I is congenital cystic dilatation of the common bile duct; type II is congenital diverticulum of the common bile duct; and type III is choledochocele. Todani refined the classification of bile duct cystic disorders into five types and included the concept of pancreaticobiliary maljunction. Type IV-A is a congenital biliary dilatation associated with intrahepatic duct dilatation, and type V is multiple intrahepatic bile duct dilatations. Congenital biliary dilatation is expressed as Ia, Ic, and IV-A. The major clinical symptoms are recurrent abdominal pain, nausea and vomiting, mild jaundice, an abdominal mass, and fever. Diagnosis of congenital biliary dilatation requires demonstration of abnormal dilatation of the bile duct and pancreaticobiliary maljunction on the basis of diagnostic imaging or anatomic abnormalities. The main complications are biliary stones, pancreatitis, spontaneous perforation of the bile duct, and carcinoma. Accordingly, the definitive treatment of congenital biliary dilatation is complete excision of the extrahepatic bile duct with Roux-en-Y hepaticojejunostomy. Complete excision of the intrapancreatic bile duct and removal of stenoses of the hepatic ducts are necessary to prevent cholangitis, hepatolithiasis, pancreatic stones, and carcinoma after surgery. Type II diverticulum, type III choledochocele, and type V are rare, and pancreaticobiliary maljunction is not usually associated. Caroli disease is usually autosomal recessive. The clinical onset of Caroli disease usually occurs during childhood, and symptoms include cholangitis, portal hypertension, and abdominal pain. The long-term prognosis for such patients is poor, with a marked predisposition to septicemia, liver abscess, resultant hepatic failure, portal hypertension, or cholangiocarcinoma.

Background Laparoscopic pancreaticoduodenectomy (LPD) requires sufficient laparoscopic training for optimal outcomes. Our aim is to determine the learning curve and investigate the factors influencing surgical outcomes during the learning curve. Methods We analyzed surgical results of 150 consecutive cases of LPD performed by three hepatopancreatobiliary surgeons during their 50 first cases. Learning curves were constructed by cumulative sum (CUSUM) analysis. Preoperative factors influencing resection time and blood loss were investigated in the introductory and stable periods. Results The learning curve could be divided into three phases: initial (1-20 cases), plateau (21-30), and stable (31-50). Resection time with lymph node dissection was significantly longer during the introductory period (initial and plateau periods) (P < 0.01) but not the stable phase (P = 0.51). Multivariate analysis revealed that patients with pancreatitis had longer resection times and massive blood loss in both the introductory and stable periods (stable phase). High visceral fat area was also significantly related to massive blood loss in the introductory period (P = 0.04). Conclusions Hepatopancreatobiliary surgeons need more than 30 cases until LPD becomes stable. Lymph node dissection and patients with high visceral fat area and concomitant pancreatitis should be avoided during the introductory period of the learning curve.

We, the editors of surgery journals, believe that conducting sex-inclusive biomedical and clinical research is imperative to improving health outcomes of men and women. Note that the word “sex” is being used rather than “gender.” Sex is the genotype by which one is born and gender is the phenotype. It is the chromosomal sex of the human, animal, tissue, or cell to which we are referring. Recent studies have shown that the majority of biomedical research in the field of surgery and related topics is conducted on male animals and male cells, even when studying diseases prevalent in women 1. Human clinical research suffers from a lack of sex-based reporting and sex-based analysis of the results 2, 3. Given these findings, the National Institutes of Health has now asked that sex be considered as a biologic variable in all National Institutes of Health-funded research 4. As such, we support uniform, defined reporting of the sex used for human, animal, tissue, and cell research in ALL manuscripts published in our journals. If only one sex is studied, authors must include a justification statement as to why a single-sex study was conducted. We also will require sex-based reporting and analysis of data for all human, animal, tissue, and cell research. As a group, we will require this among all our collective surgery journals.

The initial management of patients with suspected acute biliary infection starts with the measurement of vital signs to assess whether or not the situation is urgent. If the case is judged to be urgent, initial medical treatment should be started immediately including respiratory/circulatory management if required, without waiting for a definitive diagnosis. The patient's medical history is then taken; an abdominal examination is performed; blood tests, urinalysis, and diagnostic imaging are carried out; and a diagnosis is made using the diagnostic criteria for cholangitis/cholecystitis. Once the diagnosis has been confirmed, initial medical treatment should be started immediately, severity should be assessed according to the severity grading criteria for acute cholangitis/cholecystitis, and the patient's general status should be evaluated. For mild acute cholangitis, in most cases initial treatment including antibiotics is sufficient, and most patients do not require biliary drainage. However, biliary drainage should be considered if a patient does not respond to initial treatment. For moderate acute cholangitis, early endoscopic or percutaneous transhepatic biliary drainage is indicated. If the underlying etiology requires treatment, this should be provided after the patient's general condition has improved; endoscopic sphincterotomy and subsequent choledocholithotomy may be performed together with biliary drainage. For severe acute cholangitis, appropriate respiratory/circulatory management is required. Biliary drainage should be performed as soon as possible after the patient's general condition has been improved by initial treatment and respiratory/circulatory management. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47 . Related clinical questions and references are also included.