Background:. Hepatic artery (HA) reconstruction is occasionally required in pancreatic head cancer with arterial involvement. With recent advances in combination chemotherapy, conversion surgery has become feasible for selected patients. This study evaluates the surgical techniques, postoperative outcomes, and survival of patients who underwent pancreatic resection with HA reconstruction. Methods:. A retrospective review was conducted of 14 patients who underwent pancreatic resection with HA reconstruction at Saitama Cancer Center from 2012 to 2024. Clinical variables included demographics, tumor pathology, patterns of arterial invasion, reconstruction methods, anastomosis time, and complications. Patients were classified into 2 groups: those with common/proper HA invasion and those with replaced right HA invasion. Results:. The cohort included 9 men and 5 women (mean age, 71.9 y). Six patients had common/proper HA invasion, and 8 had replaced right HA invasion. The overall median anastomosis time was 18 minutes 16 seconds. No anastomosis-related complications occurred, and hepatic arterial flow was patent in all patients. Conclusions:. Meticulous microsurgical HA reconstruction enables safe arterial resection in selected patients with advanced pancreatic cancer. When combined with appropriate preoperative therapy and multidisciplinary management, this approach allows oncologically curative resection and may contribute to improved long-term survival.

Genomic screening is an essential, but potentially time-consuming procedure, especially in neoadjuvant settings. We evaluated the preoperative screening of the BRAF V600E mutation for recruitment to a clinical trial among patients with resectable colorectal oligometastases (CRM). In April 2022, an investigator-initiated trial was launched to investigate the efficacy and safety of perioperative use of the BEACON triplet regimen for BRAF V600E mutant resectable CRM. BRAF screening was retrospectively conducted in patients with resected colorectal liver metastases in 2019 for planning the trial and prospectively conducted in preoperative patients with resectable CRM from January 2022 to June 2025 for patient recruitment to the trial. BRAF V600E mutation was detected in 12 (3.2

Objectives: Familial adenomatous polyposis (FAP) is an inherited disorder characterized by multiple colorectal polyposis and is frequently associated with a variety of extracolonic lesions. However, neoplastic lesions of the biliary tract system, excluding those of the ampulla of Vater, are extremely rare in FAP, and the impact of APC alterations on their tumorigenesis remains unclear. We aimed to clarify the relationship between germline variants and somatic variants in the APC gene in biliary tract neoplasms (BTNs) of FAP patients. Methods: A total of 115 genetically confirmed FAP cases treated at our department between 1997 and 2024 were investigated regarding development of BTNs. APC gene analysis was performed in the BTNs. Results: Of 115 FAP cases, three developed BTNs. Case 1 was a 69-year-old female who underwent subtotal stomach-preserving pancreaticoduodenectomy for duodenal and middle bile duct carcinoma. Case 2 was a 67-year-old female who underwent pancreaticoduodenectomy for gastric, duodenal, and upper bile duct carcinoma. Case 3 was a 47-year-old male who underwent pancreas-sparing total duodenectomy with cholecystectomy for Spigelman Stage IV duodenal polyposis and gallbladder polyposis. In addition to germline pathogenic variants, somatic pathogenic variants of APC were identified in all the BTNs. Conclusions: These findings suggest that the APC two-hit theory may underlie the tumorigenesis of these rare BTNs, consistent with the pathogenic process observed in colonic and other extracolonic lesions in patients with FAP.

Aim:Spigelman stage IV duodenal polyposis (SP-stage IV DP) is associated with high duodenal cancer risk in patients with familial adenomatous polyposis (FAP). This study evaluated the surgical and oncological outcomes of pancreas-sparing total duodenectomy (PSTD) as a surgical prophylaxis for severe duodenal polyposis in FAP. Methods:Medical records were reviewed to evaluate factors concerning short- and long-term clinical and oncological outcomes in consecutive patients with FAP who underwent PSTD for SP-stage IV DP. Results:There were twenty-seven patients (median age: 48 years) from 26 families, of whom 12 were female. Clavien-Dindo grade IIIa/IIIb complications included delayed gastric emptying (n = 14) and pancreatic fistula (n = 10); no mortalities were observed. Histopathological examinations revealed no malignant neoplasms deeper than T1a in the duodenum and ampulla. Follow-up (median 6.4 years) revealed anastomotic stricture of the reconstructed neo-common channel (n = 5), anastomotic ulcer of the gastrojejunostomy site (n = 5), acute pancreatitis (n = 4), and acute cholangitis (n = 2), all of which were successfully treated endoscopically or conservatively. Malignant neoplasms after PSTD included gastric cancer (n = 3), remnant ano-rectal cancer (n = 3), ileal cancer (n = 1), ileal pouch cancer (n = 1), and endometrial cancer (n = 1). The cumulative 10-year survival rate following PSTD was 87.4%. Conclusions:PSTD for the prophylactic management of SP-stage IV DP was associated with notable but manageable postoperative morbidity. Long-term surveillance remains essential for the development of extraduodenal malignancies to confirm the oncological efficacy of this type of surgery.

Background The optimal resection for pancreatic neck cancer is challenging in clinical practice because we could dissect by pancreaticoduodenectomy or distal pancreatectomy. The purpose of this study was to evaluate the effectiveness of lymph node dissection and to help determine the optimal surgical treatment for pancreatic neck cancer. Methods We retrospectively evaluated 462 patients with pancreatic cancer who underwent curative-intent pancreatectomy between 2012 and 2022, 35 of whom had pancreatic neck cancer without preoperative radiologic gastroduodenal artery contact. We analyzed the clinicopathological characteristics, lymph node metastasis stations, and the efficacy index of lymph node dissection, which was calculated by multiplying the frequency of lymph node metastasis to each station by the 5-year survival rate of patients with positive lymph nodes at each station. Results The lymph node station with the greatest rate of metastasis was #11p (28.6%), followed by #8 (17.1%), #14 (14.3%), #13 (14.3%), #17 (9.5%), and #6 (4.8%). The efficacy indices of lymph node dissection were 14.3 for #11, 4.76 for #13, and 8.57 for #14. There were no significant differences in 5-year recurrence-free survival and 5-year overall survival between patients undergoing pancreaticoduodenectomy and those undergoing distal pancreatectomy (23.7% vs 54.7%, P = .142; 29.9% vs 51.1%, P = .179, respectively). Univariate survival analysis showed that tumor size ≥2 cm was associated with poor prognosis (hazard ratio, 3.842, P = .009). Conclusions PD with #11p lymph node dissection is preferable to DP in terms of survival benefit for pancreatic neck cancer with lymph node metastasis.

Aim:Severe duodenal polyposis associated with familial adenomatous polyposis considerably increases the risk of duodenal cancer. Pancreas-sparing total duodenectomy is an alternative surgical approach for managing severe duodenal polyposis. This study evaluated the postoperative nutritional outcomes following pancreas-sparing total duodenectomy in patients with severe duodenal polyposis associated with familial adenomatous polyposis. Methods:This retrospective analysis compared 28 patients who underwent pancreas-sparing total duodenectomy for Spigelman stage IV duodenal polyposis with 29 patients who underwent pancreatoduodenectomy for low-malignancy duodenal neoplasms. Patient demographics, postoperative complications, and nutritional parameters were analyzed at 3, 6, 9, and 12 months postoperatively. Results:Compared with patients in the pancreatoduodenectomy group, those in the pancreas-sparing total duodenectomy group were younger and had a higher incidence of previous abdominal surgeries (p < 0.01). Postoperatively, the pancreas-sparing total duodenectomy group showed significantly better preservation of total protein, albumin, and total cholesterol levels, body mass index, body weight, and psoas major muscle area compared to the pancreatoduodenectomy group (p < 0.05). Additionally, glucose tolerance was better maintained in the pancreas-sparing total duodenectomy group than in the pancreatoduodenectomy group (p < 0.01), with no patients requiring the initiation of insulin therapy or experiencing the exacerbation of diabetes. Conclusions:Pancreas-sparing total duodenectomy effectively preserves the postoperative nutritional status in patients with duodenal polyposis associated with familial adenomatous polyposis. This surgical option maintains postoperative nutritional integrity and improves long-term outcomes.

Background Hepatocellular carcinoma (HCC) has a high rate of recurrence and requires multiple treatment options. Early recurrence has been associated with poor prognosis; however, the timing of early recurrence varies in the literature. Therefore, in this study, we aimed to determine the timing of early recurrence with the best prognostic value and clarify the appropriate treatment strategy. Methods This retrospective study conducted to determine prognosis and treatments included 274 patients with HCC who underwent liver resection at the Saitama Cancer Center. The prognostic value of early recurrence at each surveillance period was calculated using Harrell's concordance index (C-index). Results The C-index at 9 months postoperatively was 0.656, which was the highest cut-off value for early recurrence. Notably, 122 patients had no recurrence, 58 had early recurrence (<9 months), and 94 had late recurrence (≥9 months). The 5-year overall survival (OS) of patients with early recurrence was worse (16.5 %, p<0.001), whereas that of those with late and no recurrences were similar (79.2 % vs. 70.9 %, p=0.86). The 5-year OS rate of patients with late intrahepatic recurrence in the surgery group was 100 %. Conclusion The optimal cutoff value for the timing of early recurrence was 9 months postoperatively. The early recurrence group had a high rate of extrahepatic recurrence and poor OS, whereas late recurrences were mostly intrahepatic, with no difference in prognosis between the late and no recurrence groups. Patients with intrahepatic recurrence after >9 months are considered for rehepatectomy because of its good outcomes. Synopsis The C-index-based optimal cutoff for the timing of early HCC recurrence was 9 months postoperatively. The early recurrence group had a high rate of extrahepatic recurrence and poor OS, whereas late recurrences were mostly intrahepatic with a good prognosis.

Background: The aim of this study was to determine the optimal treatment for patients with pancreatic cancer (PaCa) having positive peritoneal cytology (PPC). Methods: This multicenter retrospective study included patients with PPC treated at 78 high-volume centers between January 2012 and December 2020. Prognoses after resection (S-group) and initiation of nonsurgical treatment (N-group) were compared. Prognostic factors for survival in both groups were analyzed. Detailed characteristics of conversion surgery (CS) in the N-group were evaluated. Results: In total, 568 enrolled patients were classified into an S-group (n = 445) or an N-group (n = 123). Median survival times (MSTs) were 19.0 months and 19.3 months, respectively, with no significant difference in prognosis (p = .845). The intervenable prognostic factors for survival were adjuvant treatment in the S-group (p < .001) and CS in the N-group (p < .001). Following CS, the MST was prolonged to 45.6 months, and peritoneal or liver recurrence decreased considerably. CS can be expected if PPC is diagnosed before neoadjuvant treatment and when combination treatment is initiated. Conclusion: Surgical resection may not be beneficial for improving survival when PPC is evident. Chemotherapy aiming for CS may be the optimal treatment for such patients.

In the early days of the indocyanine green (ICG) fluorescence imaging techniques, the types of near-infrared imaging devices that could be used for surgery, especially for endoscopic surgery, were quite limited, but nowadays, dedicated imaging devices have become commercially available from various manufacturers. In this chapter, we will outline the functions of the endoscopic fluorescence imaging system and show the features and practical applications of intraoperative fluorescence imaging in our department.

BACKGROUND:Tumor-associated sarcoid reactions have been observed with various tumors; however, they have not been reported with uterine cancer. We present two cases of splenic sarcoid reactions that mimicked metastases a few years after uterine cancer surgery.CASE PRESENTATION:Case 1 involved a 67-year-old female patient diagnosed with endometrial cancer (pT1aN0M0, pStage Ia, grade 1). The patient underwent open total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy. Three years after the initial surgery, computed tomography (CT) and positron emission tomography CT showed multiple splenic masses with increasing numbers and sizes. Splenic metastases were diagnosed, and laparoscopic splenectomy was performed. The histopathological analysis revealed sarcoid reactions in the spleen. Case 2 involved a 47-year-old female patient diagnosed with endometrial cancer (pT1aN0M0, pStage Ia, grade 1). The patient underwent laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy. Two years after the initial surgery, multiple splenic masses were observed. We performed laparoscopic splenectomy for the splenic metastases. Granuloma formations were identified in the splenic specimen and perisplenic lymph nodes that were removed simultaneously, resulting in a final diagnosis of sarcoid reaction. A review of the lymph nodes at the time of the previous uterine surgery revealed granuloma formation. Other than the presence of splenic masses, no findings suggestive of recurrence were observed in these cases. Uterine cancer and sarcoid reactions progressed without recurrence after splenectomy.CONCLUSIONS:To the best of our knowledge, this is the first report of the late development of splenic sarcoid reactions after uterine cancer surgery. Sarcoid reactions and metastases are difficult to diagnose based on preoperative imaging results. However, reviewing the specimen at the time of the initial resection, the number of lesions, and the clinical findings (other than imaging findings) may aid in the determination of the correct diagnosis.

Cronkhite-Canada syndrome(CCS)is a rare non-inherited disease characterized by gastrointestinal polyposis and ectodermal abnormalities. We report a rare case of CCS associated with gastric cancer and gastric outlet obstruction with a review of the literature. A 75-year-old man was admitted because of frequent vomiting and hypoproteinemia. He was diagnosed with CCS due to typical clinical and laboratory findings including alopecia, nail atrophy, hypoproteinemia, and typical gastrointestinal polyposis. Upper endoscopic examination also pointed out a large gastric cancer mainly located in the antrum and the reversible pyloric obstruction caused by the gastric tumor. Biopsy of the tumor revealed tubular adenocarcinoma. Computed tomography demonstrated the dilated duodenum caused by packing of the gastric tumor. 1.5 months after prednisolone therapy, he underwent total gastrectomy with complete resection of the dilated duodenal bulb. Histological examination revealed gastric cancer(pap>tub1)classified into Stage ⅢC. Postoperative course was uneventful and he moved to another hospital. To our knowledge, including the present case, there were 20 reported cases of CCS associated with gastric cancer from Japan(1979-2022). Also, 7 cases of CCS associated with gastric outlet obstruction was reported.

Background/Aim: Patients with pancreatic ductal adenocarcinoma (PDAC) with positive peritoneal lavage cytology (CY) reportedly have poor prognoses. However, the value of diagnosis of suspicious for malignancy on CY is unknown. This study aimed to elucidate the prognostic impact of CY by focusing on CY subgroups. Patients and Methods: Data were collected from 231 resectable PDAC patients who underwent curative-intent resection. Patients were divided into three CY-based groups: negative (CY0), suspicious for malignancy (CY-S), and positive (CY1). Clinicopathological characteristics and prognostic factors were analyzed. Results: CY1 and CY-S were diagnosed in 7.8% and 3.9% of the patients, respectively. The CY1 group had significantly larger tumors and higher frequencies of distal tumors, anterior pancreatic tissue invasion, retropancreatic tissue invasion, and R1 resection than the CY0 group. Patient characteristics did not differ between the CY0 and CY-S groups. The CY1 group exhibited worse survival than the CY0 and CY-S groups (median survival time: 18.8 vs. 39.6 months, p=0.0021 and vs. 62.2 months, p=0.018). Multivariate analysis for survival indicated that a tumor size >2 cm, preoperative CA19-9 value >100 U/ml, CY1, lymph node metastasis, R1 resection, and lack of adjuvant chemotherapy were associated with poor prognosis. Both the CY1 and CY-S groups had higher frequencies of peritoneal recurrence than the CY0 group (50% vs. 11.8%, p<0.001 and 44.4% vs. 11.8%, p=0.019). Conclusion: The prognosis of the CY1 group was poor. Although CY-S was associated with a higher frequency of peritoneal recurrence than CY0, the long-term outcomes of patients with surgical treatment were acceptable.

Abstract Objectives Postoperative pancreatic fistula (POPF) is a major cause of morbidity after pancreatic surgery. Recently, endoscopic ultrasound‐guided transmural drainage (EUS‐TD) has been widely used to manage pancreatic pseudocysts after acute pancreatitis. Several studies have reported the effectiveness of EUS‐TD for POPF, although there is insufficient evidence regarding the performance of EUS‐TD for POPF. We herein report on the safety, efficacy, and appropriate timing of EUS‐TD for POPF compared with conventional percutaneous intervention. Methods Eight patients who underwent EUS‐TD of POPF and 36 patients who underwent percutaneous intervention were retrospectively enrolled. Clinical outcomes, including technical success, clinical success, and complications, were analyzed among the two groups. Results In terms of clinical outcomes between the EUS‐TD and percutaneous intervention groups, significant differences were observed in the number of interventions (1 vs. 4, p = 0.011), period of clinical success (6 days vs. 11 days, p = 0.001), incidence of complications (0 vs. 3, p = 0.021), postoperative hospital stays (27 days vs. 34 days, p = 0.027), and recurrence of POPF (0 vs. 5, p = 0.001). Conclusions EUS‐TD for POPF appears to be safe and technically feasible. This approach should be considered a therapeutic option in patients with POPF after pancreatic surgery.

Three-dimensional surgical simulation, already in use for hepatic surgery, can be used in pancreatic surgery. However, some problems still need to be overcome to achieve more precise pancreatic surgical simulation. The present study evaluates the performance of SYNAPSE VINCENT® (version 6.6, Fujifilm Medical Co., Ltd., Tokyo, Japan) in the semiautomated surgical simulation of the pancreatic parenchyma, pancreatic ducts, and peripancreatic vessels using an artificial intelligence (AI) engine designed with deep learning algorithms. One-hundred pancreatic cancer patients and a control group of 100 nonpancreatic cancer patients were enrolled. The evaluation methods for visualizing the extraction were compared using the Dice coefficient (DC). In the pancreatic cancer patients, tumor size, position, and stagewise correlations with the pancreatic parenchymal DC were analyzed. The relationship between the pancreatic duct diameter and the DC, and between the manually and AI-measured diameters of the pancreatic duct were analyzed. In the pancreatic cancer/control groups, the pancreatic parenchymal DC and pancreatic duct extraction were 0.83/0.86 and 0.84/0.77. The DC of the arteries (portal veins/veins) and associated sensitivity and specificity were 0.89/0.88 (0.89/0.88), 0.85/0.83 (0.85/0.82), and 0.82/0.81 (0.84/0.81), respectively. No correlations were observed between pancreatic parenchymal DC and tumor size, position, or stage. No correlation was observed between the pancreatic duct diameter and the DC. A positive correlation (r = 0.61, p<0.001) was observed between the manually and AI-measured diameters of the pancreatic duct. Extraction of the pancreatic parenchyma, pancreatic duct, and surrounding vessels with the SYNAPSE VINCENT® AI engine assumed to be useful as surgical simulation.

Whether albumin and bilirubin levels, platelet counts, ALBI, and ALPlat scores could be useful for the assessment of permanent liver functional deterioration after repeat liver resection was examined, and the deterioration after laparoscopic procedure was evaluated. For 657 patients with liver resection of segment or less in whom results of plasma albumin and bilirubin levels and platelet counts before and 3 months after surgery could be retrieved, liver functional indicators were compared before and after surgery. There were 268 patients who underwent open repeat after previous open liver resection, and 224 patients who underwent laparoscopic repeat after laparoscopic liver resection. The background factors, liver functional indicators before and after surgery and their changes were compared between both groups. Plasma levels of albumin (p = 0.006) and total bilirubin (p = 0.01) were decreased, and ALBI score (p = 0.001) indicated worse liver function after surgery. Laparoscopic group had poorer preoperative performance status and liver function. Changes of liver functional values before and after surgery and overall survivals were similar between laparoscopic and open groups. Plasma levels of albumin and bilirubin and ALBI score could be the indicators for permanent liver functional deterioration after liver resection. Laparoscopic group with poorer conditions showed the similar deterioration of liver function and overall survivals to open group.

Recently, the number of reports describing patients with initially unresectable biliary tract cancer (BTC) who underwent resection in the form of conversion surgery is increasing. Gemcitabine plus cisplatin (GC) combination therapy has been reported to significantly prolong the median survival time from 8.1 to 11.7 months compared with conventional gemcitabine therapy in patients with unresectable BTC. We report the case of a patient with unresectable BTC who underwent conversion surgery with a partial response to GC combination therapy. A 78-year-old woman was diagnosed with unresectable BTC with invasion of the right hepatic artery by lymph node metastasis and liver metastases. The patient received GC combination therapy. After 6 cycles of chemotherapy, the patient achieved a partial response. The radiological findings revealed a marked shrinkage in the primary lesion and the disappearance of lymph node and liver metastases. Therefore, the patient underwent conversion surgery, including biliary tract resection and regional lymph node dissection. For postoperative follow-up, the patient was monitored without receiving adjuvant chemotherapy. The patient had not exhibited recurrence during the 12-month follow-up period. We report the case of a patient with unresectable BTC who underwent conversion surgery with a partial response to GC combination therapy.

Abstract Purpose Laparoscopic liver resection (LLR) is currently an accepted approach for liver surgery in select patients. The correlation between the intraoperative position and the presence of gravity-dependent atelectasis (GDA) has been well discussed. However, LLR is performed in the left half lateral position, and the relationship between this position and the presence of GDA remains unclear. We evaluated the extent to which the intraoperative left half lateral position affects the presence of GDA. Furthermore, univariate and multivariate analyses were performed to identify potential risk factors for LLR postoperative complications with a special emphasis on the presence of GDA by comparing various patient-, liver- and surgery-related factors in a retrospective cohort. Methods We retrospectively evaluated 129 patients who underwent LLR in the left half lateral position at the Saitama Cancer Center in Saitama, Japan between March 2011 and July 2020. The frequency and duration of GDA were investigated. We divided the cohort into with GDA and without GDA groups based on a cutoff value (≥ 5 days, n = 61 and < 5 days, n = 68, respectively). Using multivariate analysis, the duration of GDA and several risk factors for LLR postoperative complications were independently assessed. Results Postoperative GDA was observed in 61 patients (47%) and lasted for 1 to 8 days in these patients. The mean duration of GDA was 4.3 days. Multivariate logistic regression analysis revealed a GDA duration of 5 days or more (odds ratio [OR], 2.03; p = 0.001) and an operating time > 388 minutes (OR, 5.31; p < 0.001) to be independent risk factors for LLR postoperative complications. Conclusions The incidence and duration of postoperative GDA are considered useful predictors of postoperative complications, and these predictors should be assessed to improve the short-term outcomes of patients undergoing LLR.