Objective: Postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy is the most serious complication of these surgical procedures; therefore, we examined the effectiveness of fasting, and administration of octreotide acetate and ulinastatin as a method of prevention. Summary of Background Data: Although various drug therapies and surgical techniques have been used for the treatment of POPF, no decisive treatment for POPF exists. Methods: The clinical course of 30 patients who developed POPF was retrospectively evaluated and compared among no dietary intake (n = 18), octreotide acetate (n = 8), and ulinastatin (n = 8) using an overlapping design. Patients were allocated to either the dietary intake or fasting (no dietary intake) group, and those in the no dietary intake group were further divided into the octreotide acetate or ulinastatin group. Results: Length of hospitalization was longer for the no dietary intake group than for the dietary intake group (P = 0.002). When considering only grade B or C POPF cases, the no dietary intake group had a longer length of hospitalization and a higher white blood cell count on day 7 after the diagnosis of POPF than the dietary intake group (P , 0.05). The white blood cell count was also higher in the octreotide acetate group than in the ulinastatin group (P = 0.021). The length of hospitalization was shorter in the ulinastatin group than in the octreotide acetate group (P = 0.025). Conclusions: The use of no dietary intake, octreotide acetate, and ulinastatin does not seem to contribute to the clinical course of patients with POPF after pancreatoduodenectomy.

Prognostic factors after treatment for intrahepatic recurrent hepatocellular carcinoma (RHCC) after hepatic resection (Hx) are controversial. The current study aimed to examine the impact of treatment modality on the prognosis of intrahepatic RHCC following Hx.

Inappropriate antimicrobial therapy for surgical site infections (SSIs) can lead to poor outcomes and an increased risk of antibiotic resistance. A nationwide survey was conducted in Japan from 2018 to 2019 to investigate the antimicrobial susceptibility of pathogens isolated from SSIs. The data were compared with those obtained in 2010 and 2014-2015 surveillance studies. Although the rate of detection of extended-spectrum b-lactamase producing strains of Escherichia coli was increased from 9.5% in 2010 to 23% in 2014-2015, the incidence decreased to 8.7% in 2018-2019. Although high susceptibility rates were detected to piperacillin/tazobactam (TAZ), the geometric mean MICs were substantially higher than to meropenem (2.67 vs 0.08 mg/mL). By contrast, relatively low geometric mean MICs (0.397 mg/mL) were demonstrated for ceftolozane/TAZ. Although the MRSA incidence rate decreased from 72% in the first surveillance to 53% in the second, no further decrease was detected in 2018-2019. For the Bacteroides fragilis group species, low levels of susceptibility were observed for moxifloxacin (65.3%), cefoxitin (65.3%), and clindamycin (CLDM) (38.9%). In particular, low susceptibility against cefoxitin was demonstrated in non-fragilis Bacteroides, especially B. thetaiotaomicron. By contrast, low susceptibility rates against CLDM were demonstrated in both B. fragilis and non-fragilis Bacteroides species, and a steady decrease in susceptibility throughout was observed (59.3% in 2010, 46.9% in 2014-2015, and 38.9% in 2018-2019). In conclusion, Japanese surveillance data revealed no significant lowering of antibiotic susceptibility over the past decade in organisms commonly associated from SSIs, with the exception of the B. fragilis group. (C) 2021 Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

Introduction: Recently, the outcome of ABO-incompatible living donor liver transplantation (LDLT) has improved due to preoperative desensitization with rituximab and plasma-exchange (PE). Preformed donor-specific antibody (DSA) may cause antibody-mediated rejection (AMR), which is a significant risk factor for mortality in LDLT. However, the optimal prophylaxis of AMR for patients with positive-DSA has not been established. We report two patients with high preformed DSA who successfully underwent LDLT after desensitization by rituximab. Methods: A total of 24 patients underwent LDLT from 2007 to 2019, including 4 ABO-incompatible patients. All the patients underwent preoperative compliment-dependent cytotoxic crossmatch test (CDC), and in the case of positive CDC, flow cytometric crossmatch test (FCXM) was performed. Two patients were positive for CDC and were both strongly positive for DSA by FCXM. One patient was ABO-incompatible and had a preformed DSA. Immunosuppression therapy for patients with preformed DSA was based on the protocol for ABO-incompatible LDLT as following: rituximab 500mg three weeks before transplantation, mycophenolate mofetil (MMF) 2000 mg daily given one week before transplantation, and pre-transplant PE, while post-transplant immunosuppression consisted of tacrolimus, MMF and steroids were given as the protocol of ABO-compatible patients after LDLT. Pre-transplant PE was performed in patients with high ABO-antibody titers after rituximab administration, of whom one ABO incompatible and with preformed DSA underwent performed pre-transplant PE, but the other patient did not. Results: AMR was not observed in any DSA-positive patients. The two patients remain well with stable graft function without any rejection episodes. Conclusion: Preoperative rituximab administration may prevent AMR in patients with strongly positive preformed DSAs in LDLT.

Hamura, Ryoga MD; Furukawa, Kenei MD, PhD; Taniai, Tomohiko MD; Shirai, Yoshihiro MD, PhD; Shiozaki, Hironori MD; Onda, Shinji MD, PhD; Gocho, Takeshi MD, PhD, FACS; Shiba, Hiroaki MD, PhD, FACS; Ishida, Yuichi MD, PhD; Yanaga, Katsuhiko MD, PhD, FACS Author Information

BACKGROUND/AIM:Organ/space surgical site infections (SSIs) are critical complications of pancreaticoduodenectomy. We investigated the impact of the time between division of the common hepatic duct and completion of biliary reconstruction [bile exposure (BE) time] on the occurrence of post-pancreaticoduodenectomy organ/space SSI.PATIENTS AND METHODS:Sixty-one patients who underwent pancreaticoduodenectomy were retrospectively studied. The impact of perioperative variables and BE time on organ/space SSI occurrence was analyzed.RESULTS:Organ/space SSIs occurred in 17 patients (28%). Patients were divided into two groups according to BE time. The incidence of organ/space SSIs was significantly higher in the long BE time group than in the short BE time group (42% versus 13%, p=0.0127). Multivariate analysis revealed that long BE times [odds ratio (OR)=4.8; p=0.0240] and soft pancreatic texture (OR=16.5; p=0.0106) were independent risk factors for organ/space SSIs.CONCLUSION:Long BE time is a risk factor for post-pancreaticoduodenectomy organ/space SSIs. Shortening BE time may reduce organ/space SSI occurrence.

Introduction: A preoperative scoring system to predict carcinoma in patients with gallbladder polyps (GBPs). Methods: Preoperative parameters of patients with GBPs who underwent cholecystectomies were used to construct a scoring system to ascertain the risk of malignancy (reference group). The scoring system developed from this approach was applied to the validation group. Results: In the reference group, 11.5% of patients had carcinomas, in whom the median age was 68 years and the polyp size was 16.9 mm. According to the univariate analysis, the significant factors for carcinoma were age ≥65 years, the presence of gallstones, polyp size ≥13 mm, solitary polyp, and sessile polyp. Age ≥65 years and polyp size ≥13 mm were significant factors according to the multivariate analysis. From these results, we developed a preoperative scoring system to predict carcinoma. The patients were divided into 1 of 2 groups: low-risk and high-risk and their malignancy rates were 4.1 and 61.1% respectively (p < 0.001). In the validation group, the malignancy rate was higher for those in the high-risk group (p = 0.016). Conclusions: The proposed preoperative scoring system based on simple clinical variables appears to be useful for predicting malignancy in patients with GBPs.

本学では2007年2月のC型肝硬変例に対する本学1例目の生体肝移植以降，2016年6月までに17名に対して計18回の生体肝移植（再肝移植1例）を施行しているが，うち10例が原発性胆汁性胆管炎（PBC）による末期肝不全例である．10症例の内訳は年齢49.5歳（中央値），女性9例，男性1例，ABO血液型不適合2例であった．ドナーは術後在院日数10日（中央値）で全例術前の状態に復帰，レシピエントは術後在院日数29.5日（中央値）で全例軽快退院，経過良好である（中央値3.2年）．全10症例で，PBC再発予防を目的として，タクロリムスおよびステロイドで免疫抑制剤導入を行った後に安定期に入ってからシクロスポリンAおよびステロイドに変更している．3例で急性拒絶反応に対して肝生検を施行したが，その際にPBCの再発は認めなかった．以上，本学におけるPBCに対する生体肝移植10例は良好な経過を示している．

Liver function is a major prognostic factor following hepatic resection for hepatocellular carcinoma (HCC), which is well correlated with the degree of fibrosis. On the other hand, the presence of liver cirrhosis itself leads to a higher incidence of HCC than chronic hepatitis. Therefore, preoperative noninvasive markers of fibrosis are important for the assessment of prognosis for treatment of HCC. The present study aimed to analyze whether aspartate aminotransferase to platelet ratio index (APRI) could predict prognosis following hepatic resection for HCC. The subjects were 162 patients who underwent hepatic resection for HCC between January 2000 and December 2011. The relationship between APRI and disease-free and overall survival were retrospectively investigated. In multivariate analysis, indocyanine green at 15 min (ICG-R15) ≥15% (P=0.0306), APRI ≥0.45 (P=0.0184), perioperative blood transfusion of red cell concentrates (RCC; P=0.0034) and TNM stage II, III or IV (P=0.0184) were significant predictors in disease-free survival. For overall survival, ICG-R15 ≥15% (P=0.0454), APRI ≥0.45 (P=0.0417), perioperative blood transfusion of RCC (P=0.0036) and TNM stage II, III or IV (P=0.0033) were significant predictors. In addition, higher APRI values were positively correlated with hepatitis C virus infection and preoperative liver function. In conclusion, APRI is an independent risk factor for disease-free and overall survival following hepatic resection for HCC.

Liver transplant recipients are considered to be at high risk for Clostridium difficile infection, with an incidence of 2.7–8.0%, which is three times higher than that among other patients. A case of a patient who suffered from pseudomembranous colitis five times after living donor liver transplantation is reported. A 60-year-old woman underwent splenectomy and living donor liver transplantation using the left lobe of her spouse for primary biliary cirrhosis. The patient made a satisfactory recovery, except for splenic vein thrombosis. She was discharged on postoperative day 36; however, she developed pseudomembranous colitis due to Clostridium difficile infection five times within 6 months after transplant and was treated with oral vancomycin each time. At the fifth recurrence of pseudomembranous colitis, the patient received vancomycin taper treatment, dietary counseling, and repeat instructions regarding hand hygiene and house cleaning. The patient recovered and is currently well without recurrence of Clostridium difficile infection 36 months after living donor liver transplantation.

症例は83歳女性．既往歴として，８年前に十二指腸乳頭部癌に対して膵頭十二指腸切除術と２年前に横行結腸癌に対し右半結腸切除を施行されている．今回は貧血と下血を主訴に当院受診した．腹部CTにて主膵管内に腫瘍を認め，小腸内視鏡にて膵空腸吻合部に腫瘍出血を認め，経カテーテル的血管塞栓術を施行し止血，軽快退院となった．小腸内視鏡の生検結果は高分化型管状腺癌であったが，免疫組織学的染色で結腸癌の発現形式とは異なること，CT上主膵管を主病変としていることより，結腸癌の転移再発は否定的であった．また，乳頭部癌再発は初発乳頭部癌がリンパ管浸潤，静脈浸潤なども認めず，pStage ⅠAであることから否定的と評価し，残膵癌と診断した．乳頭部癌に対する膵頭十二指腸切除術後の異時性残膵癌は稀ではあるが，同病態の発症を念頭にした長期の経過観察が必要であると考える．

Introduction Laparoscopic cholecystectomy (LC) is the gold standard treatment for cholelithiasis. However, LC is associated with a slightly higher rate of complications than laparotomy. To perform a safe LC, it is important to exercise caution regarding an abnormal course for the hepatic artery, although the incidence itself is low. Here, we report a rare case of LC in which the medial segment artery mimicked cystic artery. To the best of our knowledge, such a case has not yet been reported. Case Presentation A 35-year-old man visited our hospital with a complaint of epigastric pain. The symptom had continued for 2 months. Ultrasound and computed tomography revealed cholelithiasis. Magnetic resonance imaging did not show any biliary abnormalities. The patient was scheduled for an elective laparoscopic cholecystectomy. At the time of surgery, the gallbladder was slightly inflamed. After dissection of the Calot triangle, the cystic duct and a single large artery were identified. Although the critical view of safety was confirmed at first glance, dissection of periarterial adhesions revealed that the artery ran into the medial segment of the liver. Further dissection revealed short double cystic arteries branching from the aberrant artery. After the confirmation of the abnormal course of the arteries, the operation was performed safely without arterial injury. The patient made a satisfactory recovery and was discharged 3 days after operation. Conclusion The knowledge of the anatomy of the cystic artery and careful dissection are an important aspect in achieving a complication-free LC.

AIM To investigate the clinical characteristics and prognosis of surgical patients with non-B non-C hepatocellular carcinoma (NBNC-HCC) compared to those of hepatitis B virus (HBV)- and hepatitis C virus (HCV)-HCC. PATIENTS AND METHODS Clinical data and outcomes were compared among the three groups. Prognostic factors of patients with NBNC-HCC were investigated. RESULTS Compared to HBV-HCC, patients with NBNC-HCC had higher chance of hypertension (HTN) (p<0.01), diabetes mellitus (DM) and body mass index (BMI) >25 kg/m2 Compared to HCV-HCC, patients with NBNC-HCC had higher incidence of DM and higher BMI >25 kg/m2 (p<0.01). There were no significant differences in overall survival (OS) rate among the three groups. In patients with NBNC-HCC, albumin (Alb; p<0.05) was an independent prognostic factor of OS, while Alb and α-fetoprotein (AFP) were independent prognostic factors of disease-free survival (DFS; p<0.01 each). CONCLUSION Surgical patients with NBNC-HCC often have concomitant DM, HTN and high BMI, for whom factors related to prognosis were Alb and AFP.

AIM:Pancreaticoduodenectomy (PD) is still the only curative treatment for periampullary cancer. Confirming the outcomes of PD in elderly patients is important as the aging population continues to grow.PATIENTS AND METHODS:We analyzed 340 patients with periampullary cancer who underwent PD, dividing them into three groups by age: group A: aged 64 years or younger, n=115; group B: 65-74 years, n=144; and group C: 75 years or older, n=81.RESULTS:Group C had a significantly higher 60-day mortality of 6.3% (p=0.04), the lowest 5-year overall survival rate of 9.9% (p=0.02), and there was no impact of staging of the Union for International Cancer Control classification on overall survival of patients with pancreatic cancer. Independent prognostic factors of group C in the multivariate analysis were pancreatic cancer and reoperation.CONCLUSION:For elderly patients aged 75 years or over, caution should be exercised in selecting PD for patients with pancreatic cancer.

Background: The evaluation of the hepatic vascular anatomy in living liver donors is increasingly being performed by three-dimensional (3D) computed tomography (CT) angiography. However, details of hepatic artery anatomy obtained by 3D CT angiography are not always superior to those obtained by angiography. Here, we report a case in which the 3D image navigation system helped to detect segment II, III, and IV arteries (A2, A3, and A4, respectively) that individually originated from the proper hepatic artery (PHA); this could not be detected by 3D CT angiography.Case presentation: A 46-year-old man with end-stage primary biliary cirrhosis was admitted to our hospital for evaluation as a candidate for living donor liver transplantation. The patient's younger sister, aged 43 years, was the only living donor candidate. The predicted left liver graft volume with the middle hepatic vein was found to be 403 mL using the region-growing method with 3D CT software. This volume was sufficiently large for the recipient because the standard liver volume of the recipient was 1095 mL. 3D CT angiography was performed twice but could not reveal the anatomical structure of the left and middle hepatic arteries. However, simulation using the region-growing method demonstrated individual branching off of A2, A3, and A4 from the PHA; conventional angiography demonstrated the same results. Each branch was approximately 1 mm in diameter, which was too small for secure anastomosis. Therefore, we selected the right liver graft for simplicity. The postoperative course of the donor and recipient was uneventful, and they were discharged on postoperative days 10 and 46, respectively.Conclusions: In conclusion, reconstruction of the hepatic vasculature using the 3D software by region-growing method might be a useful adjunct for surgical planning in the evaluation of the hepatic arteries in living liver donors.

Preoperative systemic inflammatory response is associated with a poor long-term prognosis following resection surgery for malignant tumors. Several markers of systemic inflammation have been reported to be associated with the outcome; however, they have not currently been fully investigated. Therefore, the association between preoperative peripheral blood neutrophil count and oncological outcome following hepatic resection for colorectal liver metastasis (CRLM) was retrospectively investigated. The present study comprised 89 patients who had undergone hepatic resection for CRLM between January 2000 and March 2010. The association between preoperative peripheral blood neutrophil count and disease-free survival, in addition to overall survival, was investigated. In multivariate analysis, the presence of neoadjuvant chemotherapy (P=0.015), bilobar distribution (P=0.015) and neutrophil count ≥3,500/µl (P=0.025) were independent and significant predictors of poor disease-free survival, while significant predictors of poor overall survival consisted of >4 lymph node metastases (P=0.001), neo-adjuvant chemotherapy (P=0.003), bilobar distribution (P=0.039) and neutrophil count ≥3,500/µl (P=0.040). Additionally, tumor diameter (P=0.021) and monocyte count (P<0.0001) were observed to be significantly greater in the elevated neutrophil count group. In conclusion, preoperative peripheral blood neutrophil count may be an independent and significant indicator of poor long-term outcomes in patients with CRLM following hepatic resection.

BACKGROUND/AIMPancreaticoduodenectomy (PD) is one of the most complicated procedures. We retrospectively assessed the therapeutic outcome after PD by Junior surgeons.PATIENTS AND METHODSThis study included 253 patients. We retrospectively analyzed surgical outcomes and long-term survivals of PDs performed by Junior surgeons (surgical training year within 10 years) as compared to those by Senior surgeons (surgical training year over 10 years).RESULTSOperative time was significantly longer in junior surgeons than that in Senior surgeons (p<0.001). Intraoperative blood loss (p=0.079), hospital stay (p=0.803), complications (p=0.700), mortality (p=0.442) were comparable between the two groups. Disease-free and overall survival rates were not statistically different between the two groups in pancreatic cancer (p=0.248 and p=0.526) and in bile duct or ampullary cancer (p=0.873 and p=0.954).CONCLUSIONPD performed by Junior surgeons require approximately 70 more minutes but surgery can be performed safely under appropriate patient selection, intraoperative supervision and perioperative management with comparable long-term survival.

BACKGROUND/AIM Pancreatic resection is the only curative treatment for pancreatic and certain biliary malignancies. However, the mortality and morbidity associated with pancreatic resection remain high. PATIENTS AND METHODS The study included 114 patients with age 70 years or older who underwent pancreatic resection for pancreatic or biliary cancer between 2005 and 2014 at the Jikei University Hospital. We analyzed surgical outcomes, complications, mortality and long-term survival between patients aged 70-79 years (n=97) and those aged 80 years or over (n=17). RESULTS In patients aged 70 to 79 years, two died in-hospital and 8 required reoperation or interventional radiology (IVR). In patients aged 80 years or over, on the other hand, there was no in-hospital mortality. The incidence of complications and long-term survival were comparable. CONCLUSION Pancreatic resection for pancreatic and biliary malignancies in patients aged 80 years or over with good general condition and proper selection seems safe and acceptable.