Background: To evaluate the utility of robotassisted laparoscopic transabdominal preperitoneal re... more Background: To evaluate the utility of robotassisted laparoscopic transabdominal preperitoneal repair (R-TAPP) of postprostatectomy inguinal hernia (PIH) in patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP). Patients and Methods: This was a prospective, single-centre retrospective cohort study. R-TAPP was conducted in 74 consecutive patients from September 2016 to March 2020. With the exception of women and patients who underwent previous abdominal surgery, 70 patients were classified into two groups based on the absence or presence of PIH. Their data were retrospectively compared to those who had not undergone RALP. Results: The median operative time for the PIH group was longer compared to the non-PIH group. However, postoperative complications, including seroma formation, haematoma and surgical site infections, were not significantly different between the groups. The estimated blood loss was small, and hospitalisation duration was 1 day in all cases. Moreover, there were no hernia recurrences within the 90-day followup period in either group. Conclusion: R-TAPP is a feasible and safe approach for inguinal hernia repair, even in patients who undergo RALP for prostate cancer.
BackgroundThere are no reports of robot-assisted laparoscopic transabdominal preperitoneal inguin... more BackgroundThere are no reports of robot-assisted laparoscopic transabdominal preperitoneal inguinal hernia repair (R-TAPP) for the patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP). AimTo evaluate the feasibility and safety of R-TAPP in patients who underwent RALP for postprostatectomy inguinal hernia (PIH).MethodsThis is a prospective, single-center retrospective cohort study. R-TAPP was conducted in 74 consecutive patients from September 2016 to March 2020. Except for women and patients who underwent previous abdominal surgery, 70 patients were classified into two groups based on the absence or presence of PIH (PIH group or non-PIH group). The data were retrospectively compared to those who had not undergone RALP.ResultsSeventy patients were reviewed. Among them, 22.9% had previously undergone RALP. We identified 22 lesions in 16 patients (unilateral in 10; bilateral in 6) in the PIH group, and 67 lesions in 54 patients (unilateral in 41; bilateral in...
Background Duct-to-mucosa pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) is techn... more Background Duct-to-mucosa pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) is technically challenging, particularly in cases of soft pancreas with a nondilated main pancreatic duct (MPD). We propose a novel procedure that involves ligating the pancreas in advance to allow for MPD dilation. Methods We compared the data of 16 patients who underwent PD followed by PJ with advance ligation (AL) for soft pancreas with a nondilated MPD with that of 17 patients who underwent a conventional procedure (conventional group) without AL at a single institution between January 2015 and April 2017. MPD diameters were assessed using preoperative computed tomography and intraoperative ultrasonography. Pancreatic consistency was judged intraoperatively. The pancreatic parenchyma and MPD were ligated in advance to allow time for MPD dilation. After AL, we divided the pancreatic parenchyma. AL led to MPD dilation and facilitated PJ. Results There were significantly fewer complications in ...
Journal of Hepato-Biliary-Pancreatic Sciences, 2021
BackgroundThe high operative mortality rate after hepatopancreatoduodenectomy (HPD) is still a ma... more BackgroundThe high operative mortality rate after hepatopancreatoduodenectomy (HPD) is still a major issue. The present study explored why operative mortality differs significantly due to hospital volume.MethodSurgical case data were extracted from the National Clinical Database (NCD) in Japan from 2011 to 2014. Surgical procedures were categorized as major (≥2 sections) and minor (<2 sections) hepatectomy. Hospitals were categorized according to the certification system by the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery (JSHBPS) based on the number of major hepato‐biliary‐pancreatic surgeries performed per year. The FTR rate was defined as death in a patient with at least one postoperative complication.ResultsA total of 422 patients who underwent HPD were analyzed. The operative mortality rates in board‐certified A training institutions, board‐certified B training institutions, and non‐certified institution were 7.2%, 11.6%, and 21.4%, respectively. Multiple logistic r...
Background As the elderly population increases, cases of elderly advanced gastric cancer (AGC) al... more Background As the elderly population increases, cases of elderly advanced gastric cancer (AGC) also increase. This study aims to investigate the safety and utility of curative gastrectomy, as well as the efficacy of laparoscopic gastrectomy, for these elderly patients. Methods We retrospectively analyzed the surgical outcomes of patients with cStage IB-III AGC who underwent distal gastrectomy (DG) with D2 lymph node dissection in our institution. We compared the results between elderly patients (>75 years) and non-elderly patients (<75 years). We further divided the elderly patients into 2 groups: those who underwent laparoscopic DG (LDG) and those who underwent open DG (ODG). Further, we compared the results of the 2 groups. Results From January 2014 to March 2019, 84 patients underwent DG with D2 lymph node dissection for cStage IB-III AGC (52 elderly patients and 32 non-elderly patients). ASA was significantly higher in elderly patients; however, there was no significant di...
Background: Surgical site infections (SSIs), which are associated with preoperative malnutrition,... more Background: Surgical site infections (SSIs), which are associated with preoperative malnutrition, are a well-known potential complication of surgery that leads to increased medical costs and longer hospitalizations. Thus, surgeons need to accurately identify patients at high-risk for SSIs. Considering that the Geriatric Nutritional Risk Index (GNRI) was designed to assess the degree of malnutrition specifically among elderly patients, previous evidence (Kawaguchi study) proved that GNRI predicted the risk of SSIs in patients following pancreatoduodenectomy (PD). In this study, we aimed to validate whether that the same index could predict the risk of SSI among patients who underwent PD in our patient cohort (Ageo study). Methods: The current validation cohort study was retrospectively conducted on 93 patients at the
Postpancreatectomy hemorrhage (PPH) is the most lethal complication of pancreatoduodenectomy (PD)... more Postpancreatectomy hemorrhage (PPH) is the most lethal complication of pancreatoduodenectomy (PD). The main risk factor for PPH is the development of a postoperative pancreatic fistula (POPF). Recent evidence shows that the geriatric nutritional risk index (GNRI) may be predictive indicator for POPF. In this study, we aimed to evaluate whether GNRI is a reliable predictive marker for PPH following PD. The present study retrospectively evaluated 121 patients treated with PD at Ageo Central General Hospital in Japan between January 2015 and March 2020. We investigated the potential of age, gender, body mass index, serum albumin, American Society of Anesthesiologists classification (ASA), diabetes mellitus and smoking status, time taken for the operation, estimated blood loss, and postoperative complications (POPF, bile leak, and surgical site infections) to predict the risk of PPH following PD using univariate and multivariate analyses. Ten patients had developed PPH with an incidence...
Objective: The aim of this study was to develop and externally validate the first evidence-based ... more Objective: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). Summary Background Data: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. Methods: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AG...
HPB : the official journal of the International Hepato Pancreato Biliary Association, Jan 29, 2017
Recent studies have suggested that the difficulty of laparoscopic liver resections are related to... more Recent studies have suggested that the difficulty of laparoscopic liver resections are related to both patient and tumour factors, however the available difficulty scoring systems only incorporate tumour factors. The aim of this study was to assess the opinion of laparoscopic liver surgeons regarding the factors that affect the perceived difficulty of laparoscopic liver resections. Using a Visual Analogue Scale an international survey of laparoscopic liver surgeons was undertaken to assess the perceived difficulty of 26 factors previously demonstrated to affect the difficulty of a laparoscopic liver resection. 80 surgeons with a combined experience of over 7000 laparoscopic liver resections responded to the survey. The difficulty of laparoscopic liver surgery was suggested to be increased by a BMI > 35 by 89% of respondents; neo-adjuvant chemotherapy by 79%; repeated liver resection by 99% and concurrent procedures by 59% however these factors have not been included in the previo...
The 10-point Fistula Risk Score (FRS) has been shown to predict the development of pancreatic fis... more The 10-point Fistula Risk Score (FRS) has been shown to predict the development of pancreatic fistula (PF) after pancreatoduodenectomy (PD). However, its ability to predict PF severity is incompletely defined. This study aimed to provide external validation of the FRS and assess its role in predicting PF severity after PD. Methods: Patients who underwent PD at a single academic tertiary care center were included. Clinicopathological, demographic and perioperative data were collected. The FRS was calculated for each patient and PF severity was graded according to the International Study Group on Pancreatic Fistula standards as A, B, or C. Grades B and C were considered clinically relevant (CR-PF). Results: Data from 280 patients (mean age 64.4 years) were analyzed. PF occurred after 96 PDs (34.3%), and 68 were CR-PF (24.6%). The FRS correlated closely with the development of PF (for each 1 point increase, PF Odds Ratio 1.47, 95% Confidence Interval CI 1.28e1.70, p < 0.001). PF developed in 11.3% of patients with scores 0e1 (9.3% CR-PF), 40.6% of patients scoring 2-3 (23.4% CR-PF), and 53.6% of patients with scores of 4 or more (43.9% CR-PF) (p < 0.001). However, the score did not correlate with the severity of the fistula, with similar distributions of severity grades for each individual FRS score (p = 0.46). Conclusion: These findings externally validate the FRS as a useful tool in predicting PF after PD. The inability of FRS to predict PF severity suggests that other factors may determine the ultimate clinical sequelae of a PF.
Our study was supported by unrestricted technical assistance from Taiho Pharmaceutical Co., Ltd, ... more Our study was supported by unrestricted technical assistance from Taiho Pharmaceutical Co., Ltd, Japan. We thank Kazuto Harada, Keisuke Kosumi, and Keisuke Miyake for their technical support. We also thank Takashi Kobunai for his helpful advice.
The factors that influence long-term outcomes after living-donor liver transplantation (LDLT) for... more The factors that influence long-term outcomes after living-donor liver transplantation (LDLT) for primary biliary cirrhosis (PBC) are not well known. Compared with deceased-donor transplantation, LDLT has an increased likelihood of a related donor and a decreased number of human leukocyte antigen (HLA) mismatches. To clarify the effects of donor relatedness and HLA mismatch on the outcomes after LDLT, we retrospectively analyzed 444 Japanese patients. Donors were blood relatives for 332 patients, spouses for 105, and ''other'' for 7. The number of HLA A-B-DR mismatches was none to two in 141, three in 123, and four to six in 106 patients. The 15-year survival rate was 52.6%, and PBC recurred in 65 patients. Recipient aged 61 years or older, HLA mismatches of four or more (maximum of six), graft:recipient weight ratio less than 0.8, and husband donor were adverse indicators of patient survival. IgM 554 mg/dL or greater, donorrecipient sex mismatch, and initial immunosuppression with cyclosporine were significant risks for PBC recurrence, which did not affect patient survival. In subgroup analysis, conversion to cyclosporine from tacrolimus within 1 year diminished recurrence. Prospective studies are needed to determine the influence of pregnancy-associated sensitization and to establish an optimal immunosuppressive regimen in LDLT patients.
HPB : the official journal of the International Hepato Pancreato Biliary Association, Mar 9, 2017
Increased incorporation of minimally invasive pancreatic resections (MIPR) has emerged into hepat... more Increased incorporation of minimally invasive pancreatic resections (MIPR) has emerged into hepato-pancreato-biliary practice, however, no standardization exists for its safe adoption. Novel strategies are presented for dissemination of safe MIPR. An international State-of-the-Art conference evaluating multiple aspects of MIPR was conducted by a panel of pancreas experts in Sao Paulo, Brazil on April 20, 2016. Training and education issues were discussed regarding the introduction of novel strategies for safe dissemination of MIPR. The low volume of pancreatic resections per institution poses a challenge for surgeons to overcome their MIPR learning curve without deliberate training. A mastery-based simulation and biotissue curriculum can improve technical proficiency and allow for training of surgeons before the operating room. Video-based platforms allow for performance reporting and feedback necessary for coaching and surgical quality improvement. Centers of excellence with traini...
International collaboration is important in healthcare quality evaluation; however, few internati... more International collaboration is important in healthcare quality evaluation; however, few international comparisons of general surgery outcomes have been accomplished. Furthermore, predictive model application for risk stratification has not been internationally evaluated. The National Clinical Database (NCD) in Japan was developed in collaboration with the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), with a goal of creating a standardized surgery database for quality improvement. The study aimed to compare the consistency and impact of risk factors of 3 major gastroenterological surgical procedures in Japan and the United States (US) using web-based prospective data entry systems: right hemicolectomy (RH), low anterior resection (LAR), and pancreaticoduodenectomy (PD). Data from NCD and ACS-NSQIP, collected over 2 years, were examined. Logistic regression models were used for predicting 30-day mortality for both countries. Models were exchanged and evaluated to determine whether the models built for one population were accurate for the other population.
Background. Anatomical resections have been reported to achieve better long-term outcomes compare... more Background. Anatomical resections have been reported to achieve better long-term outcomes compared with partial resections for the treatment of hepatocellular carcinoma (HCC). Despite this, laparoscopic anatomical resections are very challenging operations, especially when approaching the posterosuperior segments of the liver (IVa, VII, and VIII). We report a full laparoscopic anatomical segment 8 resection focusing on the technical aspects of the Glissonian approach. Methods. A routine follow-up CT scan of an 80-year-old women affected by hepatitis C-related liver cirrhosis showed a 3-cm HCC in segment 8. Three-dimensional reconstruction was performed to evaluate the liver anatomy, the relationship of the lesion with major vessels, and the borders of segment 8. A true anatomical segmentectomy was performed by using selective occlusion of segment's 8 Glissonian pedicle, which was identified from the liver hilum. Indocyanine green (ICG) dye demarcation was used as a guidance during parenchymal transection. 1-4 Results. Operative time was 420 min, and blood loss was 261 mL. The patient had an uneventful postoperative course and was discharged home after 8 days. Conclusions. Full laparoscopic anatomical segment 8 resection is a technically challenging operation. The use of the Glissonian approach and the aid of ICG dye could be of help, but advanced laparoscopic skills are necessary to complete such a difficult procedure safely. 5-13 ACKNOWLEDGMENT The authors thank Mr. Emanuele Berardi for his kind support during video editing.
Journal of Hepato-biliary-pancreatic Sciences, Mar 12, 2021
Background and aims: This study aimed to assess the safety and efficacy of endoscopic ultrasound ... more Background and aims: This study aimed to assess the safety and efficacy of endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) in the management of benign pancreatic tumors. Methods: In a single-center, prospective study, 10 patients with benign solid pancreatic tumors underwent EUS-RFA. After inserting the RFA electrode into pancreatic mass, the radiofrequency generator was activated to deliver 50 W of ablation power for 10 s. Complete ablation was defined by the disappearance of enhancing tissue at the tumor site on imaging. Results: In 10 patients, 16 sessions of EUS-RFA were successfully performed. There were 7 cases of nonfunctioning neuroendocrine tumor, 1 case of insulinoma, and 2 cases of solid pseudopapillary neoplasm; the median largest diameter of the tumors was 20 mm (range, 8e28 mm). The anatomical locations of the pancreatic tumors were as follows: head (n = 4), body (n = 5), and tail (n = 1). During follow-up (median 13 months, range 8e30 months), the postprocedure imaging showed complete ablation in 7 patients. The median EUS diameter of the tumors changed from 20 mm (IQR 15e24 mm) at the baseline to 6.5 mm (IQR 3.7e11.3) at the end of the follow-up (p < .001). In the 16 total ablation procedures, the procedure-related adverse events included one patient with abdominal pain (6.2%) and one with pancreatitis (6.2%). Conclusions: EUS-RFA may be a safe and potentially effective treatment option in selected patients. Multiple sessions may be required if there is a remnant or recurrent mass, and procedure-related adverse events must be cautiously monitored.
Objective: To investigate the frequency of laparoscopic liver resection (LLR) nationwide in Japan... more Objective: To investigate the frequency of laparoscopic liver resection (LLR) nationwide in Japan. Background: LLR was initially limited to basic liver resection, but is becoming more common in advanced liver resection. Methods: Retrospective observational study of 148,507 patients registered in the National Clinical Database 2011–2017. Excluded: liver resection with biliary and vascular reconstruction. Results: LLR or open liver resection (OLR) was performed in 1848 (9.9%) and 16,888 (90.1%) patients, respectively, in 2011, whereas in 2017, LLR had increased to 24.8% and OLR decreased to 75.2% of resections (5648 and 17,099 patients, respectively). There was an annual increasing trend of LLR, starting at 9.9%, then 13.8%, 17.3%, 21.2%, 18.1%, 21.0%, and finally 24.8% in 2017. Basic LLR became more common, up to 30.8% of LR in 2017. Advanced LLR increased from 3.3% of all resections in 2011 to 10.8% in 2017. Throughout the years observed, there were fewer complications in LLR than OLR. Operative mortality was 3.6% for both advanced LLR and OLR in 2011, and decreased to 1.0% and 2.0%, respectively, in 2017. Mortality for both basic LLR and basic OLR were low and did not change throughout the study, at 0.5% and 1.6%, respectively, in 2011 and 0.5% and 1.1%, in 2017. Conclusions: LLR has rapidly become widespread in Japan. Basic LLR is now a standard option, and advanced LLR, while not as common yet, has been increasing year by year. LLR has been safely developed with low mortality and complications rate relative to OLR.
Journal of Hepato-biliary-pancreatic Sciences, Jul 1, 2015
BackgroundThe aim of this study was to compare the long‐term outcomes and perioperative outcomes ... more BackgroundThe aim of this study was to compare the long‐term outcomes and perioperative outcomes of laparoscopic liver resection (LLR) with those of open liver resection (OLR) for hepatocellular carcinoma (HCC) between well‐matched patient groups.MethodsHepatocellular carcinoma patients underwent primary liver resection between 2000 and 2010, were collected from 31 participating institutions in Japan and were divided into LLR (n = 436) and OLR (n = 2969) groups. A one‐to‐one propensity case‐matched analysis was used with covariates of baseline characteristics, including tumor characteristics and surgical procedures of hepatic resections. Long‐term and short‐term outcomes were compared between the matched two groups.ResultsThe two groups were well balanced by propensity score matching and 387 patients were matched. There were no significant differences in overall survival and disease‐free survival between LLR and OLR. The median blood loss (158 g vs. 400 g, P &lt; 0.001) was significantly less with LLR, and the median postoperative hospital stay (13 days vs. 16 days, P &lt; 0.001) was significantly shorter for LLR. Complication rate (6.7% vs. 13.0%, P = 0.003) was significantly less in LLR.ConclusionCompared with OLR, LLR in selected patients with HCC showed similar long‐term outcomes, associated with less blood loss, shorter hospital stay, and fewer postoperative complications.
Background: To evaluate the utility of robotassisted laparoscopic transabdominal preperitoneal re... more Background: To evaluate the utility of robotassisted laparoscopic transabdominal preperitoneal repair (R-TAPP) of postprostatectomy inguinal hernia (PIH) in patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP). Patients and Methods: This was a prospective, single-centre retrospective cohort study. R-TAPP was conducted in 74 consecutive patients from September 2016 to March 2020. With the exception of women and patients who underwent previous abdominal surgery, 70 patients were classified into two groups based on the absence or presence of PIH. Their data were retrospectively compared to those who had not undergone RALP. Results: The median operative time for the PIH group was longer compared to the non-PIH group. However, postoperative complications, including seroma formation, haematoma and surgical site infections, were not significantly different between the groups. The estimated blood loss was small, and hospitalisation duration was 1 day in all cases. Moreover, there were no hernia recurrences within the 90-day followup period in either group. Conclusion: R-TAPP is a feasible and safe approach for inguinal hernia repair, even in patients who undergo RALP for prostate cancer.
BackgroundThere are no reports of robot-assisted laparoscopic transabdominal preperitoneal inguin... more BackgroundThere are no reports of robot-assisted laparoscopic transabdominal preperitoneal inguinal hernia repair (R-TAPP) for the patients who underwent robot-assisted laparoscopic radical prostatectomy (RALP). AimTo evaluate the feasibility and safety of R-TAPP in patients who underwent RALP for postprostatectomy inguinal hernia (PIH).MethodsThis is a prospective, single-center retrospective cohort study. R-TAPP was conducted in 74 consecutive patients from September 2016 to March 2020. Except for women and patients who underwent previous abdominal surgery, 70 patients were classified into two groups based on the absence or presence of PIH (PIH group or non-PIH group). The data were retrospectively compared to those who had not undergone RALP.ResultsSeventy patients were reviewed. Among them, 22.9% had previously undergone RALP. We identified 22 lesions in 16 patients (unilateral in 10; bilateral in 6) in the PIH group, and 67 lesions in 54 patients (unilateral in 41; bilateral in...
Background Duct-to-mucosa pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) is techn... more Background Duct-to-mucosa pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD) is technically challenging, particularly in cases of soft pancreas with a nondilated main pancreatic duct (MPD). We propose a novel procedure that involves ligating the pancreas in advance to allow for MPD dilation. Methods We compared the data of 16 patients who underwent PD followed by PJ with advance ligation (AL) for soft pancreas with a nondilated MPD with that of 17 patients who underwent a conventional procedure (conventional group) without AL at a single institution between January 2015 and April 2017. MPD diameters were assessed using preoperative computed tomography and intraoperative ultrasonography. Pancreatic consistency was judged intraoperatively. The pancreatic parenchyma and MPD were ligated in advance to allow time for MPD dilation. After AL, we divided the pancreatic parenchyma. AL led to MPD dilation and facilitated PJ. Results There were significantly fewer complications in ...
Journal of Hepato-Biliary-Pancreatic Sciences, 2021
BackgroundThe high operative mortality rate after hepatopancreatoduodenectomy (HPD) is still a ma... more BackgroundThe high operative mortality rate after hepatopancreatoduodenectomy (HPD) is still a major issue. The present study explored why operative mortality differs significantly due to hospital volume.MethodSurgical case data were extracted from the National Clinical Database (NCD) in Japan from 2011 to 2014. Surgical procedures were categorized as major (≥2 sections) and minor (<2 sections) hepatectomy. Hospitals were categorized according to the certification system by the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery (JSHBPS) based on the number of major hepato‐biliary‐pancreatic surgeries performed per year. The FTR rate was defined as death in a patient with at least one postoperative complication.ResultsA total of 422 patients who underwent HPD were analyzed. The operative mortality rates in board‐certified A training institutions, board‐certified B training institutions, and non‐certified institution were 7.2%, 11.6%, and 21.4%, respectively. Multiple logistic r...
Background As the elderly population increases, cases of elderly advanced gastric cancer (AGC) al... more Background As the elderly population increases, cases of elderly advanced gastric cancer (AGC) also increase. This study aims to investigate the safety and utility of curative gastrectomy, as well as the efficacy of laparoscopic gastrectomy, for these elderly patients. Methods We retrospectively analyzed the surgical outcomes of patients with cStage IB-III AGC who underwent distal gastrectomy (DG) with D2 lymph node dissection in our institution. We compared the results between elderly patients (>75 years) and non-elderly patients (<75 years). We further divided the elderly patients into 2 groups: those who underwent laparoscopic DG (LDG) and those who underwent open DG (ODG). Further, we compared the results of the 2 groups. Results From January 2014 to March 2019, 84 patients underwent DG with D2 lymph node dissection for cStage IB-III AGC (52 elderly patients and 32 non-elderly patients). ASA was significantly higher in elderly patients; however, there was no significant di...
Background: Surgical site infections (SSIs), which are associated with preoperative malnutrition,... more Background: Surgical site infections (SSIs), which are associated with preoperative malnutrition, are a well-known potential complication of surgery that leads to increased medical costs and longer hospitalizations. Thus, surgeons need to accurately identify patients at high-risk for SSIs. Considering that the Geriatric Nutritional Risk Index (GNRI) was designed to assess the degree of malnutrition specifically among elderly patients, previous evidence (Kawaguchi study) proved that GNRI predicted the risk of SSIs in patients following pancreatoduodenectomy (PD). In this study, we aimed to validate whether that the same index could predict the risk of SSI among patients who underwent PD in our patient cohort (Ageo study). Methods: The current validation cohort study was retrospectively conducted on 93 patients at the
Postpancreatectomy hemorrhage (PPH) is the most lethal complication of pancreatoduodenectomy (PD)... more Postpancreatectomy hemorrhage (PPH) is the most lethal complication of pancreatoduodenectomy (PD). The main risk factor for PPH is the development of a postoperative pancreatic fistula (POPF). Recent evidence shows that the geriatric nutritional risk index (GNRI) may be predictive indicator for POPF. In this study, we aimed to evaluate whether GNRI is a reliable predictive marker for PPH following PD. The present study retrospectively evaluated 121 patients treated with PD at Ageo Central General Hospital in Japan between January 2015 and March 2020. We investigated the potential of age, gender, body mass index, serum albumin, American Society of Anesthesiologists classification (ASA), diabetes mellitus and smoking status, time taken for the operation, estimated blood loss, and postoperative complications (POPF, bile leak, and surgical site infections) to predict the risk of PPH following PD using univariate and multivariate analyses. Ten patients had developed PPH with an incidence...
Objective: The aim of this study was to develop and externally validate the first evidence-based ... more Objective: The aim of this study was to develop and externally validate the first evidence-based guidelines on minimally invasive pancreas resection (MIPR) before and during the International Evidence-based Guidelines on Minimally Invasive Pancreas Resection (IG-MIPR) meeting in Miami (March 2019). Summary Background Data: MIPR has seen rapid development in the past decade. Promising outcomes have been reported by early adopters from high-volume centers. Subsequently, multicenter series as well as randomized controlled trials were reported; however, guidelines for clinical practice were lacking. Methods: The Scottisch Intercollegiate Guidelines Network (SIGN) methodology was used, incorporating these 4 items: systematic reviews using PubMed, Embase, and Cochrane databases to answer clinical questions, whenever possible in PICO style, the GRADE approach for assessment of the quality of evidence, the Delphi method for establishing consensus on the developed recommendations, and the AG...
HPB : the official journal of the International Hepato Pancreato Biliary Association, Jan 29, 2017
Recent studies have suggested that the difficulty of laparoscopic liver resections are related to... more Recent studies have suggested that the difficulty of laparoscopic liver resections are related to both patient and tumour factors, however the available difficulty scoring systems only incorporate tumour factors. The aim of this study was to assess the opinion of laparoscopic liver surgeons regarding the factors that affect the perceived difficulty of laparoscopic liver resections. Using a Visual Analogue Scale an international survey of laparoscopic liver surgeons was undertaken to assess the perceived difficulty of 26 factors previously demonstrated to affect the difficulty of a laparoscopic liver resection. 80 surgeons with a combined experience of over 7000 laparoscopic liver resections responded to the survey. The difficulty of laparoscopic liver surgery was suggested to be increased by a BMI > 35 by 89% of respondents; neo-adjuvant chemotherapy by 79%; repeated liver resection by 99% and concurrent procedures by 59% however these factors have not been included in the previo...
The 10-point Fistula Risk Score (FRS) has been shown to predict the development of pancreatic fis... more The 10-point Fistula Risk Score (FRS) has been shown to predict the development of pancreatic fistula (PF) after pancreatoduodenectomy (PD). However, its ability to predict PF severity is incompletely defined. This study aimed to provide external validation of the FRS and assess its role in predicting PF severity after PD. Methods: Patients who underwent PD at a single academic tertiary care center were included. Clinicopathological, demographic and perioperative data were collected. The FRS was calculated for each patient and PF severity was graded according to the International Study Group on Pancreatic Fistula standards as A, B, or C. Grades B and C were considered clinically relevant (CR-PF). Results: Data from 280 patients (mean age 64.4 years) were analyzed. PF occurred after 96 PDs (34.3%), and 68 were CR-PF (24.6%). The FRS correlated closely with the development of PF (for each 1 point increase, PF Odds Ratio 1.47, 95% Confidence Interval CI 1.28e1.70, p < 0.001). PF developed in 11.3% of patients with scores 0e1 (9.3% CR-PF), 40.6% of patients scoring 2-3 (23.4% CR-PF), and 53.6% of patients with scores of 4 or more (43.9% CR-PF) (p < 0.001). However, the score did not correlate with the severity of the fistula, with similar distributions of severity grades for each individual FRS score (p = 0.46). Conclusion: These findings externally validate the FRS as a useful tool in predicting PF after PD. The inability of FRS to predict PF severity suggests that other factors may determine the ultimate clinical sequelae of a PF.
Our study was supported by unrestricted technical assistance from Taiho Pharmaceutical Co., Ltd, ... more Our study was supported by unrestricted technical assistance from Taiho Pharmaceutical Co., Ltd, Japan. We thank Kazuto Harada, Keisuke Kosumi, and Keisuke Miyake for their technical support. We also thank Takashi Kobunai for his helpful advice.
The factors that influence long-term outcomes after living-donor liver transplantation (LDLT) for... more The factors that influence long-term outcomes after living-donor liver transplantation (LDLT) for primary biliary cirrhosis (PBC) are not well known. Compared with deceased-donor transplantation, LDLT has an increased likelihood of a related donor and a decreased number of human leukocyte antigen (HLA) mismatches. To clarify the effects of donor relatedness and HLA mismatch on the outcomes after LDLT, we retrospectively analyzed 444 Japanese patients. Donors were blood relatives for 332 patients, spouses for 105, and ''other'' for 7. The number of HLA A-B-DR mismatches was none to two in 141, three in 123, and four to six in 106 patients. The 15-year survival rate was 52.6%, and PBC recurred in 65 patients. Recipient aged 61 years or older, HLA mismatches of four or more (maximum of six), graft:recipient weight ratio less than 0.8, and husband donor were adverse indicators of patient survival. IgM 554 mg/dL or greater, donorrecipient sex mismatch, and initial immunosuppression with cyclosporine were significant risks for PBC recurrence, which did not affect patient survival. In subgroup analysis, conversion to cyclosporine from tacrolimus within 1 year diminished recurrence. Prospective studies are needed to determine the influence of pregnancy-associated sensitization and to establish an optimal immunosuppressive regimen in LDLT patients.
HPB : the official journal of the International Hepato Pancreato Biliary Association, Mar 9, 2017
Increased incorporation of minimally invasive pancreatic resections (MIPR) has emerged into hepat... more Increased incorporation of minimally invasive pancreatic resections (MIPR) has emerged into hepato-pancreato-biliary practice, however, no standardization exists for its safe adoption. Novel strategies are presented for dissemination of safe MIPR. An international State-of-the-Art conference evaluating multiple aspects of MIPR was conducted by a panel of pancreas experts in Sao Paulo, Brazil on April 20, 2016. Training and education issues were discussed regarding the introduction of novel strategies for safe dissemination of MIPR. The low volume of pancreatic resections per institution poses a challenge for surgeons to overcome their MIPR learning curve without deliberate training. A mastery-based simulation and biotissue curriculum can improve technical proficiency and allow for training of surgeons before the operating room. Video-based platforms allow for performance reporting and feedback necessary for coaching and surgical quality improvement. Centers of excellence with traini...
International collaboration is important in healthcare quality evaluation; however, few internati... more International collaboration is important in healthcare quality evaluation; however, few international comparisons of general surgery outcomes have been accomplished. Furthermore, predictive model application for risk stratification has not been internationally evaluated. The National Clinical Database (NCD) in Japan was developed in collaboration with the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), with a goal of creating a standardized surgery database for quality improvement. The study aimed to compare the consistency and impact of risk factors of 3 major gastroenterological surgical procedures in Japan and the United States (US) using web-based prospective data entry systems: right hemicolectomy (RH), low anterior resection (LAR), and pancreaticoduodenectomy (PD). Data from NCD and ACS-NSQIP, collected over 2 years, were examined. Logistic regression models were used for predicting 30-day mortality for both countries. Models were exchanged and evaluated to determine whether the models built for one population were accurate for the other population.
Background. Anatomical resections have been reported to achieve better long-term outcomes compare... more Background. Anatomical resections have been reported to achieve better long-term outcomes compared with partial resections for the treatment of hepatocellular carcinoma (HCC). Despite this, laparoscopic anatomical resections are very challenging operations, especially when approaching the posterosuperior segments of the liver (IVa, VII, and VIII). We report a full laparoscopic anatomical segment 8 resection focusing on the technical aspects of the Glissonian approach. Methods. A routine follow-up CT scan of an 80-year-old women affected by hepatitis C-related liver cirrhosis showed a 3-cm HCC in segment 8. Three-dimensional reconstruction was performed to evaluate the liver anatomy, the relationship of the lesion with major vessels, and the borders of segment 8. A true anatomical segmentectomy was performed by using selective occlusion of segment's 8 Glissonian pedicle, which was identified from the liver hilum. Indocyanine green (ICG) dye demarcation was used as a guidance during parenchymal transection. 1-4 Results. Operative time was 420 min, and blood loss was 261 mL. The patient had an uneventful postoperative course and was discharged home after 8 days. Conclusions. Full laparoscopic anatomical segment 8 resection is a technically challenging operation. The use of the Glissonian approach and the aid of ICG dye could be of help, but advanced laparoscopic skills are necessary to complete such a difficult procedure safely. 5-13 ACKNOWLEDGMENT The authors thank Mr. Emanuele Berardi for his kind support during video editing.
Journal of Hepato-biliary-pancreatic Sciences, Mar 12, 2021
Background and aims: This study aimed to assess the safety and efficacy of endoscopic ultrasound ... more Background and aims: This study aimed to assess the safety and efficacy of endoscopic ultrasound (EUS)-guided radiofrequency ablation (RFA) in the management of benign pancreatic tumors. Methods: In a single-center, prospective study, 10 patients with benign solid pancreatic tumors underwent EUS-RFA. After inserting the RFA electrode into pancreatic mass, the radiofrequency generator was activated to deliver 50 W of ablation power for 10 s. Complete ablation was defined by the disappearance of enhancing tissue at the tumor site on imaging. Results: In 10 patients, 16 sessions of EUS-RFA were successfully performed. There were 7 cases of nonfunctioning neuroendocrine tumor, 1 case of insulinoma, and 2 cases of solid pseudopapillary neoplasm; the median largest diameter of the tumors was 20 mm (range, 8e28 mm). The anatomical locations of the pancreatic tumors were as follows: head (n = 4), body (n = 5), and tail (n = 1). During follow-up (median 13 months, range 8e30 months), the postprocedure imaging showed complete ablation in 7 patients. The median EUS diameter of the tumors changed from 20 mm (IQR 15e24 mm) at the baseline to 6.5 mm (IQR 3.7e11.3) at the end of the follow-up (p < .001). In the 16 total ablation procedures, the procedure-related adverse events included one patient with abdominal pain (6.2%) and one with pancreatitis (6.2%). Conclusions: EUS-RFA may be a safe and potentially effective treatment option in selected patients. Multiple sessions may be required if there is a remnant or recurrent mass, and procedure-related adverse events must be cautiously monitored.
Objective: To investigate the frequency of laparoscopic liver resection (LLR) nationwide in Japan... more Objective: To investigate the frequency of laparoscopic liver resection (LLR) nationwide in Japan. Background: LLR was initially limited to basic liver resection, but is becoming more common in advanced liver resection. Methods: Retrospective observational study of 148,507 patients registered in the National Clinical Database 2011–2017. Excluded: liver resection with biliary and vascular reconstruction. Results: LLR or open liver resection (OLR) was performed in 1848 (9.9%) and 16,888 (90.1%) patients, respectively, in 2011, whereas in 2017, LLR had increased to 24.8% and OLR decreased to 75.2% of resections (5648 and 17,099 patients, respectively). There was an annual increasing trend of LLR, starting at 9.9%, then 13.8%, 17.3%, 21.2%, 18.1%, 21.0%, and finally 24.8% in 2017. Basic LLR became more common, up to 30.8% of LR in 2017. Advanced LLR increased from 3.3% of all resections in 2011 to 10.8% in 2017. Throughout the years observed, there were fewer complications in LLR than OLR. Operative mortality was 3.6% for both advanced LLR and OLR in 2011, and decreased to 1.0% and 2.0%, respectively, in 2017. Mortality for both basic LLR and basic OLR were low and did not change throughout the study, at 0.5% and 1.6%, respectively, in 2011 and 0.5% and 1.1%, in 2017. Conclusions: LLR has rapidly become widespread in Japan. Basic LLR is now a standard option, and advanced LLR, while not as common yet, has been increasing year by year. LLR has been safely developed with low mortality and complications rate relative to OLR.
Journal of Hepato-biliary-pancreatic Sciences, Jul 1, 2015
BackgroundThe aim of this study was to compare the long‐term outcomes and perioperative outcomes ... more BackgroundThe aim of this study was to compare the long‐term outcomes and perioperative outcomes of laparoscopic liver resection (LLR) with those of open liver resection (OLR) for hepatocellular carcinoma (HCC) between well‐matched patient groups.MethodsHepatocellular carcinoma patients underwent primary liver resection between 2000 and 2010, were collected from 31 participating institutions in Japan and were divided into LLR (n = 436) and OLR (n = 2969) groups. A one‐to‐one propensity case‐matched analysis was used with covariates of baseline characteristics, including tumor characteristics and surgical procedures of hepatic resections. Long‐term and short‐term outcomes were compared between the matched two groups.ResultsThe two groups were well balanced by propensity score matching and 387 patients were matched. There were no significant differences in overall survival and disease‐free survival between LLR and OLR. The median blood loss (158 g vs. 400 g, P &lt; 0.001) was significantly less with LLR, and the median postoperative hospital stay (13 days vs. 16 days, P &lt; 0.001) was significantly shorter for LLR. Complication rate (6.7% vs. 13.0%, P = 0.003) was significantly less in LLR.ConclusionCompared with OLR, LLR in selected patients with HCC showed similar long‐term outcomes, associated with less blood loss, shorter hospital stay, and fewer postoperative complications.
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Papers by Go Wakabayashi