Impact of Total Number of Lymph Node Retrieval on Patients with Esophageal Carcinoma Deserves Additional Investigation

Right Hepatic Vein Reconstruction with an Autologous Jugular Vein Graft to Expand the Surgical Indications for Liver Tumors Abstract Purpose We herein report 3 cases in which the right hepatic vein (RHV) involved with a liver tumor was reconstructed using an autologous jugular vein graft to raise the curability and to increase the functional volume of the liver remnant (LR). Case 1 Cholangiocellular carcinoma (diameter 6.0 cm) in the left lobe invaded the RHV, the branch of the RHV which drains segment 7 (V7) and the middle hepatic vein (MHV). Because the ratio of the LR drained by the inferior right hepatic vein (IRHV) was 26.7%, extended left lobectomy including MHV with RHV and V7 reconstruction was carried out, resulting in a good outcome and an uneventful operative course. Surgical margins on the liver resection plane and at the IVC were 5 mm and partially zero, respectively. Case 2 Cholangiolocellular carcinoma (diameter 9.0 cm) in the left lobe and the anterior segment invaded the RHV, V7, IVC and bile duct. In this case, the IRHV was present and not involved with the tumor. Because the ratio of the LR drained by the IRHV was 26.1%, left hepatic trisectionectomy with RHV, V7, IVC, and bile duct reconstruction was performed, leading to a good operative course. Surgical margins on the liver resection plane and at the IVC were 8 mm and partially zero, respectively. Case 3 Hepatocellular carcinoma (diameter 2.7 cm) in segment 7 invaded the RHV. Because the hepatic functional reserve had decreased due to the presence of hepatitis C virus, extended subsegmentectomy (segment 7) with RHV reconstruction was performed, thus resulting in a sufficiently maintained LR function. Surgical margin on the liver resection plane was 7 mm. Conclusion RHV reconstruction with an autologous jugular vein graft is considered to be useful for safely expanding the surgical indications for liver tumors.

A Tailored Strategy for Recipient Hepatectomy: Left Portal Flow Preserving High Hilar Dissection Abstract Background Lee et al. (Liver Transpl 10(9):1158–1162, 2004) reported high hilar dissection (HHD) technique as a novel method for recipient hepatectomy to overcome limitations of conventional hilar dissection (CHD). HHD allowed performing multiple tension-free biliary anastomoses and easy reconstruction of double portal vein orifices. However, longer anhepatic phase is its main drawback. We describe a new modification of original HHD, called left portal vein flow preserving HHD (LFP-HHD). The new technique aims to gain the balance between CHD and original HHD. Methods The detailed technique of recipient hepatectomy by LFP-HHD is shown in the electronic video file. It involves high intrahepatic division of hilar structures while maintaining portal drainage through maintained left portal vein (LPV). Control of right hemi-liver inflow allows for division of right hepatic vein, and safe dissection of inferior vena cava (IVC) and hilar structures. According to coordination with donor surgery, the liver could be easily explanted. Discussion LFP-HHD has the same principle of original HHD allowing for multiple tension-free well-vascularized biliary anastomoses. LFP-HHD allows for shortening of anhepatic phase duration as portal venous drainage is continued through maintained LPV avoiding prolonged total portal clamping with bowel edema or the need for temporary porto-caval shunt. On the other hand, the number and the length of the hilar structures can be decreased compared with the original HHD technique. However, the level of division of the hilar structures is acceptable in most of the cases. Conclusion LFP-HHD is a novel simple technique for recipient hepatectomy that can be tailored for certain clinical conditions.

Letter to the Editor: Initial Experience with Endoscopic Pyloromyotomy, with Description and Video of Technique

Timed Stair-Climbing as a Surrogate Marker for Sarcopenia Measurements in Predicting Surgical Outcomes Abstract Background Estimating sarcopenia by measuring psoas muscle density (PMD) has been advocated as a method to accurately predict post-operative morbidity. The aim of the present study was to determine whether the Timed Stair Climb (TSC) could be used to replace PMD measurements in predicting morbidity. Methods Patients were prospectively enrolled from March 2014–2015 and were eligible if they were undergoing an abdominal operation. PMD was measured using pre-operative CT scans obtained within 90 days of surgery. Ninety-day complications were assessed using the Accordion Severity Grading System. Multivariable analysis was performed to identify risk factors associated with operative morbidity. Results Of the patients, 298 were enrolled and completed TSC prior to undergoing an operation. Using the According Grading System, a grade 2 or higher complication occurred in 72 (24. 2%) patients with 8 (2.7%) deaths. There was an indirect relationship between PMD and TSC (P < 0.0001) and a direct relationship between TSC and complications (P = 0.04). On multivariable analysis decreasing PMD (P = 0.018) and increasing TSC (P = 0.026) were predictive of post-operative morbidity. Receiver operating characteristic curves demonstrated that the TSC was superior to both the ACS NSQIP Risk Calculator and PMD in predicting outcomes (TSC vs. PMD, P = 0.012; PMD vs. ACS NSQIP, P = 0.013; TSC vs. ACS NSQIP, P < 0.0001). Conclusion TSC, PMD, and the ACS NSQIP calculator are all useful tools; however, the TSC is superior in predicting post-operative morbidity.

Detours on the Road to Recovery: What Factors Delay Readiness to Return to Intended Oncologic Therapy (RIOT) After Liver Resection for Malignancy? Abstract Background Poor recovery after oncologic hepatic resection delays Return to Intended Oncologic Therapy (RIOT) and shortens survival. In order to identify at-risk patients, this study was designed to determine which psychosocial and perioperative factors are associated with delayed RIOT readiness. Methods A prospectively maintained database was queried to identify consecutive patients undergoing hepatectomy for malignancy from 2015 to 2017. Perioperative factors were compared between patients with early (≤ 28 postoperative days) vs. delayed (> 28 postoperative days) clearance to RIOT. Univariate analysis and multivariable logistic regression were performed. Results Of 114 patients, 76 patients (67%) had an open surgical approach, 32 (28%) had a major hepatectomy, and 6 (5%) had a major complication, with no mortalities. Eighty-two patients (72%) had early and 32 patients (28%) had delayed RIOT readiness. Patients with high preoperative symptom burden were more likely to have delayed RIOT readiness (OR 3.1, 95% CI 1.1–8.4, p = 0.024). On multivariable analysis, open surgical approach (OR 6.9, 95% CI 1.4–34.7, p = 0.018), length of stay > 5 days (OR 3.6, 95% CI 1.4–9.4, p = 0.010), and any complication (OR 3.4, 95% CI 1.1–10.7, p = 0.033) were associated with delayed RIOT readiness. Postoperative factors associated with delayed RIOT readiness included nutritional and wound-healing parameters. Conclusions This study highlights the previously under-described importance of preoperative patient symptom burden on delayed postoperative recovery. As a cancer patient’s return to oncologic therapy after hepatectomy has a substantial impact on survival, it is critical to adhere to enhanced recovery principles and address all other modifiable factors that delay recovery.

The Extrahepatic Glissonian Versus Hilar Dissection Approach for Laparoscopic Formal Right and Left Hepatectomies in Patients with Hepatocellular Carcinoma Abstract Background Few studies have been performed to evaluate the value of the Glissonian approach (GA) for laparoscopic formal hemihepatectomy. The purpose of this study was to compare the outcomes of extrahepatic GA with those of the conventional hilar dissection approach for laparoscopic formal right and left hepatectomies in patients with hepatocellular carcinoma (HCC). Methods Between January 2015 and October 2017, a total of 95 HCC patients who underwent pure laparoscopic formal hemihepatectomies, of whom 49 underwent the GA, were included in this study. After a 1:1 propensity score matching, 42 laparoscopic GA hepatectomies were compared to 42 conventional approach (CA) hepatectomies. We have analyzed perioperative and oncologic outcomes of the two different operative approaches for HCC treatments. Results The GA did not increase the postoperative overall complication rates (P = 0.415) or the mean comprehensive complication index (P = 0.414) when compared with the CA. However, the operative time was significantly shorter (P = 0.006), and intraoperative blood loss was significantly lower (P < 0.001) in the GA group than in the CA group. There were no significant differences between the GA and CA groups regarding 3-year overall survival rate (P = 0.765) or 3-year disease-free survival rate (P = 0.622). Conclusions Pure laparoscopic extrahepatic GA hemihepatectomy is safe and feasible, and it was associated with similar complication rates and equivalent 3-year survival outcomes compared to the conventional approach in selected patients with HCC.

Nomogram to Assist in Surgical Plan for Hepatocellular Carcinoma: a Prediction Model for Microvascular Invasion Abstract Background Microvascular invasion (MVI) relates to poor survival in hepatocellular carcinoma (HCC) patients. In this study, we aim at developing a nomogram for MVI prediction and potential assistance in surgical planning. Methods A total of 357 patients were assigned to training (n = 257) and validation (n = 100) cohort. Univariate and multivariate analyses were used to reveal preoperative predictors for MVI. A nomogram incorporating independent predictors was constructed and validated. Disease-free survival was compared between patients, and the potential of the predicted MVI in making surgical procedure was also explored. Results Pathological examination confirmed MVI in 140 (39.2%) patients. Imaging features including larger tumor, intra-tumoral artery, tumor type, and higher serum AFP independently correlated with MVI. The nomogram showed desirable performance with an AUROC of 0.803 (95% CI, 0.746–0.860) and 0.814 (95% CI, 0.720–0.908) in the training and validation cohorts, respectively. Good calibration were also revealed by calibration curve in both cohorts. The decision curve analysis indicated that the prediction nomogram was of promising usefulness in clinical work. In addition, survival analysis revealed that patients with positive-predicted MVI suffered a higher risk of early recurrence (P < 0.01). There was no difference in disease-free survival between anatomic or non-anatomic resection in large HCC or small HCC without nomogram-predicted MVI. However, anatomic resection improved disease-free survival in small HCC with nomogram-predicted MVI. Conclusions The nomogram obtained desirable results in predicting MVI. Patients with predicted MVI were associated with early recurrence and anatomic resection was recommended for small HCC patients with predicted MVI.

Nationwide Outcome of Gastrectomy with En-Bloc Partial Pancreatectomy for Gastric Cancer Abstract Background Radical gastrectomy is the cornerstone of the treatment of gastric cancer. For tumors invading the pancreas, en-bloc partial pancreatectomy may be needed for a radical resection. The aim of this study was to evaluate the outcome of gastrectomies with partial pancreatectomy for gastric cancer. Methods Patients who underwent gastrectomy with or without partial pancreatectomy for gastric or gastro-oesophageal junction cancer between 2011 and 2015 were selected from the Dutch Upper GI Cancer Audit (DUCA). Outcomes were resection margin (pR0) and Clavien–Dindo grade ≥ III postoperative complications and survival. The association between partial pancreatectomy and postoperative complications was analyzed with multivariable logistic regression. Overall survival of patients with partial pancreatectomy was estimated using the Kaplan–Meier method. Results Of 1966 patients that underwent gastrectomy, 55 patients (2.8%) underwent en-bloc partial pancreatectomy. A pR0 resection was achieved in 45 of 55 patients (82% versus 85% in the group without additional resection, P = 0.82). Clavien–Dindo grade ≥ III complications occurred in 21 of 55 patients (38% versus 17%, P < 0.001). Median overall survival [95% confidence interval] was 15 [6.8–23.2] months. For patients with and without perioperative systemic therapy, median survival was 20 [12.3–27.7] and 10 [5.7–14.3] months, and for patients with pR0 and pR1 resection, it was 20 [11.8–28.3] and 5 [2.4–7.6] months, respectively. Conclusions Gastrectomy with partial pancreatectomy is not only associated with a pR0 resection rate of 82% but also with increased postoperative morbidity. It should only be performed if a pR0 resection is feasible.

Venous Thromboembolism in Necrotizing Pancreatitis: an Underappreciated Risk Abstract Background Necrotizing pancreatitis (NP) is a severe systemic inflammatory process. We have observed a high incidence of venous thromboembolism (VTE) in NP patients. However, remarkably few data exist to document the true incidence of VTE—including splanchnic vein thrombosis (SVT), extremity deep venous thrombosis (eDVT), and pulmonary embolism (PE)—in NP. Therefore, we sought to determine the incidence and risk factors for VTE in NP patients. Methods Retrospective review of all NP patients treated at a single academic center between 2005 and 2015. VTE diagnosis was confirmed by ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and/or ventilation/perfusion (V/Q) scan. Descriptive statistics and univariate analysis were applied where appropriate; p value < 0.05 was considered statistically significant. Results Five hundred and forty-five NP patients (median age 53 years; 65% males) were reviewed. VTE was diagnosed in 312 patients (57%). SVT was found in 50%, eDVT in 16%, and PE in 6%. VTE in multiple sites was found in 22% of patients. VTE was diagnosed a median of 37 days following pancreatitis diagnosis. Seventy-nine percent of patients required at least one surgical procedure over the course of their NP. Patients requiring surgery had a DVT incidence of 58%; however, VTE was diagnosed preoperatively in 63%. Male gender, history of previous DVT, infected necrosis, development of organ failure, and development of respiratory failure were identified as risk factors for VTE (p = 0.001–0.04) by univariate analysis. Conclusions Venous thromboembolism is extremely common in necrotizing pancreatitis. Regular ultrasound screening may be considered to facilitate early diagnosis in this extremely high-risk population.