Kazuyuki Gyoten - Academia.edu (original) (raw)

Papers by Kazuyuki Gyoten

PLOS ONE

Background The optimal surgical indication after preoperative chemoradiotherapy (CRT) remains a s... more Background The optimal surgical indication after preoperative chemoradiotherapy (CRT) remains a subject of debate for patients with pancreatic ductal adenocarcinoma (PDAC) because early recurrence often occurs even after curative-intent resection. The present study aimed to identify perioperative risk factors of early recurrence for patients with PDAC who underwent curative-intent resection after preoperative CRT. Methods Two hundred three patients with PDAC who underwent curative-intent resection after preoperative CRT from February 2005 to December 2018 were retrospectively analyzed. The optimal threshold for differentiating between early and late recurrence was determined by the minimum p-value approach. Multivariate regression analysis was performed to identify predictive factors for early recurrence. Results In 130 patients who developed recurrence after resection, 52 who had an initial recurrence within 12 months were defined as the early recurrence group, and the remaining 78...

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques

Additional file 1. Detailed data of HCC patients who underwent hepatectomy.

Transplantation Proceedings, 2022

BACKGROUND In living donor liver transplantation, surgical damage is a risk for graft dysfunction... more BACKGROUND In living donor liver transplantation, surgical damage is a risk for graft dysfunction. We hypothesized that postoperative donor laboratory data reflect both donor liver damage and graft damage. Therefore, we evaluated how donor surgical factors affected recipient graft function and prognosis. PATIENTS AND METHODS From March 2002 to December 2020, 130 consecutive recipients and donors who underwent adult-to-adult living donor liver transplantation were analyzed. Donor perioperative surgical factors were evaluated to assess risk factors for recipient 90-day mortality by univariate analysis. RESULTS Donor postoperative maximum levels of aspartate aminotransferase (AST; P = .016), alanine transaminase (P = .048), and prothrombin time-international normalized ratio (P = .034) were risk factors. Receiver operating characteristic analysis identified 214 U/L as the most appropriate cutoff value of donor postoperative AST. After excluding 22 pairs of patients without donor data, the 108 pairs were divided into 2 groups based on donor maximum AST (D-mAST) level: the low D-mAST group (D-mAST < 241 U/L, n = 39) and the high D-mAST group (D-mAST ≥ 241 U/L, n = 69). Donor age was significantly higher in recipients in the high D-mAST group than in the low D-mAST group (P = .033). Postoperative recipient maximum AST and alanine transaminase levels and 90-day mortality were significantly higher in the high D-mAST group than in the low D-mAST group (P = .001, P = .006, and P = .009, respectively). There were no significant differences in long-term survival, although 5-year survival was slightly lower in the high D-mAST group. CONCLUSIONS Surgical liver damage to grafts, as assessed by postoperative donor AST levels, affected recipient short-term survival.

Surgical Endoscopy, 2021

Background Although Laparoscopic splenectomy (LS) have been proven to the standard operation for ... more Background Although Laparoscopic splenectomy (LS) have been proven to the standard operation for removal of spleen, the rate of conversion to open surgery is still higher than those of other laparoscopic surgeries, especially for huge spleen. In order to reduce the rate of conversion to open surgery, we had developed LS using modified splenic hilum hanging (MSHH) maneuver: the splenic pedicle was transected en bloc using a surgical stapler after hanging splenic hilum with an atraumatic penrose drain tube. Methods Between January 2005 and December 2019, we retrospectively assessed 94 patients who underwent LS. MSHH maneuver was performed in 37 patients (39.4%). We compared the intra-and postoperative outcomes between patients with or without MSHH maneuver. To adjust for differences in preoperative characteristics and blood examination, propensity score matching was used at a 1:1 ratio, resulting in a comparison of 29 patients per group. Predictive factors of conversion from LS to open surgery were elucidated using the uni-and multi-variate analyses. Results After the propensity score matching, blood loss (268 ml vs. 50 ml), the rate of conversion to open surgery (27.6% vs. 0%), and postoperative hospital stays (15 days vs. 10 days) were significantly decreased in patients with MSHH maneuver, respectively. Among 94 patients, 19 patients (20.2%) underwent conversion to open surgery. In multivariate analysis, spleen volume (SV) and LS without MSHH maneuver were independent predictive factors of conversion to open surgery, respectively. Additionally, cutoff value of SV for conversion to open surgery was 802 ml (sensitivity: 0.684, specificity: 0.827, p < 0.001). Conclusions LS using MSHH maneuver seems to be useful surgical technique to improve intraoperative outcomes and reduce the rate of conversion from LS to open surgery resulting in shorten postoperative hospital stay.

Pancreatology, 2020

Background: Arterial pseudoaneurysm is a rare but potentially fatal complication after pancreatic... more Background: Arterial pseudoaneurysm is a rare but potentially fatal complication after pancreaticoduodenectomy (PD). This study aimed to evaluate the incidence and predictors associated with pseudoaneurysm formation and patient death caused by its rupture. Patients and method: We retrospectively reviewed the data of 453 patients who underwent PD from April 2007 to February 2019. Uni-and multivariate analysis and receiver operating characteristic (ROC) curve analysis were performed to identify risk factors and optimal cutoff values. Results: Among the 453 patients, 22 (4.9%) developed pseudoaneurysm after PD. Median duration from surgery to detection of pseudoaneurysm was 17.0 (1e51) days. The locations of pseudoaneurysms were hepatic artery in 8, splenic artery in 3, gastroduodenal artery in 4, gastric artery in 2 and others in 5 patients, and 72.7% (16/22) of patients presented with hemorrhage. All pseudoaneurysms were treated using angioembolization. Lower age (<65.5 years, p ¼ 0.004), prolonged operation time (Cutoff ˃610 min, p ¼ 0.026) and postoperative pancreatic fistula (POPF) (p ¼ 0.013) were the independent risk factors for development of pseudoaneurysm. 6 (27.3%) patients died due to rupture of pseudoaneurysm and prolonged operation time (Cutoff ˃657 min, p ¼ 0.043) was a significant risk factor for death related to pseudoaneurysm. Conclusion: Prolonged operating time was identified as a risk factor for both pseudoaneurysm formation and patient death following pseudoaneurysm bleeding. Interventional radiology treatment offered a central role in the treatment of pseudoaneurysms after PD. Therefore, it is important to have a high index of suspicion in high risk patients of the possibility of pseudoaneurysm formation and bleeding.

Journal of Gastrointestinal Surgery, 2021

Perihilar cholangiocarcinoma often involves the adjacent vasculature, including the portal vein a... more Perihilar cholangiocarcinoma often involves the adjacent vasculature, including the portal vein and hepatic artery. Combined vascular resection and reconstruction of the portal vein is more common than vascular resection and reconstruction of the hepatic artery. Herein, we aimed to elucidate the long-term outcomes in patients who underwent vascular resection and reconstruction for perihilar cholangiocarcinoma. Between January 2004 and December 2020, 106 patients with perihilar cholangiocarcinoma were grouped into the no resection (n = 58), resection-portal vein (n = 31), and resection-hepatic artery with or without that of portal vein (n = 17) groups. There were no significant differences in morbidity and mortality between the three groups. The resection-portal vein and resection-hepatic artery groups had a significantly higher number of advanced tumors than the no resection group, but no significant differences were detected in the rates of lymph node metastasis and R0 resection between the three groups. The 5-year disease-specific survival in the resection-portal vein (37.6%) and resection-hepatic artery (26.9%) groups were poorer than that in the no resection group (47.8%), although the former groups had a significantly better prognosis than the latter group (7.0%). Multivariate analysis identified high preoperative carcinoembryonic antigen level (>5.7 ng/mL), intrahepatic metastasis, and non-R0 resection as independent poor prognostic factors. Although the perioperative course in the resection-portal vein and hepatic artery groups was similar to that in the no resection group, the long-term prognoses were poor in the resection-portal vein and hepatic artery groups. Pre- and postoperative multidisciplinary therapy is required for patients with vascular resection and reconstruction.

PLOS ONE, 2021

Peripancreatic fluid collections have been observed in most patients with postoperative pancreati... more Peripancreatic fluid collections have been observed in most patients with postoperative pancreatic fistula after distal pancreatectomy; however, optimal management remains unclear. This study aimed to evaluate the management and outcomes of patients with postoperative pancreatic fistula and verify the significance of computed tomography values for predicting peripancreatic fluid infections after distal pancreatectomy. We retrospectively investigated 259 consecutive patients who underwent distal pancreatectomy. Grade B postoperative pancreatic fistula patients were divided into two subgroups (B-antibiotics group and B-intervention group) and outcomes were compared. Predictive factor analysis of peripancreatic fluid infection was performed. Clinically relevant postoperative pancreatic fistulas developed in 88 (34.0%) patients. The duration of hospitalization was significantly longer in the B-intervention (n = 54) group than in the B-antibiotics group (n = 31; 41 vs. 17 days, p < 0....

Langenbeck's Archives of Surgery, 2020

Aim High-level hepatobiliary pancreatic (HBP) surgeries are highly associated with surgical site ... more Aim High-level hepatobiliary pancreatic (HBP) surgeries are highly associated with surgical site infections (SSIs), in which microorganisms have a significant role. In the present study, we investigated whether gastric Candida colonization had a significant role in SSIs after high-level HBP surgeries. Methods Between May 2016 and February 2017, the 66 patients who underwent high-level HBP surgeries were enrolled in the present study. The gastric juice was prospectively collected through nasogastric tube after general anesthesia induction and was incubated onto the CHROMagar Candida plate for the cultivation of various Candida species. First of all, we compared the incidence of SSIs according to the presence or absence of Candida species in gastric juice. Secondly, we evaluated the variables contributing to the development of SSIs by multivariate analysis. The protocol was approved by the medical ethics committee of Mie University Hospital (No.2987). Results Gastric Candida colonizat...

Surgery Today, 2021

To investigate whether proximal subtotal pancreatectomy (PSTP) is superior to total pancreatectom... more To investigate whether proximal subtotal pancreatectomy (PSTP) is superior to total pancreatectomy (TP) for preserving postoperative endocrine function, and to identify the pre-operative risk factors influencing prognosis after TP and PSTP. The subjects of this retrospective study were patients who underwent TP (n = 15) or PSTP (n = 16) between 2008 and 2018 in our hospital. First, we compared the incidence of hypoglycemia within 30 days after surgery and the total daily amount of insulin needed in the 30 days after TP vs. PSTP. Then, we compared the prognoses between the groups. The incidence of hypoglycemia in the 30 days after surgery was significantly lower in the PSTP group than in the TP group (n = 0 vs. n = 5; p < 0.001). The total amount of daily insulin given was also significantly lower after PSTP than after TP: (0 units vs. 18 units, p = 0.001). Lower lymphocyte counts (p = 0.014), lower cholinesterase (p = 0.021), and lower prognostic nutrition index (p = 0.021) were identified as significant risk factors for hypoglycemia in the TP group. Low cholinesterase (p = 0.015) and a low prognostic nutrition index (p = 0.048) were significantly associated with an unfavorable prognosis in the TP group, but not in the PSTP group. PSTP may be a feasible alternative to TP to preserve endocrine function, especially for malnourished patients.

PLOS ONE, 2021

Background In many malignancies including intrahepatic cholangiocarcinoma (iCCA), prognostic sign... more Background In many malignancies including intrahepatic cholangiocarcinoma (iCCA), prognostic significance of host-related inflammatory / immunonutritional markers have attracted a lot of attention. However, it is unclear which is the strongest prognostic indicator for iCCA among these markers. The aim of this study was to firstly evaluate the prognostic utility of inflammatory / immunonutritional markers in resected iCCA patients using a multiple comparison in addition to a new marker, lymphocyte-to-C-reactive protein (CRP) score. Methods A total of sixty iCCA patients, who underwent surgical resection between October 2004 and April 2019, were enrolled in this study. Their clinical and pathological data were retrospectively assessed using univariate and multivariate analysis to determine prognostic predictors for disease specific survival (DSS). Moreover, these patients, who were divided into high and low groups based on lymphocyte-to-CRP score, were compared these survival outcomes...

Pancreatology, 2021

BACKGROUND The clinical value and predictors of a favorable histological response to preoperative... more BACKGROUND The clinical value and predictors of a favorable histological response to preoperative chemoradiotherapy (CRT) in pancreatic ductal adenocarcinoma (PDAC) remains undefined. OBJECTIVE To assess the significance and predictors of a favorable histological response to preoperative CRT in patients with localized PDAC. METHODS The study included 203 patients with localized PDAC undergoing curative-intent resection after CRT. The rate of R0 resection and overall survival (OS) and recurrence-free survival (RFS) were correlated with the grading of histological response to determine optimal stratification. Clinical factors associated with a significant histological response were evaluated using multivariate regression analysis. RESULTS Among all patients, eight patients (3.9%) had a grade 4 (pCR); 40 (19.4%) had a grade 3 estimated rate of residual neoplastic cells <10% (near-pCR); and 155 (76.7%) had a grade 1/2 limited response. The 48 patients with pCR/near-pCR achieved significantly higher R0 resection rate (100%) than those with grade 1/2 (80.0%). The 5-year OS and RFS rates were significantly higher in the patients with pCR/near-pCR (45.3% and 36.5%) than in those with grade 1/2 (27.1% and 18.5%). Gemcitabine plus S-1 based CRT, serum CA19-9 level after CRT <83 U/mL, and interval from initial treatment to surgery ≥4.4 months were independent predictive factors for pCR/near-pCR. CONCLUSIONS pCR or near-pCR to preoperative CRT contributed to achieving a high rate of R0 resection and improving survival for localized PDAC. The use of gemcitabine plus S-1 as a radiosensitizer, lower serum CA19-9 level after CRT, and longer preoperative treatment duration were significantly associated with pCR or near-pCR.

BMC Gastroenterology, 2020

Background We experienced a rare case of intraductal papillary mucinous neoplasm arising from San... more Background We experienced a rare case of intraductal papillary mucinous neoplasm arising from Santorini’s duct (SD) forming a tumor protruding into the duodenum . Case presentation A 71-year-old woman was incidentally diagnosed with a 3 cm type Isp polypoid tumor in the second portion of the duodenum at another hospital. Enhanced CT and endoscopic ultrasound revealed that the origin of this protruding tumor was arising from SD and that the tumor mimicked a pedunculated duodenal tumor. Our preoperative diagnosis was a malignant pancreatic tumor arising from SD with invasion into the duodenum. She underwent a subtotal stomach-preserving pancreaticoduodenectomy, and the resected specimen showed a 25 mm tumor protruding into the duodenum with a villous surface. The pathological findings revealed that the tumor was intraductal papillary mucinous adenoma (IPMA) arising from SD. Conclusions To the best of our knowledge, this is the first case of IPMA protruding into the duodenal lumen from...

Annals of Surgery, 2020

Objective: The aim of the study was to identify the prognostic factors before neoadjuvant chemora... more Objective: The aim of the study was to identify the prognostic factors before neoadjuvant chemoradiotherapy (NCRT) in the patients with localized PDAC. Furthermore, to identify the post-surgical survival predictors of patients with LAPC. Summary of background data: Surgical resection may occupy an important position in multimodal therapy for patients with LAPC; however, its indication and who obtains the true benefits, is still uncovered. Materials and Method: From 2005 to 2017, 319 patients with localized PDAC who underwent NCRT were reviewed. Only 159 patients were diagnosed with LAPC, of these 72 patients underwent surgical resection. We examined the pre-NCRT prognostic factors in the entire cohort and conducted further subgroup analysis for evaluating the post-surgical prognostic factors in LAPC patients under the pretext of favorable local tumor control. Results: In the entire cohort, pre-NCRT CEA value was recognized as the most significant prognostic indicator by multivariate...

BMC Surgery, 2020

Background Our aim is to elucidate the true preoperative risk factors for postoperative pancreati... more Background Our aim is to elucidate the true preoperative risk factors for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), making it possible to select POPF high-risk patients preoperatively regardless of intraoperative pancreatic consistency judged by the surgeon’s hand. Methods Among the 298 patients who underwent PD with pancreaticojejunostomy from 2007 to 2016, 262 patients had preoperative CT configurations that could be precisely evaluated. Risk factor analyses were conducted using various perioperative factors, including preoperative CT findings, such as CT values of the pancreas, pancreas-visceral fat CT value ratio and pancreatic outer contour. Pancreatic outer contour was further divided into smooth- (smooth interlobular) and serrated-type contours (feathery, irregular interlobular) by preoperative CT. Results In terms of the incidence of POPF, among the 262 patients, POPF grade B/C was found in 27 (10.3%): grade B in 23 (8.8%) and grade C in 4 (...

Background Several inflammation-based scores are used to assess the surgical outcomes of hepatoce... more Background Several inflammation-based scores are used to assess the surgical outcomes of hepatocellular carcinoma (HCC). The aim of the present study was to elucidate the prognostic value of the prognostic nutritional index (PNI) in HCC patients who underwent hepatectomy with special attention to preoperative liver functional reserve.Methods Preoperative demographic and tumor-related factors were analyzed in 189 patients with HCC undergoing initial hepatectomy from August 2005 to May 2016 to identify significant prognostic factors.Results Multivariate analysis for overall survival (OS) revealed that female gender (p=0.005), tumor size (p<0.001) and PNI (p=0.001) were independent prognostic factors. Compared to the High PNI group (PNI ≥37, n=172), the Low PNI group (PNI <37, n=17) had impaired liver function and significantly poorer OS (13% vs. 67% in 5-year survival, p=0.001) and recurrence-free survival (RFS) (8 vs. 25 months in median survival time, p=0.002). In the subgroup...

Journal of Pediatric Surgery, 2018

Long-term functional outcomes after pylorus preserving pancreaticoduodenectomy from childhood thr... more Long-term functional outcomes after pylorus preserving pancreaticoduodenectomy from childhood through middle age: 30-year follow-up of nutritional status, pancreatic function, and morphological changes of the pancreatic remnant ☆ To the Editor: We read with great interest the paper by Park et al. reporting long-term functional outcomes of pylorus preserving pancreaticoduodenectomy (PPPD) in children-nutritional status, pancreatic function, GI function and QOL [1]. The authors reported that PPPD in children did not present significant problems except for one patient with DM during the followup period ranging from 3 to 18 years and at the age at follow-up ranging from 4 to 28 years old. They focused on adolescent growth including pancreatic functions after PPPD in children. However, there has been no report of functional outcomes after PPPD from childhood through middle age. Case: 42 years old male, who underwent PPPD for solid pseudopapillary tumors of the pancreas (SPT) 30 years ago, visited our hospital as a follow-up after PPPD. When he was 12 years old and underwent PPPD [2], his height was 145 cm tall and his body weight was 36.5 kg, and he became 175 cm tall and 67 kg 30 years after surgery. He has been well and worked as a truck driver for 20 years without any postoperative complications including diarrhea, though he had consumed alcohol 60 g/day and smoked 40 cigarettes/day for 22 years. As to laboratory data, the serum level of fasting blood glucose was 94 mg/dl (normal, b 110 mg/dl) and HbA1c was 5.2% (4.6%-5.6%), showing normal pancreatic endocrine functions. The serum albumin level was 4.8 g/dl (3.8-5.3 g/dl), total cholesterol level was 203 mg/dl (120-220 mg/dl), and lipase level was 29.0 U/L (11-53 U/L). A CT scan is shown in Fig. 1 and revealed that no fatty change of the liver developed, the maximum thickness of the remnant pancreas was 16 mm, the maximum diameter of the main pancreatic duct was 3 mm, and the remnant pancreatic volume was 23.1 ml, revealing no atrophic change [3,4]. The patients who underwent pancreaticoduodenectomy (PD) or PPPD might encounter the atrophic change of the remnant pancreas and the impairment of exocrine and endocrine pancreatic function during the long term periods after surgery. The various disorders regarding the remnant pancreatic dysfunction sometimes greatly influence postoperative quality of life. In children, PPPD is rarely performed considering the possibility of growth retardation owing to postoperative complications. Our patient successfully underwent PPPD at the age of 12 and has been well for more than 30 years without any growth retardation and pancreatic disorder. However, it still remains unclear whether PPPD for children might affect the pancreatic function and morphological changes of the remnant pancreas from childhood through middle age. For further evaluation, multicenter study using a large number of patients should be needed.

Pancreatology, 2016

Prospective analysis to reveal the incidence of biliary candidiasis after pancreatoduodenectomy: ... more Prospective analysis to reveal the incidence of biliary candidiasis after pancreatoduodenectomy: Negative impact of biliary candidiasis on the occurrence of SSIs and usefulness of CHROMagar Candida plate

PLOS ONE

Background The optimal surgical indication after preoperative chemoradiotherapy (CRT) remains a s... more Background The optimal surgical indication after preoperative chemoradiotherapy (CRT) remains a subject of debate for patients with pancreatic ductal adenocarcinoma (PDAC) because early recurrence often occurs even after curative-intent resection. The present study aimed to identify perioperative risk factors of early recurrence for patients with PDAC who underwent curative-intent resection after preoperative CRT. Methods Two hundred three patients with PDAC who underwent curative-intent resection after preoperative CRT from February 2005 to December 2018 were retrospectively analyzed. The optimal threshold for differentiating between early and late recurrence was determined by the minimum p-value approach. Multivariate regression analysis was performed to identify predictive factors for early recurrence. Results In 130 patients who developed recurrence after resection, 52 who had an initial recurrence within 12 months were defined as the early recurrence group, and the remaining 78...

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques

Additional file 1. Detailed data of HCC patients who underwent hepatectomy.

Transplantation Proceedings, 2022

BACKGROUND In living donor liver transplantation, surgical damage is a risk for graft dysfunction... more BACKGROUND In living donor liver transplantation, surgical damage is a risk for graft dysfunction. We hypothesized that postoperative donor laboratory data reflect both donor liver damage and graft damage. Therefore, we evaluated how donor surgical factors affected recipient graft function and prognosis. PATIENTS AND METHODS From March 2002 to December 2020, 130 consecutive recipients and donors who underwent adult-to-adult living donor liver transplantation were analyzed. Donor perioperative surgical factors were evaluated to assess risk factors for recipient 90-day mortality by univariate analysis. RESULTS Donor postoperative maximum levels of aspartate aminotransferase (AST; P = .016), alanine transaminase (P = .048), and prothrombin time-international normalized ratio (P = .034) were risk factors. Receiver operating characteristic analysis identified 214 U/L as the most appropriate cutoff value of donor postoperative AST. After excluding 22 pairs of patients without donor data, the 108 pairs were divided into 2 groups based on donor maximum AST (D-mAST) level: the low D-mAST group (D-mAST < 241 U/L, n = 39) and the high D-mAST group (D-mAST ≥ 241 U/L, n = 69). Donor age was significantly higher in recipients in the high D-mAST group than in the low D-mAST group (P = .033). Postoperative recipient maximum AST and alanine transaminase levels and 90-day mortality were significantly higher in the high D-mAST group than in the low D-mAST group (P = .001, P = .006, and P = .009, respectively). There were no significant differences in long-term survival, although 5-year survival was slightly lower in the high D-mAST group. CONCLUSIONS Surgical liver damage to grafts, as assessed by postoperative donor AST levels, affected recipient short-term survival.

Surgical Endoscopy, 2021

Background Although Laparoscopic splenectomy (LS) have been proven to the standard operation for ... more Background Although Laparoscopic splenectomy (LS) have been proven to the standard operation for removal of spleen, the rate of conversion to open surgery is still higher than those of other laparoscopic surgeries, especially for huge spleen. In order to reduce the rate of conversion to open surgery, we had developed LS using modified splenic hilum hanging (MSHH) maneuver: the splenic pedicle was transected en bloc using a surgical stapler after hanging splenic hilum with an atraumatic penrose drain tube. Methods Between January 2005 and December 2019, we retrospectively assessed 94 patients who underwent LS. MSHH maneuver was performed in 37 patients (39.4%). We compared the intra-and postoperative outcomes between patients with or without MSHH maneuver. To adjust for differences in preoperative characteristics and blood examination, propensity score matching was used at a 1:1 ratio, resulting in a comparison of 29 patients per group. Predictive factors of conversion from LS to open surgery were elucidated using the uni-and multi-variate analyses. Results After the propensity score matching, blood loss (268 ml vs. 50 ml), the rate of conversion to open surgery (27.6% vs. 0%), and postoperative hospital stays (15 days vs. 10 days) were significantly decreased in patients with MSHH maneuver, respectively. Among 94 patients, 19 patients (20.2%) underwent conversion to open surgery. In multivariate analysis, spleen volume (SV) and LS without MSHH maneuver were independent predictive factors of conversion to open surgery, respectively. Additionally, cutoff value of SV for conversion to open surgery was 802 ml (sensitivity: 0.684, specificity: 0.827, p < 0.001). Conclusions LS using MSHH maneuver seems to be useful surgical technique to improve intraoperative outcomes and reduce the rate of conversion from LS to open surgery resulting in shorten postoperative hospital stay.

Pancreatology, 2020

Background: Arterial pseudoaneurysm is a rare but potentially fatal complication after pancreatic... more Background: Arterial pseudoaneurysm is a rare but potentially fatal complication after pancreaticoduodenectomy (PD). This study aimed to evaluate the incidence and predictors associated with pseudoaneurysm formation and patient death caused by its rupture. Patients and method: We retrospectively reviewed the data of 453 patients who underwent PD from April 2007 to February 2019. Uni-and multivariate analysis and receiver operating characteristic (ROC) curve analysis were performed to identify risk factors and optimal cutoff values. Results: Among the 453 patients, 22 (4.9%) developed pseudoaneurysm after PD. Median duration from surgery to detection of pseudoaneurysm was 17.0 (1e51) days. The locations of pseudoaneurysms were hepatic artery in 8, splenic artery in 3, gastroduodenal artery in 4, gastric artery in 2 and others in 5 patients, and 72.7% (16/22) of patients presented with hemorrhage. All pseudoaneurysms were treated using angioembolization. Lower age (<65.5 years, p ¼ 0.004), prolonged operation time (Cutoff ˃610 min, p ¼ 0.026) and postoperative pancreatic fistula (POPF) (p ¼ 0.013) were the independent risk factors for development of pseudoaneurysm. 6 (27.3%) patients died due to rupture of pseudoaneurysm and prolonged operation time (Cutoff ˃657 min, p ¼ 0.043) was a significant risk factor for death related to pseudoaneurysm. Conclusion: Prolonged operating time was identified as a risk factor for both pseudoaneurysm formation and patient death following pseudoaneurysm bleeding. Interventional radiology treatment offered a central role in the treatment of pseudoaneurysms after PD. Therefore, it is important to have a high index of suspicion in high risk patients of the possibility of pseudoaneurysm formation and bleeding.

Journal of Gastrointestinal Surgery, 2021

Perihilar cholangiocarcinoma often involves the adjacent vasculature, including the portal vein a... more Perihilar cholangiocarcinoma often involves the adjacent vasculature, including the portal vein and hepatic artery. Combined vascular resection and reconstruction of the portal vein is more common than vascular resection and reconstruction of the hepatic artery. Herein, we aimed to elucidate the long-term outcomes in patients who underwent vascular resection and reconstruction for perihilar cholangiocarcinoma. Between January 2004 and December 2020, 106 patients with perihilar cholangiocarcinoma were grouped into the no resection (n = 58), resection-portal vein (n = 31), and resection-hepatic artery with or without that of portal vein (n = 17) groups. There were no significant differences in morbidity and mortality between the three groups. The resection-portal vein and resection-hepatic artery groups had a significantly higher number of advanced tumors than the no resection group, but no significant differences were detected in the rates of lymph node metastasis and R0 resection between the three groups. The 5-year disease-specific survival in the resection-portal vein (37.6%) and resection-hepatic artery (26.9%) groups were poorer than that in the no resection group (47.8%), although the former groups had a significantly better prognosis than the latter group (7.0%). Multivariate analysis identified high preoperative carcinoembryonic antigen level (>5.7 ng/mL), intrahepatic metastasis, and non-R0 resection as independent poor prognostic factors. Although the perioperative course in the resection-portal vein and hepatic artery groups was similar to that in the no resection group, the long-term prognoses were poor in the resection-portal vein and hepatic artery groups. Pre- and postoperative multidisciplinary therapy is required for patients with vascular resection and reconstruction.

PLOS ONE, 2021

Peripancreatic fluid collections have been observed in most patients with postoperative pancreati... more Peripancreatic fluid collections have been observed in most patients with postoperative pancreatic fistula after distal pancreatectomy; however, optimal management remains unclear. This study aimed to evaluate the management and outcomes of patients with postoperative pancreatic fistula and verify the significance of computed tomography values for predicting peripancreatic fluid infections after distal pancreatectomy. We retrospectively investigated 259 consecutive patients who underwent distal pancreatectomy. Grade B postoperative pancreatic fistula patients were divided into two subgroups (B-antibiotics group and B-intervention group) and outcomes were compared. Predictive factor analysis of peripancreatic fluid infection was performed. Clinically relevant postoperative pancreatic fistulas developed in 88 (34.0%) patients. The duration of hospitalization was significantly longer in the B-intervention (n = 54) group than in the B-antibiotics group (n = 31; 41 vs. 17 days, p < 0....

Langenbeck's Archives of Surgery, 2020

Aim High-level hepatobiliary pancreatic (HBP) surgeries are highly associated with surgical site ... more Aim High-level hepatobiliary pancreatic (HBP) surgeries are highly associated with surgical site infections (SSIs), in which microorganisms have a significant role. In the present study, we investigated whether gastric Candida colonization had a significant role in SSIs after high-level HBP surgeries. Methods Between May 2016 and February 2017, the 66 patients who underwent high-level HBP surgeries were enrolled in the present study. The gastric juice was prospectively collected through nasogastric tube after general anesthesia induction and was incubated onto the CHROMagar Candida plate for the cultivation of various Candida species. First of all, we compared the incidence of SSIs according to the presence or absence of Candida species in gastric juice. Secondly, we evaluated the variables contributing to the development of SSIs by multivariate analysis. The protocol was approved by the medical ethics committee of Mie University Hospital (No.2987). Results Gastric Candida colonizat...

Surgery Today, 2021

To investigate whether proximal subtotal pancreatectomy (PSTP) is superior to total pancreatectom... more To investigate whether proximal subtotal pancreatectomy (PSTP) is superior to total pancreatectomy (TP) for preserving postoperative endocrine function, and to identify the pre-operative risk factors influencing prognosis after TP and PSTP. The subjects of this retrospective study were patients who underwent TP (n = 15) or PSTP (n = 16) between 2008 and 2018 in our hospital. First, we compared the incidence of hypoglycemia within 30 days after surgery and the total daily amount of insulin needed in the 30 days after TP vs. PSTP. Then, we compared the prognoses between the groups. The incidence of hypoglycemia in the 30 days after surgery was significantly lower in the PSTP group than in the TP group (n = 0 vs. n = 5; p < 0.001). The total amount of daily insulin given was also significantly lower after PSTP than after TP: (0 units vs. 18 units, p = 0.001). Lower lymphocyte counts (p = 0.014), lower cholinesterase (p = 0.021), and lower prognostic nutrition index (p = 0.021) were identified as significant risk factors for hypoglycemia in the TP group. Low cholinesterase (p = 0.015) and a low prognostic nutrition index (p = 0.048) were significantly associated with an unfavorable prognosis in the TP group, but not in the PSTP group. PSTP may be a feasible alternative to TP to preserve endocrine function, especially for malnourished patients.

PLOS ONE, 2021

Background In many malignancies including intrahepatic cholangiocarcinoma (iCCA), prognostic sign... more Background In many malignancies including intrahepatic cholangiocarcinoma (iCCA), prognostic significance of host-related inflammatory / immunonutritional markers have attracted a lot of attention. However, it is unclear which is the strongest prognostic indicator for iCCA among these markers. The aim of this study was to firstly evaluate the prognostic utility of inflammatory / immunonutritional markers in resected iCCA patients using a multiple comparison in addition to a new marker, lymphocyte-to-C-reactive protein (CRP) score. Methods A total of sixty iCCA patients, who underwent surgical resection between October 2004 and April 2019, were enrolled in this study. Their clinical and pathological data were retrospectively assessed using univariate and multivariate analysis to determine prognostic predictors for disease specific survival (DSS). Moreover, these patients, who were divided into high and low groups based on lymphocyte-to-CRP score, were compared these survival outcomes...

Pancreatology, 2021

BACKGROUND The clinical value and predictors of a favorable histological response to preoperative... more BACKGROUND The clinical value and predictors of a favorable histological response to preoperative chemoradiotherapy (CRT) in pancreatic ductal adenocarcinoma (PDAC) remains undefined. OBJECTIVE To assess the significance and predictors of a favorable histological response to preoperative CRT in patients with localized PDAC. METHODS The study included 203 patients with localized PDAC undergoing curative-intent resection after CRT. The rate of R0 resection and overall survival (OS) and recurrence-free survival (RFS) were correlated with the grading of histological response to determine optimal stratification. Clinical factors associated with a significant histological response were evaluated using multivariate regression analysis. RESULTS Among all patients, eight patients (3.9%) had a grade 4 (pCR); 40 (19.4%) had a grade 3 estimated rate of residual neoplastic cells <10% (near-pCR); and 155 (76.7%) had a grade 1/2 limited response. The 48 patients with pCR/near-pCR achieved significantly higher R0 resection rate (100%) than those with grade 1/2 (80.0%). The 5-year OS and RFS rates were significantly higher in the patients with pCR/near-pCR (45.3% and 36.5%) than in those with grade 1/2 (27.1% and 18.5%). Gemcitabine plus S-1 based CRT, serum CA19-9 level after CRT <83 U/mL, and interval from initial treatment to surgery ≥4.4 months were independent predictive factors for pCR/near-pCR. CONCLUSIONS pCR or near-pCR to preoperative CRT contributed to achieving a high rate of R0 resection and improving survival for localized PDAC. The use of gemcitabine plus S-1 as a radiosensitizer, lower serum CA19-9 level after CRT, and longer preoperative treatment duration were significantly associated with pCR or near-pCR.

BMC Gastroenterology, 2020

Background We experienced a rare case of intraductal papillary mucinous neoplasm arising from San... more Background We experienced a rare case of intraductal papillary mucinous neoplasm arising from Santorini’s duct (SD) forming a tumor protruding into the duodenum . Case presentation A 71-year-old woman was incidentally diagnosed with a 3 cm type Isp polypoid tumor in the second portion of the duodenum at another hospital. Enhanced CT and endoscopic ultrasound revealed that the origin of this protruding tumor was arising from SD and that the tumor mimicked a pedunculated duodenal tumor. Our preoperative diagnosis was a malignant pancreatic tumor arising from SD with invasion into the duodenum. She underwent a subtotal stomach-preserving pancreaticoduodenectomy, and the resected specimen showed a 25 mm tumor protruding into the duodenum with a villous surface. The pathological findings revealed that the tumor was intraductal papillary mucinous adenoma (IPMA) arising from SD. Conclusions To the best of our knowledge, this is the first case of IPMA protruding into the duodenal lumen from...

Annals of Surgery, 2020

Objective: The aim of the study was to identify the prognostic factors before neoadjuvant chemora... more Objective: The aim of the study was to identify the prognostic factors before neoadjuvant chemoradiotherapy (NCRT) in the patients with localized PDAC. Furthermore, to identify the post-surgical survival predictors of patients with LAPC. Summary of background data: Surgical resection may occupy an important position in multimodal therapy for patients with LAPC; however, its indication and who obtains the true benefits, is still uncovered. Materials and Method: From 2005 to 2017, 319 patients with localized PDAC who underwent NCRT were reviewed. Only 159 patients were diagnosed with LAPC, of these 72 patients underwent surgical resection. We examined the pre-NCRT prognostic factors in the entire cohort and conducted further subgroup analysis for evaluating the post-surgical prognostic factors in LAPC patients under the pretext of favorable local tumor control. Results: In the entire cohort, pre-NCRT CEA value was recognized as the most significant prognostic indicator by multivariate...

BMC Surgery, 2020

Background Our aim is to elucidate the true preoperative risk factors for postoperative pancreati... more Background Our aim is to elucidate the true preoperative risk factors for postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD), making it possible to select POPF high-risk patients preoperatively regardless of intraoperative pancreatic consistency judged by the surgeon’s hand. Methods Among the 298 patients who underwent PD with pancreaticojejunostomy from 2007 to 2016, 262 patients had preoperative CT configurations that could be precisely evaluated. Risk factor analyses were conducted using various perioperative factors, including preoperative CT findings, such as CT values of the pancreas, pancreas-visceral fat CT value ratio and pancreatic outer contour. Pancreatic outer contour was further divided into smooth- (smooth interlobular) and serrated-type contours (feathery, irregular interlobular) by preoperative CT. Results In terms of the incidence of POPF, among the 262 patients, POPF grade B/C was found in 27 (10.3%): grade B in 23 (8.8%) and grade C in 4 (...

Background Several inflammation-based scores are used to assess the surgical outcomes of hepatoce... more Background Several inflammation-based scores are used to assess the surgical outcomes of hepatocellular carcinoma (HCC). The aim of the present study was to elucidate the prognostic value of the prognostic nutritional index (PNI) in HCC patients who underwent hepatectomy with special attention to preoperative liver functional reserve.Methods Preoperative demographic and tumor-related factors were analyzed in 189 patients with HCC undergoing initial hepatectomy from August 2005 to May 2016 to identify significant prognostic factors.Results Multivariate analysis for overall survival (OS) revealed that female gender (p=0.005), tumor size (p<0.001) and PNI (p=0.001) were independent prognostic factors. Compared to the High PNI group (PNI ≥37, n=172), the Low PNI group (PNI <37, n=17) had impaired liver function and significantly poorer OS (13% vs. 67% in 5-year survival, p=0.001) and recurrence-free survival (RFS) (8 vs. 25 months in median survival time, p=0.002). In the subgroup...

Journal of Pediatric Surgery, 2018

Long-term functional outcomes after pylorus preserving pancreaticoduodenectomy from childhood thr... more Long-term functional outcomes after pylorus preserving pancreaticoduodenectomy from childhood through middle age: 30-year follow-up of nutritional status, pancreatic function, and morphological changes of the pancreatic remnant ☆ To the Editor: We read with great interest the paper by Park et al. reporting long-term functional outcomes of pylorus preserving pancreaticoduodenectomy (PPPD) in children-nutritional status, pancreatic function, GI function and QOL [1]. The authors reported that PPPD in children did not present significant problems except for one patient with DM during the followup period ranging from 3 to 18 years and at the age at follow-up ranging from 4 to 28 years old. They focused on adolescent growth including pancreatic functions after PPPD in children. However, there has been no report of functional outcomes after PPPD from childhood through middle age. Case: 42 years old male, who underwent PPPD for solid pseudopapillary tumors of the pancreas (SPT) 30 years ago, visited our hospital as a follow-up after PPPD. When he was 12 years old and underwent PPPD [2], his height was 145 cm tall and his body weight was 36.5 kg, and he became 175 cm tall and 67 kg 30 years after surgery. He has been well and worked as a truck driver for 20 years without any postoperative complications including diarrhea, though he had consumed alcohol 60 g/day and smoked 40 cigarettes/day for 22 years. As to laboratory data, the serum level of fasting blood glucose was 94 mg/dl (normal, b 110 mg/dl) and HbA1c was 5.2% (4.6%-5.6%), showing normal pancreatic endocrine functions. The serum albumin level was 4.8 g/dl (3.8-5.3 g/dl), total cholesterol level was 203 mg/dl (120-220 mg/dl), and lipase level was 29.0 U/L (11-53 U/L). A CT scan is shown in Fig. 1 and revealed that no fatty change of the liver developed, the maximum thickness of the remnant pancreas was 16 mm, the maximum diameter of the main pancreatic duct was 3 mm, and the remnant pancreatic volume was 23.1 ml, revealing no atrophic change [3,4]. The patients who underwent pancreaticoduodenectomy (PD) or PPPD might encounter the atrophic change of the remnant pancreas and the impairment of exocrine and endocrine pancreatic function during the long term periods after surgery. The various disorders regarding the remnant pancreatic dysfunction sometimes greatly influence postoperative quality of life. In children, PPPD is rarely performed considering the possibility of growth retardation owing to postoperative complications. Our patient successfully underwent PPPD at the age of 12 and has been well for more than 30 years without any growth retardation and pancreatic disorder. However, it still remains unclear whether PPPD for children might affect the pancreatic function and morphological changes of the remnant pancreas from childhood through middle age. For further evaluation, multicenter study using a large number of patients should be needed.

Pancreatology, 2016

Prospective analysis to reveal the incidence of biliary candidiasis after pancreatoduodenectomy: ... more Prospective analysis to reveal the incidence of biliary candidiasis after pancreatoduodenectomy: Negative impact of biliary candidiasis on the occurrence of SSIs and usefulness of CHROMagar Candida plate