According to recent international consensus conferences, pure laparoscopic donor hepatectomy (PLDH), particularly right and left hepatectomies, is not yet considered a standard practice because ...studies remain limited. Thus, we present the outcomes of more than 500 PLDH patients, mostly receiving a right hepatectomy. To our knowledge, this is the largest study to date on PLDH. Data from all living liver donors who underwent PLDH at 5 centers in Korea until June 2018 were retrospectively analyzed. The outcomes of both donors and recipients were included. Pearson correlation analysis was used to explore the relationship between the duration of surgery and cumulative experience at each center, which reflects the learning curve. Overall, 545 PLDH cases were analyzed, including 481 right hepatectomies, 25 left hepatectomies, and 39 left lateral sectionectomies (LLS). The open conversion was necessary for 10 (1.8%) donors, and none of the donors died or experienced irreversible disability. Notably, there were 25 (4.6%) patients with major complications (higher than Clavien‐Dindo grade 3). All centers except one showed a significant decrease in surgery duration as the number of cases accumulated. Regarding recipient outcomes, there were 110 cases (20.2%) of early major complications and 177 cases (32.5%) of late major complications. This study shows the early and late postoperative outcomes of 545 donors and corresponding recipients, including 481 right hepatectomies and 25 left hepatectomies, from 5 experienced centers. Although the results are comparable to those of previously reported open donor hepatectomy series, further studies are needed to consider PLDH a new standard practice.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Our previous randomized controlled trial revealed no difference in 2‐year overall survival (OS) between extended and standard resection for pancreatic adenocarcinoma. The present study ...evaluated the 5‐year OS and recurrence patterns according to the extent of pancreatectomy.
Methods
Between 2006 and 2009, 169 consecutive patients were prospectively enrolled and randomized to standard (n = 83) or extended resection (n = 86) groups to compare 5‐year OS rate, long‐term recurrence patterns and factors associated with long‐term survival.
Results
The surgical R0 rate was similar between the standard and extended groups (85.5 vs. 90.7%, P = 0.300). Five‐year OS (18.4 vs. 14.4%, P = 0.388), 5‐year disease‐free survival (14.8 vs. 14.0%, P = 0.531), and overall recurrence rates (74.7 vs. 69.9%, P = 0.497) were not significantly different between the two groups, although the incidence of peritoneal seeding was higher in the extended group (25 vs. 8.1%, P = 0.014).
Conclusions
Extended pancreatectomy does not have better short‐term and long‐term survival outcomes, and shows similar R0 rates and overall recurrence rates compared with standard pancreatectomy. Extended pancreatectomy does not have to be performed routinely for all cases of resectable pancreatic adenocarcinoma, especially considering its associated increased morbidity shown in our previous study.
Highlight
Jang and colleagues conducted a multicenter randomized controlled trial to evaluate long‐term overall survival and recurrence patterns according to the extent of pancreatectomy for pancreatic head cancer. Extended pancreatectomy did not demonstrate better short‐term and long‐term survival outcomes, and showed similar R0 rates and recurrence rates compared with standard pancreatectomy.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Circulating tumor DNA (ctDNA) has emerged as a candidate biomarker for cancer screening. However, studies on the usefulness of ctDNA for postoperative recurrence monitoring are limited. The present ...study monitored ctDNA in postoperative blood by employing cancer-specific rearrangements. Personalized cancer-specific rearrangements in 25 gastric cancers were analyzed by whole-genome sequencing (WGS) and were employed for ctDNA monitoring with blood up to 12 months after surgery. Personalized cancer-specific rearrangements were identified in 19 samples. The median lead time, which is the median duration between a positive ctDNA detection and recurrence, was 4.05 months. The presence of postoperative ctDNA prior to clinical recurrence was significantly correlated with cancer recurrence within 12 months of surgery (P = 0.029); in contrast, no correlation was found between cancer recurrence and the presence of preoperative ctDNA, suggesting the clinical usefulness of postoperative ctDNA monitoring for cancer recurrence in gastric cancer patients. However, the clinical application of ctDNA can be limited by the presence of ctDNA non-shedders (42.1%, 8/19) and by inconsistent postoperative ctDNA positivity.
IMPORTANCE The number of geriatric patients who undergo surgery has been increasing, but there are insufficient tools to predict postoperative outcomes in the elderly. OBJECTIVE To design a ...predictive model for adverse outcomes in older surgical patients. DESIGN, SETTING, AND PARTICIPANTS From October 19, 2011, to July 31, 2012, a single tertiary care center enrolled 275 consecutive elderly patients (aged ≥65 years) undergoing intermediate-risk or high-risk elective operations in the Department of Surgery. MAIN OUTCOMES AND MEASURES The primary outcome was the 1-year all-cause mortality rate. The secondary outcomes were postoperative complications (eg, pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission), length of hospital stay, and discharge to nursing facility. RESULTS Twenty-five patients (9.1%) died during the follow-up period (median interquartile range, 13.3 11.5-16.1 months), including 4 in-hospital deaths after surgery. Twenty-nine patients (10.5%) experienced at least 1 complication after surgery and 24 (8.7%) were discharged to nursing facilities. Malignant disease and low serum albumin levels were more common in the patients who died. Among the geriatric assessment domains, Charlson Comorbidity Index, dependence in activities of daily living, dependence in instrumental activities of daily living, dementia, risk of delirium, short midarm circumference, and malnutrition were associated with increased mortality rates. A multidimensional frailty score model composed of the above items predicted all-cause mortality rates more accurately than the American Society of Anesthesiologists classification (area under the receiver operating characteristic curve, 0.821 vs 0.647; P = .01). The sensitivity and specificity for predicting all-cause mortality rates were 84.0% and 69.2%, respectively, according to the model’s cutoff point (>5 vs ≤5). High-risk patients (multidimensional frailty score >5) showed increased postoperative mortality risk (hazard ratio, 9.01; 95% CI, 2.15-37.78; P = .003) and longer hospital stays after surgery (median interquartile range, 9 5-15 vs 6 3-9 days; P < .001). CONCLUSIONS AND RELEVANCE The multidimensional frailty score based on comprehensive geriatric assessment is more useful than conventional methods for predicting outcomes in geriatric patients undergoing surgery.
Background
Laparoscopic pancreaticoduodenectomy (LPD) is technically demanding and there is much controversy about its safety. We evaluated the learning curve for pure LPD based on the clinical ...outcomes of consecutive patients treated by a single surgeon.
Methods
We reviewed the medical records of 119 consecutive patients who underwent LPD by a single surgeon between June 2013 and August 2018. The learning curve was evaluated using the cumulative summation (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. Perioperative outcomes were compared among the learning curve phases.
Results
CUSUM analysis of the operation time showed that the operation time improved after the 47th case. RA-CUSUM analysis showed the learning curve for surgical failure, defined as severe complications (Clavien–Dindo grade ≥ 3) or open conversion, comprised three phases (phase 1: cases 1–60; phase 2: cases 61–83; phase 3: cases 84–119). There were no significant differences in operation time among the three phases. Intraoperative blood loss decreased significantly over the three phases (
P
= 0.032). There were no postoperative deaths. The rates of postoperative complications, pancreatic fistula (grade B/C), and post-pancreatic hemorrhage were significantly lower in phase 3 than in phase 2 (2.8% vs. 21.7%,
P
= 0.019; 2.8% vs. 17.4%,
P
= 0.049; 0% vs. 13.0%,
P
= 0.026), but not between phases 1 and 2. Postoperative hospital stay decreased progressively, and was significantly shorter in phase 3 than in phase 1 (9.1 vs. 16.7 days,
P
= 0.001).
Conclusions
The LPD failure rate decreased after the first 60 cases and stabilized after 84 cases. For safe dissemination of LPD, it is important to shorten the long learning curve and decrease the unfavorable outcomes in the early phase of the learning curve.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Tissue-infiltrating Ly6Chi monocytes play diverse roles in immunity, ranging from pathogen killing to immune regulation. How and where this diversity of function is imposed remains poorly understood. ...Here we show that during acute gastrointestinal infection, priming of monocytes for regulatory function preceded systemic inflammation and was initiated prior to bone marrow egress. Notably, natural killer (NK) cell-derived IFN-γ promoted a regulatory program in monocyte progenitors during development. Early bone marrow NK cell activation was controlled by systemic interleukin-12 (IL-12) produced by Batf3-dependent dendritic cells (DCs) in the mucosal-associated lymphoid tissue (MALT). This work challenges the paradigm that monocyte function is dominantly imposed by local signals after tissue recruitment, and instead proposes a sequential model of differentiation in which monocytes are pre-emptively educated during development in the bone marrow to promote their tissue-specific function.
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•Monocytes acquire regulatory properties in bone marrow early during gut infection•Infection-induced IFN-γ alters monocyte precursors in the bone marrow•Bone-marrow-resident NK cells prime monocytes for regulatory function•IL-12 produced in the gut activates bone marrow NK cells, instructing hematopoiesis
Ly6Chi monocytes play diverse roles in tissue immunity, but how this diversity of function is imposed remains poorly understood. Askenase and colleagues demonstrate that during infection, NK cells prime monocytes for regulatory function prior to bone marrow egress in response to systemic signals emanating from the infected tissue.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
To investigate whether preoperative malnutrition in patients who underwent curative pancreaticoduodenectomy (PD) in pancreatic head cancer correlated with short‐term outcomes.
Methods
This ...study was a retrospective review of medical records from January 2004 to December 2018. Preoperative malnutrition was defined as body mass index (BMI) <18.5 kg/m2, or hypoalbuminemia with serum albumin level < 3.5 g/dL within 30 days before surgery.
Results
Of the 289 eligible patients, 60 patients (20.7%) were classified as the malnutrition group. The estimated blood loss (EBL, mL) (964.1 ± 879.7 vs 597.7 ± 501.7, P = .044) and transfusion rate (51.7% vs 18.8%, P < .001) was significantly higher in the malnutrition group than no‐malnutrition group. The hospital stay (days) (20.5 ± 12.2 vs 18.1 ± 13.6, P = .05) was significantly longer in the malnutrition group. The open conversion rate (45.4% vs 6.67%, P < .001) and major complication rate (36.7% vs 21.8%, P = .032) was significantly higher in the malnutrition group. In multivariate analysis, preoperative malnutrition was found to be the predictor of postoperative complication (HR 1.971 95% confidence interval 1.071‐3.624, P = .029).
Conclusion
Preoperative malnutrition in patients who underwent curative PD for pancreatic head cancer is associated with adverse short‐term outcomes.
Highlight
No study has been reported on the association between preoperative malnutrition and surgical outcomes in pancreatic cancer. Among patients who underwent curative pancreaticoduodenectomy, Lee and colleagues revealed that those with preoperative malnutrition had increased blood loss, open conversion rates, hospital stay, and complication rates compared with those without preoperative malnutrition.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Introduction
The ability to stratify the difficulty of minimally invasive liver resection (MILR) allows surgeons at different phases of the learning curve to tackle cases of appropriate difficulty ...safely. Several difficulty scoring systems (DSS) have been formulated which attempt to accurately stratify this difficulty. The present study aims to review the literature pertaining to the existing DSS for MILR.
Methods
We performed a systematic review and metanalysis of the literature reporting on the formulation, supporting data, and comparison of DSS for MILR.
Results
A total of 11 studies were identified which reported on the formulation of unique DSS for MILR. Five of these (Ban, Iwate, Hasegawa, Institut Mutaliste Montsouris IMM, and Southampton DSS) were externally validated and shown to predict difficulty of MILR via a range of outcome measures. The Ban DSS was supported by pooled data from 10 studies (9 LLR, 1 RLR), Iwate by 10 studies (8 LLR, 2 RLR), Hasegawa by four studies (all LLR), IMM by eight studies (all LLR), and Southampton by five studies (all LLR). There was no clear superior DSS.
Conclusion
The existing DSS were all effective in predicting difficulty of MILR. Present studies comparing between DSS have not established a clear superior system, and the five main DSS have been found to be predictive of difficulty in LLR and two of these in RLR.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Developing materials with the capability of changing their innate features can help to unravel direct interactions between cells and ligand‐displaying features. This study demonstrates the grafting ...of magnetic nanohelices displaying cell‐adhesive Arg‐Gly‐Asp (RGD) ligand partly to a material surface. These enable nanoscale control of rapid winding (“W”) and unwinding (“UW”) of their nongrafted portion, such as directional changes in nanohelix unwinding (lower, middle, and upper directions) by changing the position of a permanent magnet while keeping the ligand‐conjugated nanohelix surface area constant. The unwinding (“UW”) setting cytocompatibility facilitates direct integrin recruitment onto the ligand‐conjugated nanohelix to mediate the development of paxillin adhesion assemblies of macrophages that stimulate M2 polarization using glass and silicon substrates for in vitro and in vivo settings, respectively, at a single cell level. Real time and in vivo imaging are demonstrated that nanohelices exhibit reversible unwinding, winding, and unwinding settings, which modulate time‐resolved adhesion and polarization of macrophages. It is envisaged that this remote, reversible, and cytocompatible control can help to elucidate molecular‐level cell–material interactions that modulate regenerative/anti‐inflammatory immune responses to implants.
The use of ligand‐presenting nanohelices is reported that are partly grafted to a material surface to enable magnetic field‐controlled unwinding and winding of their nongrafted portion. It is demonstrated that the unwinding of ligand‐conjugated nanohelix facilitates direct integrin recruitment onto the ligand‐conjugated nanohelix on a single cell level to mediate paxillin adhesion assembly that stimulates M2 polarization of macrophages.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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