Among about 120,000 cases of laparoscopic cholecystectomies (LC) yearly performed in Japan, bile duct injury (BDI) caused by the misidentification between the common bile duct and the gallbladder ...duct has occurred in about 600 cases. The main causes of BDI were that the surgeons did not fully confirm the landmark or misidentified the landmark. This study previously developed an AI system and confirm the ability to indicate anatomical landmarks in real-time, however the function which prevents BDI has not been confirmed. Therefore, this study developed an experimental application by using an eye tracking device, and established an evaluation method for whether a surgeon consciously watches the landmarks on an image of endoscopic camera or not. This paper reports our developed application and introduces the experimental results.
Background
According to the National Clinical Database of Japan, the incidence of bile duct injury (BDI) during laparoscopic cholecystectomy has hovered around 0.4% for the last 10 years and has not ...declined. On the other hand, it has been found that about 60% of BDI occurrences are due to misidentifying anatomical landmarks. However, the authors developed an artificial intelligence (AI) system that gave intraoperative data to recognize the extrahepatic bile duct (EHBD), cystic duct (CD), inferior border of liver S4 (S4), and Rouviere sulcus (RS). The purpose of this research was to evaluate how the AI system affects landmark identification.
Methods
We prepared a 20-s intraoperative video before the serosal incision of Calot’s triangle dissection and created a short video with landmarks overwritten by AI. The landmarks were defined as landmark (LM)-EHBD, LM-CD, LM-RS, and LM-S4. Four beginners and four experts were recruited as subjects. After viewing a 20-s intraoperative video, subjects annotated the LM-EHBD and LM-CD. Then, a short video is shown with the AI overwriting landmark instructions; if there is a change in each perspective, the annotation is changed. The subjects answered a three-point scale questionnaire to clarify whether the AI teaching data advanced their confidence in verifying the LM-RS and LM-S4. Four external evaluation committee members investigated the clinical importance.
Results
In 43 of 160 (26.9%) images, the subjects transformed their annotations. Annotation changes were primarily observed in the gallbladder line of the LM-EHBD and LM-CD, and 70% of these shifts were considered safer changes. The AI-based teaching data encouraged both beginners and experts to affirm the LM-RS and LM-S4.
Conclusion
The AI system provided significant awareness to beginners and experts and prompted them to identify anatomical landmarks linked to reducing BDI.
Abstract Background Although findings from drip infusion cholangiography with computed tomography (DIC‐CT) are useful in preoperative anatomic evaluation for laparoscopic cholecystectomy (LC), their ...relationship with intraoperative surgical difficulty based on the difficulty score (DS) proposed by Tokyo Guidelines 2018 is unclear. We examined this relationship. Methods Data were collected from 202 patients who underwent LC for benign gallbladder (GB) disease with preoperative DIC‐CT in our department. DIC‐CT findings were classified into GB‐positive and GB‐negative groups based on GB opacification, and clinical characteristics were compared. DS assessed only on findings from around Calot's triangle was considered “cDS”, and patients were divided into cDS ≤2 and ≥3 groups. Preoperative data including DIC‐CT findings were evaluated using multivariate analysis. Results DIC‐CT findings showed 151 (74.8%) GB‐positive and 51 (25.2%) GB‐negative patients. Surgical outcomes were significantly better in the GB‐positive versus GB‐negative group for operation time (107 vs. 154 min, p < .001), blood loss (8 vs. 25 mL, p < .001), cDS (0.8 vs. 2.2, p < .001), and critical view of safety score (4.0 vs. 3.1, p < .001). cDS was ≤2 in 174 (86.1%) and ≥3 in 28 (13.9%) patients. By multivariate analysis, DIC‐CT findings and alkaline phosphatase values were independent factors predicting intraoperative difficulty. Conclusion DIC‐CT findings are useful for predicting cDS in LC.
Background
Short-chain fatty acids (SCFAs) and gut microbiota have health-related effects and are associated with a wide range of disorders. However, the changes of SCFAs and their receptors after ...sleeve gastrectomy (SG) remain unclear. This study aimed to examine changes of SCFAs and their receptors after SG in an obese rat model.
Methods
Thirty obese Sprague–Dawley rats eating a high-energy diet for 6 weeks were divided into three groups: sham-operated (SO) control, pair-fed (PF) control, and SG group. Six weeks after the surgery, metabolic parameters, SCFA levels in the blood and stool, mRNA and protein expression of SCFA receptors in the ileum and epididymal fat, and gut microbiota were examined.
Results
Metabolic parameters in the SG group were significantly improved compared with the SO group. Acetic acid levels in the blood and stool were significantly higher in the SG group than the PF group. The butyric acid level in the stool was also significantly higher in the SG group than in the PF group. In the ileum and epididymal fat, mRNA and protein expression of GPR41 was significantly higher in the SG group than in the other two groups, and mRNA and protein expression of GPR43 was significantly higher in the SG group than in the PF group. Increases in the genera
Enterococcus
,
Lactobacillus
,
Lactococcus
, and
Clostridium
were observed in the stool after SG.
Conclusions
SG may activate SCFA pathways through a change in gut microbiota.
Background
Attention to anatomical landmarks in the appropriate surgical phase is important to prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC). Therefore, we created a ...cross-AI system that works with two different AI algorithms simultaneously, landmark detection and phase recognition. We assessed whether landmark detection was activated in the appropriate phase by phase recognition during LC and the potential contribution of the cross-AI system in preventing BDI through a clinical feasibility study (J-SUMMIT-C-02).
Methods
A prototype was designed to display landmarks during the preparation phase and Calot's triangle dissection. A prospective clinical feasibility study using the cross-AI system was performed in 20 LC cases. The primary endpoint of this study was the appropriateness of the detection timing of landmarks, which was assessed by an external evaluation committee (EEC). The secondary endpoint was the correctness of landmark detection and the contribution of cross-AI in preventing BDI, which were assessed based on the annotation and 4-point rubric questionnaire.
Results
Cross-AI-detected landmarks in 92% of the phases where the EEC considered landmarks necessary. In the questionnaire, each landmark detected by AI had high accuracy, especially the landmarks of the common bile duct and cystic duct, which were assessed at 3.78 and 3.67, respectively. In addition, the contribution to preventing BDI was relatively high at 3.65.
Conclusions
The cross-AI system provided landmark detection at appropriate situations. The surgeons who previewed the model suggested that the landmark information provided by the cross-AI system may be effective in preventing BDI. Therefore, it is suggested that our system could help prevent BDI in practice.
Trial registration
University Hospital Medical Information Network Research Center Clinical Trial Registration System (UMIN000045731).
Graphical abstract
Background
A stapler is usually used for transection and closure of the pancreas in distal pancreatectomy (DP) or central pancreatectomy (CP). When the pancreas is transected to the right of the ...portal vein, it is difficult to use a stapler and clinically relevant postoperative pancreatic fistula (CR-POPF) frequently occurs. We report on the efficacy of pancreaticojejunostomy (PJ) of the pancreatic stump for patients in whom stapler use is difficult.
Methods
Patients who underwent DP or CP were enrolled in this study. The pancreas was usually transected by a stapler, and ultrasonic coagulating shears (UCS) were used depending on the tumor situation. When using UCS, hand-sewn closure or PJ was performed for the pancreatic stump. The relationship between clinicopathological factors and the methods of pancreatic transection and closure were investigated.
Results
In total, 164 patients underwent DP or CP, and the pancreas was transected with a stapler in 150 patients and UCS in 14 patients. The rate of CR-POPF was higher and the postoperative hospital stay was longer in the UCS group than in the stapler group. PJ of the pancreatic stump, which was performed for 7 patients, did not worsen intraoperative factors. CR-POPF was not seen in these 7 patients, which was significantly less than that with hand-sewn closure.
Conclusions
PJ of the pancreatic stump during DP or CP reduces CR-POPF compared with hand-sewn closure and may be useful especially when the pancreas is transected to the right of the portal vein.
Background
The Critical View of Safety (CVS) was proposed in 1995 to prevent bile duct injury during laparoscopic cholecystectomy (LC). The achievement of CVS was evaluated subjectively. This study ...aimed to develop an artificial intelligence (AI) system to evaluate CVS scores in LC.
Materials and methods
AI software was developed to evaluate the achievement of CVS using an algorithm for image classification based on a deep convolutional neural network. Short clips of hepatocystic triangle dissection were converted from 72 LC videos, and 23,793 images were labeled for training data. The learning models were examined using metrics commonly used in machine learning.
Results
The mean values of precision, recall,
F
-measure, specificity, and overall accuracy for all the criteria of the best model were 0.971, 0.737, 0.832, 0.966, and 0.834, respectively. It took approximately 6 fps to obtain scores for a single image.
Conclusions
Using the AI system, we successfully evaluated the achievement of the CVS criteria using still images and videos of hepatocystic triangle dissection in LC. This encourages surgeons to be aware of CVS and is expected to improve surgical safety.
Graphical abstract
Background
Clinically relevant postoperative pancreatic fistula (CR-POPF) is a major complication of pancreatoduodenectomy (PD). A pancreatic stent is usually used for drainage of the pancreatic ...duct, but the best type of the stent remains unclear. The aim of this study was to investigate perioperative factors and their influence on the risk of CR-POPF following PD.
Methods
From 2006 to 2019, the records of 246 patients who underwent PD were retrospectively reviewed, and the relationship between perioperative factors including type of pancreatic stent and CR-POPF was investigated. External or internal pancreatic stents were used for drainage of the pancreatic duct, and the internal stent was inserted 1 cm into the jejunum to decrease stent obstruction.
Results
External and internal pancreatic stents were used in 137 and 109 patients, respectively. Multivariate analysis revealed that the diameter of the main pancreatic duct (odds ratio = 0.292, 95% confidence interval = 0.140–0.605,
P
= 0.001), diagnosis (odds ratio = 3.359, 95% confidence interval = 1.498–7.693,
P
= 0.003), and type of pancreatic stent (odds ratio = 0.435, 95% confidence interval = 0.203–0.934,
P
= 0.033) were independent factors related to CR-POPF after PD. Internal stent was associated with a low rate of CR-POPF (
P
< 0.001) and short postoperative hospital stay (
P
< 0.001) compared to external stent.
Conclusion
A short pancreatic internal stent could decrease the incidence of CR-POPF.
Background
Laparoscopic liver resection (LLR) is possible in many patients, but pure LLR is sometimes difficult to complete, and unplanned intraoperative hand-assisted laparoscopic surgery (HALS) or ...open conversion is sometimes necessary. However, appropriate indications and timing for conversion are unclear. This study aimed to clarify the indications for HALS and open conversion from pure LLR.
Methods
We collected data from 208 patients who underwent LLR from January 2010 to February 2021 in our department. We retrospectively examined these data between cases of unplanned intraoperative HALS conversion, open conversion, and pure LLR, and clarified risk factors and indications for HALS or open conversion.
Results
There were 191 pure LLRs, nine HALS conversions, and eight open conversions. In the HALS conversion group versus pure LLR group, body mass index (BMI) (27.0 vs. 23.7 kg/m
2
,
p
= 0.047), proportions of patients with history of upper abdominal surgery (78% vs. 33%;
p
= 0.006), repeat hepatectomy (56% vs. 15%;
p
= 0.002), S7 or S8 tumor location (67% vs. 35%;
p
= 0.049), and difficulty score (DS) ≥ 7 (56% vs. 19%;
p
= 0.008) were significantly higher, and surgical time (339 vs. 239 min;
p
= 0.031) was significantly longer. However, postoperative states were not significantly different between the two groups. The BMI cutoff value for risk of unplanned intraoperative conversion determined by receiver operating characteristic curve analysis was 25 kg/m
2
, and the proportion of patients with BMI ≥ 25 kg/m
2
(89% vs. 31%,
p
< 0.001) was significantly higher in the HALS conversion versus pure LLR group. In the open conversion group, although there were no significant differences compared to the HALS group in clinicopathological factors except for sex, blood loss was greater (1425 vs. 367 mL;
p
< 0.001).
Conclusion
Risk factors for considering HALS during LLR were patients with a history of upper abdominal surgery including repeat hepatectomy, BMI ≥ 25 kg/m
2
, S7 or S8 tumor location, DS ≥ 7, and prolonged surgical time. Furthermore, uncontrollable intraoperative bleeding was an indication for open conversion.
Aim
The number of surgeries for pancreatic ductal adenocarcinoma (PDAC) in older adults has been rising. This study aimed to evaluate the technical and oncological safety of pancreatectomy for older ...adults aged ≥75 years with PDAC by retrospectively comparing their short‐ and long‐term outcomes with those of younger adults aged <75 years.
Methods
Data were collected from 117 patients who underwent pancreatectomy for PDAC in our department. The indication for surgery regarding patient characteristics was considered according to each patient's American Society of Anesthesiologists physical status and Eastern Cooperative Oncology Group Performance Status Scale. Data of older adults (n = 32) were compared with those of younger adults (n = 85), and comprised patient background, surgical factors, postoperative course, histopathological factors and prognostic factors. Additionally, prognostic nutritional index values preoperatively and at 1 and 6 months postoperatively were compared between the two groups.
Results
Although American Society of Anesthesiologists physical status and comorbidities were worse in older adults, there were no significant differences in surgical factors, postoperative courses and histopathological factors between the two groups. The overall complication rate tended to be higher in older adults (40.6%) than in younger adults (29.4%). There were no differences in median lengths of recurrence‐free survival and overall survival (older adults vs younger adults: 12 vs 13 months, P = 0.545, and 26 vs 20 months, P = 0.535, respectively) between the two groups. Furthermore, no significant differences were found in prognostic nutritional index preoperatively to 6 months after surgery.
Conclusion
With careful determination of surgical indications, pancreatectomy for PDAC can be carried out with acceptable post‐pancreatectomy morbidity in younger adults. Geriatr Gerontol Int 2023; 23: 531–536.
This study aimed to evaluate the technical and oncological safety of pancreatectomy for older adults aged ≥75 years with pancreatic ductal adenocarcinoma by retrospectively comparing their short‐ and long‐term outcomes with those of younger adults aged <75 years. With careful determination of surgical indications, pancreatectomy for pancreatic ductal adenocarcinoma can be carried out with acceptable post‐pancreatectomy morbidity in older patients.
