Tsuyoshi Notake

Secondary aortoduodenal fistula (sADF) is a rare but life‐threatening complication following abdominal aortic aneurysm repair. Its management requires multidisciplinary collaboration; however, even gastrointestinal surgeons—who play a pivotal role in duodenal resection and reconstruction—often lack sufficient experience with this condition. Therefore, a clear understanding of sADF is essential for gastrointestinal surgeons. We retrospectively analyzed 16 sADF patients who underwent combined vascular and gastrointestinal reconstruction at Shinshu University Hospital between September 2018 and December 2025. We describe our step‐by‐step approach to radical resection of the third portion of the duodenum performed in collaboration with cardiovascular surgeons. The procedure includes complete division of the Treitz ligament, mobilization of the fourth portion from the uncinate process, preservation of the papilla of Vater, en bloc resection of the involved segment, and duodenojejunostomy. The greater omentum is mobilized through a retrocolonic route to facilitate secure graft coverage following vascular reconstruction. Postoperative course, complications, and survival rates were evaluated. The median age was 75 years (range: 67–83 years). The median operation time was 651 min (range 481–1477 min), and the median blood loss was 3050 mL (range 850–15 000 mL). Severe postoperative complications (Clavien–Dindo classification grade IIIa or higher) occurred in 10 patients (63%), and the 90‐day mortality rate was 21%. The 1‐year overall survival rate was 57%. Careful multidisciplinary coordination and precise gastrointestinal surgical technique are essential for achieving safe and durable management of this complex condition.

Thoracoabdominal hernias (TH), encompassing abdominal wall hernias such as flank hernias and diaphragmatic hernias, are rare conditions with poorly defined epidemiology and no standardized surgical strategy. Repair is technically challenging because it requires reconstruction across distinct anatomical structures, including the diaphragm, ribs, and abdominal wall. Optimal repair methods remain controversial. A 70-year-old man with a history of descending aortic aneurysm repair presented with a progressive left flank bulge. Computed tomography revealed a large flank hernia accompanied by diaphragmatic deformation, suggesting a concomitant diaphragmatic hernia. Surgical repair was performed via a previous thoracoabdominal incision. Intraoperatively, dehiscence of the diaphragm from the rib cage was identified. The diaphragmatic defect was primarily closed and reinforced by anchoring the diaphragm to the ribs using full-thickness sutures. Subsequently, the flank hernia was repaired using a modified extraperitoneal mesh repair with wide dissection and cranial fixation of the mesh to the ribs, followed by additional onlay mesh reinforcement. The postoperative course was uneventful, and no recurrence or chronic pain was observed during follow-up. Combined reconstruction of the diaphragm and abdominal wall using rib-anchored diaphragmatic repair and extraperitoneal mesh placement may be an effective option for complex thoracoabdominal hernias. This approach enables secure fixation and broad mesh overlap while minimizing postoperative bulging. Further studies are needed to validate its safety, durability, and long-term outcomes.

Aim: Postoperative delirium in elderly patients is a critical clinical issue because of its adverse effect on recovery and prognosis. The National Clinical Database (NCD) Risk Calculator, a clinical tool developed in Japan, is widely used to predict various postoperative complications, including delirium. In this study, we aimed to develop a more accurate delirium prediction model by integrating the NCD Risk Calculator with additional clinical indicators. Methods: This study included 106 patients who underwent segmentectomy or more extensive procedures for hepatocellular carcinoma between 2013 and 2023. The training cohort comprised patients treated between 2013 and 2017, and those treated afterward formed the validation cohort. In the training cohort, we assessed the NCD Risk Calculator and additional indices for the favorable‐risk group, and validated the best‐performing index in combination with the NCD Risk Calculator. Results: Using the median predicted risk (6.4%) as a threshold, the adverse‐risk group had a significantly higher incidence of delirium than the favorable‐risk group ( p < 0.01). Among several indices, the 5‐Item Modified Frailty Index (mFI‐5) showed the strongest association with delirium (AUC 0.76, p < 0.01). Patients classified as high‐risk by both the NCD Risk Calculator and mFI‐5 had significantly higher delirium incidence in the training ( p < 0.01) and validation ( p = 0.05) cohorts. Multivariate analysis identified high‐risk status as an independent predictor of postoperative delirium ( p < 0.01). Conclusion: The combination of the NCD Risk Calculator and mFI‐5 enhances predictive accuracy and serves as a reliable tool for assessing delirium risk in older patients.

Background: The effectiveness of intraperitoneal chemotherapy using paclitaxel (i.p.‐PTX) in pancreatic ductal adenocarcinoma (PDAC) patients with peritoneal dissemination remains elusive. The aim of this study is to investigate the clinical outcome of patients treated with i.p.‐PTX combined with systemic chemotherapy compared with current standard chemotherapy including gemcitabine plus nab‐paclitaxel and FOLFIRINOX.Methods: Data of patients with peritoneal dissemination was retrospectively collected and analyzed (i.p.‐PTX, n = 83; control, n = 86). Inverse probability of treatment‐weighted analyses (IPTW) was used to balance baseline characteristics between two groups. Survival curves were estimated using Kaplan–Meier method, and the differences were compared using the log‐rank test.Results: No significant differences were noted in overall survival (14.9 vs. 15.5 months, p = 0.481) and progression free survival (9.5 vs. 9.1 months, p = 0.267) between i.p.‐PTX and the control groups. Nevertheless, i.p.‐PTX (9.9 months) significantly prolonged the median progression‐free survival (PFS) time compared with the control (8.6 months), among the matched patients using IPTW (hazard ratio 0.666, p = 0.041). Moreover, subgroup analysis among the patients whose primary tumor were evaluated either as resectable or borderline resectable disease revealed significantly better overall survival in the i.p.‐PTX group compared with the control group (21.3 vs. 14.7 months, hazard ratio; 0.532, p = 0.033). Conversion surgery was more frequently performed in the i.p.‐PTX group than the control group (24% vs. 4%, p = 0.006).Conclusion: The i.p. PTX regimen prolonged PFS but not overall survival, and subgroup analysis suggested the possibility of survival benefit in patients with occult peritoneal dissemination whose primary tumor was classified as resectable/borderline resectable disease.

Background: The Naples prognostic score (NPS) is a remarkable marker of short‐ and long‐term outcomes in various types of cancer. However, its impact on the postoperative outcomes of hepatocellular carcinoma remains controversial. This study aimed to clarify the impact of the NPS on the prognosis and incidence of postoperative complications in hepatocellular carcinoma.Methods: Patients with hepatocellular carcinoma (n = 374) were categorized into high‐ and low‐Naples prognostic score groups; their postoperative outcomes were compared. Prognostic and risk factors for severe postoperative complications were identified using multivariate analyses.Results: The low‐Naples prognostic score group had significantly longer overall and recurrence‐free survivals than the high‐Naples prognostic score group (p = 0.03 and 0.04, respectively). Subgroup analysis revealed a superior predictive value of the NPS in the group with a single tumor (p = 0.03), tumor diameter ≤5 cm (p = 0.04), and tumor stage I or II (p = 0.04). A high NPS was an independent prognostic factor for overall survival (hazard ratio, 1.45; 95% confidence interval (CI), 1.01–2.05; and p = 0.04). The NPS 2–4 group had a higher incidence of the Clavien–Dindo grade ≥ IIIa postoperative complications than the 0–1 group (p = 0.03) and a score of 2–4 was identified as an independent risk factor for the Clavien–Dindo grade ≥ IIIa postoperative complications (odds ratio, 2.06; 95% CI, 1.01–4.20; and p = 0.05).Conclusions: The NPS effectively predicts postoperative outcomes in patients with hepatocellular carcinoma.

Median arcuate ligament syndrome (MALS) is a rare condition characterized by nonspecific symptoms, such as abdominal pain, nausea, and vomiting. Furthermore, the development and rupture of pancreaticoduodenal artery aneurysms pose a potentially fatal risk. Median arcuate ligament release (MALR) is useful in the treatment of MALS, with most procedures performed laparoscopically. However, detailed descriptions of laparoscopic MALR (lap‐MALR) procedures are rare. In this study, we performed lap‐MALR via an anterior approach with dissection of the right lateral wall of the celiac artery (CA). For optimal visualization of the right side of the CA, the right branch of the inferior phrenic artery was divided. We believe that this procedure allows the MAL to be released within a sufficient surgical field and without excess or deficiency. Here, we present the details of six patients who underwent lap‐MALR for varying indications; three for pancreaticoduodenal artery aneurysms due to CA obstruction (unruptured, n = 1; ruptured, n = 2), two cases prior to hepato‐biliary‐pancreatic surgery, and one symptomatic case. In all cases, lap‐MALR was performed as described above, and the CA stenosis was successfully released. Our case series demonstrates the safety and reliability of our lap‐MALR procedure in the treatment of MALS‐related disorders, including pancreaticoduodenal artery aneurysms associated with CA compression.

Background and Aim: Post‐hepatectomy liver failure (PHLF) after major hepatopancreatoduodenectomy (HPD) is a challenge to overcome. However, the appropriate target proportion of the future liver remnant (pFLR) to prevent severe PHLF in major HPD remains uncertain. This study aimed to determine the minimum pFLR required for safe major HPD.Methods: This retrospective study involved 48 major HPD patients. We assessed pFLR and remnant liver function scores (pFLR × albumin‐bilirubin [ALBI] / albumin‐indocyanine green evaluation [ALICE]/plasma clearance rate of indocyanine green [KICG]) as predictors for Grade B/C PHLF and established safety criteria.Results: Grade B/C PHLF occurred in 40% of the patients (n = 19), leading to severe morbidity and two in‐hospital deaths. pFLR was a good predictor of Grade B/C PHLF [area under the curve (AUC) 0.80, p < 0.01] with a 45% optimal cutoff. While all remnant liver function scores predicted PHLF, the remnant ALICE demonstrated the best predictability (AUC 0.85, p < 0.01), with the sensitivity and specificity at 89% and 83%, respectively, using −0.86 as the cutoff. Independent risk factors for Grade B/C PHLF were remnant ALICE ≥−0.86 and blood loss ≥1500 mL. Grade B/C PHLF developed in 14% with pFLR ≥45% but reached 64% with pFLR <45%. However, the rate could be reduced to 33% with remnant ALICE <−0.86.Conclusion: To prevent Grade B/C PHLF, a pFLR ≥45% is recommended. Nevertheless, major HPD may be considered in patients with good remnant liver function.

Background: The superiority of anatomical liver resection (AR) for localized hepatocellular carcinoma (HCC) over nonanatomical liver resection (NR) remains controversial. This study aimed to investigate the impact of AR in preventing local and early HCC recurrence.Methods: A total of 280 patients who underwent initial liver resection for solitary HCC ≤5 cm in diameter were categorized into the AR and NR groups and compared using propensity score matching analysis.Results: Between the matched pairs (n = 87 in each group), the incidence rates of local and early (recurrence within 2 years after surgery) recurrences in the AR group were significantly lower than those in the NR group (13.8% vs. 28.7%, p = .025; 20.7% vs. 35.6%, p = .028, respectively). The overall survival in the AR group was better than that in the NR group (median: 13.4 vs. 7.6 years, p = .003). NR was among independent risk factors for early recurrence (odds ratio: 1.98, 95% CI: 1.1–3.6, p = .023) and prognostic factors for local recurrence (hazard ratio: 2.44, 95% CI: 1.4–4.4, p = .003).Conclusion: AR is superior in controlling local and early recurrence postoperatively for solitary HCC ≤5 cm in diameter compared with NR.

Aim: Methods of predicting severe postoperative complications after anatomical resection for hepatocellular carcinoma are yet to be established. We aimed to clarify the relationship between inflammation‐based prognostic scores and liver fibrosis markers and the incidence of postoperative complications after anatomical resection for hepatocellular carcinoma as well as the usefulness of these markers in surgical procedure selection.Methods: We included 374 patients with hepatocellular carcinoma who had undergone initial hepatectomy between January 2007 and December 2021. The association between inflammation‐based prognostic scores or liver fibrosis markers and postoperative complications was evaluated, and severe postoperative complication rates in the high‐risk group defined by these markers were compared in terms of surgical procedure.Results: The advanced lung cancer inflammation index and nonalcoholic fatty liver disease fibrosis score correlated significantly with severe postoperative complications after anatomical resection, with areas under the curve of 0.67 and 0.61, respectively. The combined advanced lung cancer inflammation index and nonalcoholic fatty liver disease fibrosis score resulted in a larger area under the curve (0.69). Furthermore, in the high‐risk group determined by the combined score, the anatomical resection group had a significantly higher incidence of severe complications than the partial resection group (P < 0.01). There were no significant differences in prognosis among the surgical procedures in the high‐risk group.Conclusion: The combined advanced lung cancer inflammation index and nonalcoholic fatty liver disease fibrosis score serves as a predictive marker for severe postoperative complications after anatomical resection. This combined marker may contribute to appropriate surgical procedure selection.

Purpose Here, we evaluated the usefulness of intratumoral perfusion analysis using preoperative contrast-enhanced CT (E-CT) to assess biological features of non-functional pancreatic neuroendocrine neoplasms (NF-PanNENs). Methods We retrospectively studied 44 patients who underwent curative surgery for NF-PanNENs. We used preoperative E-CT with compartment model analysis to calculate the tumor perfusion parameters K1 (inflow rate constant), 1/k2 (mean transit time), and K1/k2 (distribution volume). We assessed the association between perfusion parameters and biological features of NF-PanNENs, including the WHO classification tumor histopathological grade and prognosis after surgery. Results Patients in this study had a neuroendocrine tumor (NET) G1 (n = 32) or NET G2 (n = 12). Neither NET G3 or NEC tumors were observed. Among perfusion parameters, K1 was the most accurate predictor of the high-grade tumor (AUC: 0.726). K1-low (< 0.028 s⁻¹) was significantly associated with large tumors (≥ 20 mm) (p = 0.022), high mitotic index (p = 0.017), high Ki-67 index (p = 0.004), and lymphatic invasion (p = 0.025). Synchronous extra-pancreatic metastasis, including lymph node metastasis or liver metastasis, more frequently developed in K1-low patients than in K1-high patients (29% vs 4%, p = 0.025). Disease-free survival of patients with a K1-low tumor was poorer than that of patients with a K1-high tumor (p = 0.005). Furthermore, no patient with a K1-high tumor developed recurrence after initial surgery. Conclusion The perfusion parameters obtained using E-CT were significantly associated with biological features and prognosis of NF-PanNENs.