Background: Hepatocellular carcinoma (HCC) larger than 10 cm has a poor prognosis, with high recurrence rates, particularly distant metastases. This study examined whether lenvatinib treatment followed by liver resection improves the outcomes for large HCCs compared with upfront surgery. Methods: We retrospectively analyzed 30 patients with HCC larger than 10 cm who underwent hepatectomy at our institution between January 2008 and December 2023. The study cohort included 30 patients: 9 received preoperative lenvatinib treatment followed by hepatectomy (LEN group), while 21 patients underwent upfront surgery (UFS group). We compared the clinicopathological characteristics, surgical outcomes, recurrence patterns, and survival between the two groups. Results: The median duration of lenvatinib administration was 1.8 months, with partial response in two patients (22.2%) and stable disease in seven patients (77.7%). While lenvatinib treatment significantly decreased serum albumin levels (p < 0.05) and increased ALBI scores (p = 0.03), the surgical outcomes including blood loss, operation time, and complication rates were comparable between the two groups. The 3-year recurrence-free survival rate was significantly higher in the LEN group compared with the UFS group (66.7% vs. 16.1%, p = 0.027). The 3-year overall survival rate was also higher in the LEN group, though not statistically significant (85.7% vs. 56.1%, p = 0.059). Notably, distant metastasis rates were lower in the LEN group compared with the UFS group (11.1% vs. 47.6%, p = 0.10). Conclusions: Preoperative lenvatinib treatment followed by hepatectomy for large HCC (> 10 cm) may reduce recurrence, particularly distant metastases, and potentially improve long-term survival. This approach may be a promising strategy for large HCCs, which traditionally have a poor prognosis with upfront surgery alone.

Objectives: Pancreatic simple mucinous cysts (SMCs) are characterized by cystic lesions >1 cm in size, lacking ovarian-type stroma and lined by a single layer of bland epithelium. Although SMCs are typically considered benign, sporadic cases with KRAS mutations suggest its potential inclusion within the spectrum of low-grade mucinous neoplasms. This study reported a case of pancreatic SMC with co-occurring KRAS and GNAS mutations to discuss their potential implications in the management of pancreatic cystic lesions. Materials and Methods: A 54-year-old woman with a 5-year history of pancreatic cysts was initially diagnosed with a branch-duct intraductal papillary mucinous neoplasm presented with abdominal distension. Imaging revealed a rapidly enlarging cystic lesion, prompting spleen-preserving distal pancreatectomy. Targeted amplicon sequencing was performed on the resected cystic wall and background pancreatic tissues. In addition, a literature review of 127 reported SMC cases was conducted to analyze demographics, imaging findings, pathologic findings, and genetic mutations. Results: Histopathologic analysis confirmed SMC, and genetic testing revealed KRAS and GNAS mutations in the cyst walls. At 32 months after surgery, the patient remained recurrence-free. The median age of the 127 patients was 66 years. The common imaging features included cyst enlargement and wall enhancement. KRAS mutations were found in 35% of the 65 cases, and our case is the first to report GNAS mutations. Conclusion: This is the first report of pancreatic SMC with co-occurring KRAS and GNAS mutations. SMC should be considered a differential diagnosis of pancreatic cystic lesions. Surgical intervention may be warranted based on findings.

Objective. This prospective comparative study evaluated the efficacy and relationship between laparoscopic origami crane training (LOCT) and the Fundamentals of Laparoscopic Surgery (FLS) score using 3D vs 2D laparoscopy. Methods. From 2020 to 2023, fourth-year medical students at Asahikawa Medical University created 20 origami cranes (1 per day) in a laparoscopic dry box. FLS scores were assessed 5 times, corresponding to every fifth crane. Primary outcomes included LOCT production time, quality, and FLS scores, analyzed using the Mann–Whitney U test and repeated-measures ANOVA. Results. Eighteen participants were divided into 2 groups: 8 in the 3D laparoscopy (3D) group and ten in the 2D laparoscopy (2D) group. At the end of the study, the 3D group (16.5 min) produced cranes significantly faster than the 2D group (27 min, P = 0.02). Repeated-measures ANOVA showed that the production time, origami crane score, and FLS score improved over time. The 3D group had a significantly shorter production time (F (1, 16) = 8, P = 0.01). The origami crane score was not significantly different between the groups (F (1, 7) = 3, P = 0.13) but tended to be higher in the 3D group. No significant differences were found in the FLS scores between the groups for any task. A significant negative correlation between LOCT production time and FLS score in both groups confirmed that shorter production time correlated with higher FLS scores. Conclusions. LOCT is effective for extraclinical laparoscopic training and correlates with FLS scores. 3D laparoscopy may help beginners develop depth perception, improve bimanual and hand-eye coordination, and enhance LOCT effectiveness.

INTRODUCTION: Open abdomen management (OAM) is sometimes required in patients with severe peritonitis and septic shock when primary fascial closure is unsafe or impossible. Mesh-mediated fascial traction (MMFT) combined with negative pressure wound therapy (NPWT) is a useful strategy for delayed fascial closure. However, fascial dehiscence may still occur after definitive closure in patients with multiple risk factors for impaired wound healing. Reports describing retention sutures as a salvage adjunct for fascial dehiscence after MMFT are scarce. We report a high-risk case in which re-closure with adjunctive retention sutures maintained abdominal wall closure after fascial dehiscence following staged closure.CASE PRESENTATION: A man in his 60s with obesity and ongoing corticosteroid therapy for interstitial pneumonia was transferred to our hospital with upper abdominal pain and profound septic shock. CT showed extraluminal gas predominantly in the upper abdomen and pelvic ascites, but the perforation site was unclear. Emergency exploratory laparotomy revealed perforated sigmoid diverticulitis. Because of severe hemodynamic instability, segmental sigmoid colectomy was performed, and OAM was initiated. After second-look surgery, primary fascial closure remained difficult because of marked bowel edema and obesity. MMFT combined with NPWT was therefore performed. The abdominal wall defect gradually decreased, and fascial closure was achieved on POD 13. However, fascial dehiscence occurred on POD 17, with the small intestine in direct contact with the fascial sutures. On POD 18, re-closure was performed using fascial re-suturing combined with 4 retention sutures. During closure, the fascia was gradually approximated toward the midline with manual lateral-to-medial compression of the trunk, and the skin was left open with continued NPWT. The patient was transferred for rehabilitation on POD 100. At 1-year follow-up, the wound was fully epithelialized, and no obvious incisional hernia was observed.CONCLUSIONS: Fascial dehiscence may occur even after staged closure with MMFT and NPWT in high-risk patients. Adjunctive retention sutures may be a salvage option for re-closure when conventional fascial re-suturing alone is considered insufficient.

Background/Objectives: A postoperative recovery capacity-enhancement program, Enhanced Recovery After Surgery (ERAS), has recently been developed according to evidence regarding perioperative management, recognizing the importance of perioperative rehabilitation. We examined the effectiveness of perioperative rehabilitation in patients with sarcopenia undergoing hepato-biliary-pancreatic (HBP) surgery. Methods: We evaluated 155 patients who underwent high-level HBP surgery from August 2017 to December 2019. We recorded their preoperative nutritional index (prognostic nutritional index and controlling nutritional status (CONUT) score), skeletal muscle index (SMI), surgical operation, and postoperative course. SMI was measured by bioimpedance analysis using an InBody S10®. Results: We analyzed data for 155 patients, including 68 in the sarcopenia (S) group and 87 in the non-sarcopenia (NS) group, according to the Asian Working Group for Sarcopenia criteria. The CONUT score was significantly higher and the nutritional status was poorer in the S group than in the NS group. The number of diabetic cases was also significantly higher in the S group than in the NS group. There was no significant difference in serious postoperative complications (Clavien–Dindo grade ≥ IIIa) between the groups, including pleural effusion and ascites that was difficult to treat. There was also no significant difference in length of hospital stay between the two groups. Conclusions: Among patients undergoing HBP surgery, patients with sarcopenia are likely to have poorer nutritional status and SMI; however, perioperative rehabilitation may help to avoid serious postoperative complications and long-term hospitalization after surgery.

Background/Objectives: The impact of preoperative zinc (Zn) status on the survival and recurrence of patients with hepatocellular carcinoma (HCC) after hepatectomy remains unclear. This study aimed to clarify whether preoperative Zn deficiency affects the prognosis of patients with HCC undergoing initial curative hepatectomy. Methods: We retrospectively reviewed 105 patients who underwent initial curative hepatectomy for HCC at our institution (2011–2018). Preoperative Zn deficiency was defined as serum Zn < 70 µg/dL. Clinical and tumor parameters were compared between patients with and without Zn deficiency. Disease-free and overall survival were evaluated using the Kaplan–Meier method, and prognostic factors were identified via univariate and multivariate Cox proportional hazards analyses. Subgroup analyses were conducted based on age, gender, and etiology. Results: Among 105 patients, 46 (43.8%) showed Zn deficiency (Zn deficiency group), whereas 59 (56.2%) showed normal Zn (normal Zn group). Compared with the normal-Zn group, the Zn deficiency group showed significantly lower hemoglobin, prothrombin activity, serum albumin, and smaller tumor size (all p < 0.05). The Zn deficiency group experienced significantly worse disease-free survival (p = 0.015) but no difference in overall survival (p = 0.63). On multivariate analysis, zinc deficiency (hazard ratio [HR] 1.83, p = 0.040) and prothrombin activity (HR 0.98, p = 0.042) were independent predictors of worse disease-free survival. Subgroup analysis revealed that Zn deficiency was significantly associated with elevated recurrence risk in patients with HCV-related liver disease (HR 3.67, p = 0.013). Conclusions: Preoperative Zn deficiency is an independent predictor of worse DFS after curative hepatectomy. Although further large-scale studies are required to confirm these findings, evaluating preoperative Zn status may help identify patients at high risk of HCC recurrence.