Background: Although previous reports have shown a lower proportion of the ACTN3 XX genotype (R577X nonsense polymorphism) in sprint/power athletes compared with controls, possibly attributed to the importance of skeletal muscle function associated with alpha-actinin-3 deficiency, the findings on association between endurance athlete status and R577X genotype are equivocal. Purpose: The present study was undertaken to examine association of ACTN3 R577X genotype with elite Japanese endurance athlete status. Subjects and Methods: Subjects comprised 79 elite Japanese endurance runners (E) who participated in competition at national level and 96 Japanese controls (C). We divided endurance runners into two groups, i.e., 42 national level runners (E-N) and 37 international level runners (E-I) who had represented Japan in international competition. R577X genotype (rs1815739) was analyzed by direct sequencing. Frequency differences of polymorphisms between athletes and controls were examined by Chi-square tests. Result: The R allele frequency tended to be higher in E group than in C group (P=0.066). When we divided E into two groups, the R allele frequency in E-I group was significantly higher than that in C group (P=0.046); whereas there were no significant differences between E-N and C groups (p=0.316). Then, the three genetic models were tested. In the additive genetic model (RR>RX>XX), there were significantly differences between E-I and C (P=0.038), but not the dominant (RR vs. RX+XX) and the recessive (RR+RX vs. XX) genetic models. Conclusion: R allele of the R577X genotype in the ACTN3 gene was associated with elite Japanese endurance athlete status.

Background: The technique of pancreatoduodenectomy (PD) has evolved, and artery first’ approach was considered for the intraoperative early determination of resectability for borderline resectable cases before the ‘point of no return’ and avoidance of blood congestion resulted in the reduction of blood loss. Also, active application of energy device was useful for the reduced operative time and blood loss. Recently, 3D simulation for hepatobiliary pancreatic surgery has been useful and mandatory. In this presentation, we introduced our recent refinements and advances for PD. ‘Artery first’ approach and vessel sealing system for PD: ‘Artery first’ approach were considered as six different methods as follows; 1) Superior approach, 2) Anterior approach, 3) Posterior approach, 4) Left posterior approach, 5) Right/ medial uncinate approach and 6) Mesenteric approach. A while ago, we preferably applied the mesenteric approach to PD, and also the combination of this approach with vessel sealing system (VSS) significantly reduced intraoperative blood loss (Mesenteric approach with VSS, n=21 vs. non-‘Artery first’ approach without VSS, n=78; 320±174ml vs. 486±263ml, p<0.01). Modified de-rotation method as complete ‘Artery first’ approach: Most recently, for further refinement of operative procedure, we refined a right/medial uncinate and posterior approach as modified de-rotation method. Point of view in this method was the complete clockwise rotation of small intestinal mesentery including ascending colon, in order to linearize from duodenum to jejunum and look at the direct front of superior mesenteric artery (SMA), vein (SMV) and some branched jejunal vessels originated from SMA and SMV (Fig.). Thereby, in the posterior view, the easy dissection of all pancreatic branch originated from SMA can be done. This modified de-rotation method was possible to achieve the complete ‘Artery first’ approach. Preoperative 3D simulation of arterial and venous anatomy: Until now, we applied 3D volumetery software (SYNAPSE VINCENT®) as preoperative simulation for hepatic resection. And recently, for evaluation of the position relationship between arteries and veins surround pancreas head, we adopted this software before PD. As first step, arteries and veins are automatically identified, and small vessels are manually traced on the axial CT view. After that, 3D arterial and venous simulations are combined. Grasp of detailed vessel anatomy and its relationship using preoperative 3D simulation enable to safely perform PD, even in young surgeons (operative time; young 512±49 vs. senior 445±41 min, p<0.01), (blood loss; young 353±203 vs. senior 246±109 ml, p=0.16). Conclusion: Those refinements and advances are possible to safely and easily perform pancreatoduodenectomy.

Background: The technique of pancreatoduodenectomy (PD) has evolved, andartery first’ approach was considered for the intraoperative early determinationof resectability for borderline resectable cases before the ‘point of no return’and avoidance of blood congestion resulted in the reduction of blood loss. Also,active application of energy device was useful for the reduced operative time andblood loss. Recently, 3D simulation for hepatobiliary pancreatic surgery has beenuseful and mandatory. In this presentation, we introduced our recent refinementsand advances for PD.‘Artery first’ approach and vessel sealing system for PD: ‘Artery first’ approachwere considered as six different methods as follows; 1) Superior approach, 2)Anterior approach, 3) Posterior approach, 4) Left posterior approach, 5) Right/medial uncinate approach and 6) Mesenteric approach. A while ago, wepreferably applied the mesenteric approach to PD, and also the combination ofthis approach with vessel sealing system (VSS) significantly reduced intraoperativeblood loss (Mesenteric approach with VSS, n=21 vs. non-‘Artery first’ approachwithout VSS, n=78; 320±174ml vs. 486±263ml, p<0.01).Modified de-rotation method as complete ‘Artery first’ approach: Most recently,for further refinement of operative procedure, we refined a right/medial uncinateand posterior approach as modified de-rotation method. Point of view in thismethod was the complete clockwise rotation of small intestinal mesenteryincluding ascending colon, in order to linearize from duodenum to jejunumand look at the direct front of superior mesenteric artery (SMA), vein (SMV) andsome branched jejunal vessels originated from SMA and SMV (Fig.). Thereby, inthe posterior view, the easy dissection of all pancreatic branch originated fromSMA can be done. This modified de-rotation method was possible to achieve thecomplete ‘Artery first’ approach.Preoperative 3D simulation of arterial and venous anatomy:Until now, we applied 3D volumetery software (SYNAPSE VINCENT®) aspreoperative simulation for hepatic resection. And recently, for evaluation of theposition relationship between arteries and veins surround pancreas head, weadopted this software before PD. As first step, arteries and veins are automaticallyidentified, and small vessels are manually traced on the axial CT view. Afterthat, 3D arterial and venous simulations are combined. Grasp of detailed vesselanatomy and its relationship using preoperative 3D simulation enable to safelyperform PD, even in young surgeons (operative time; young 512±49 vs. senior445±41 min, p<0.01), (blood loss; young 353±203 vs. senior 246±109 ml,p=0.16).Conclusion: Those refinements and advances are possible to safely and easilyperform pancreatoduodenectomy.

INTRODUCTION: Recent technical innovation in liver surgery is remarkable. Now, for example, a preoperative 3D-simulation of the liver is a routine modality, and indispensable (or essential) for liver surgery. The aim of this presentation is to clarify various kinds of progresses and future perspective in liver surgery. PREOPERATIVE MODALITIES 1) One-stop shopping of 3D-simulation of the liver: We newly developed 3D-simulation using a software of SYNAPSE VINCENT Ver. 3.1 (Fujifilm Medical, Tokyo, Japan), in which biliary system is simultaneously reconstructed in one dynamic MD-CT. This technique avoids position error which occurred in 3D fusion image using another modality such as DIC–CT or MRCP, as well as unnecessary radiation exposure. 2) Assessment of partial functional reserve: We have reported new methods to astimate regional hepatic functional reserve using hepatocyte-phase of EOB-MRI (J Gastroenterol 2012), and fusion image of 3D-CT and asialoscintigraphy using 99m-Tc galactosyl human albumin. The method of EOB-MRI utilized character of hepatocyte-uptake of EOB through membrane transporters on hepatocytes. The other used fusion of both asialoscintigram of hepatic functional reserve and 3D-simulation by the above-mentioned software. Those techniques provided accurate estimation of partial functional volume, and help surgeons’ decision making of resection volume. INTRAOPERATIVE MODALITIES: 1) Navigation using iPad: navigation using iPad in which preoperative 3D-image data are uploaded in advance, tumor location, accurate and anatomical orientation can confirm in the operative field during operation. This technique enable not only operators also assistants or students to better understand precise anatomy. 2) Indocyanine green (ICG) fluorescent image-guided navigation: this technique using HyperEye Medical System (MIZUHO IKAKOGYO Co., Ltd. Tokyo, Japan) help us to confirm tattooing of target segment and parenchymal intersegmental plane, and detect hepatic tumors (metastatic and HCC) near liver surface as well as invisible tumor inside the liver. CONCLUSIONS: Various advancements such as preoperative 3D-simulation including partial functional reserve estimation and intraoperative navigation techniques enabled surgeons to easily and safely perform hepatic resection.

Background: The glissonean pedicle approach was introduced by Couinaud and Takasaki in the early 1980s. The key of the glissonean pedicle approach is clamping the pedicle first, secondly confirming the territory, and finally dissecting the liver parenchyma. In this presentation, we introduced our recent refinements of glissonean pedicle approach for liver resection. “Approach to the glissonean pedicles at the hepatic hilus” Couinaud described three approaches to the hepatic hilus. 1) Intra-fascial access (Control method): The conventional dissection at the hilus or within the sheath is referred to as intrafascial access However, dissection performed under the hilar plate is dangerous and surgeons have to consider any variations of the hepatic artery and bile ducts. 2) Extra-fascial access (Glissonean pedicle approach): The glissonean pedicle is dissected from the liver parenchyma at the hepatic hilus before dissecting the liver parenchyma. This procedure prevents intrahepatic metastasis of HCC, which spreads along the portal vein and improves the overall survival after surgery. 3) Extra-fascial and transfissural access: If the main portal fissure or the left suprahepatic fissure is opened after dissecting the liver parenchyma, the surgeon can confirm the pedicles that arise from the hilar plate or the umbilical plate. “Operative techniques” 1) Preoperative 3D simulation of the precise anatomy of portal vein, hepatic artery and bile duct at hepatic hilus should be performed. 2) Right glissonean pedicle: The hilar plate is detached from the quadrate lobe. The assistant pulls the liver parenchyma cranially and the operator conversely pulls the hepatoduodenal ligament caudally. Mayo scissors are inserted along the liver parenchyma between the liver parenchyma and glissonean capsule (Fig.1). Then forceps are inserted in the same way and the right main pedicle is taped (Fig.2). The right anterior and posterior glissonean pedicles are taped as well. 3) Left glissonean pedicle: The hilar plate is detached from the liver parenchyma. Then, the Arantius duct is confirmed and the left pedicle is dissected along the left pedicle at the ventral side of the Arantius duct. “Pitfall of glissonean pedicle approach” The right pedicle should be dissected in the liver side as much as possible to prevent the injury of left hepatic duct. If possible, the right pedicle is recommended to be dissected at the level of the second branches separately (Fig.3). The right posterior hepatic duct sometimes branches from the left hepatic duct and the Arantius duct is confirmed and the left pedicle should be dissected along the left pedicle at the ventral side of the Arantius duct because the right posterior hepatic duct branches from the left hepatic duct at the dorsal side of Arantius’ duct. In addition, the intraoperative cholangiogram should be used in the case with the abnormal anatomy of bile duct. Conclusions: Any anatomical hepatectomy can be performed using “glissonean pedicle approach” which allows simple, safe and easy liver resection.