The impact of Model for End-Stage Liver Disease score on deceased donor liver transplant outcomes in low volume liver transplantation center: a retrospective and singlecenter study

Purpose@#In June 2016, the Model for End-Stage Liver Disease (MELD) score was employed in South Korea instead of the Child-Turcotte-Pugh (CTP) score. This study compared the outcomes of deceased donor liver transplantation (DDLT) before and after the MELD system application. @*Methods@#This retrospective study reviewed 48 patients who underwent DDLT for end-stage liver disease at a single tertiary referral center between January 2014 and December 2018. The patients were categorized into the pre-MELD (22 patients) and post-MELD (26 patients) groups. The demographics, postoperative outcomes, and overall survival time were evaluated between the 2 groups. @*Results@#The 2 groups had no differences in age, sex, ABO type, etiology for liver transplantation, CTP-score, operation time, cold ischemic time, and amount of red blood cell transfusion, although their MELD score differed significantly (postMELD group, 36.2 ± 4.9; pre-MELD group, 27.7 ± 11.8; P < 0.001). The post-MELD group has longer intensive care unit stay (11.2 ± 9.5 days vs. 5.7 ± 4.5 days, P = 0.018) and hospital stay than the pre-MELD group (36.8 ± 26 days vs. 22.8 ± 9.3 days, P = 0.016). The 1-year survival rate was lower in the post-MELD group (61.5% vs. 86.4%, P = 0.029). @*Conclusion@#After MELD allocation, patients with high MELD scores had increased DDLT and consequently required a longer recovery time, which could negatively affect survival. According to the experience of a small-volume center, these problems were related to both severe organ shortages in South Korea and MELD allocation.

Distribution and Characteristics of Pancreatic Volume Using Computed Tomography Volumetry / 대한의료정보학회지

Objectives@#Changes in the pancreatic volume (PV) are useful as potential clinical markers for some pancreatic-related diseases. The objective of this study was to measure the volume of the pancreas using computed tomography (CT) volumetry and to evaluate the relationships between sex, age, body mass index (BMI), and sarcopenia. @*Methods@#We retrospectively analyzed the abdominal CT scans of 1,003 subjects whose ages ranged between 10 and 90 years. The pancreas was segmented manually to define the region of interest (ROI) based on CT images, and then the PVs were measured by counting the voxels in all ROIs within the pancreas boundary. Sarcopenia was identified by examination of CT images that determined the crosssectional area of the skeletal muscle around the third lumbar vertebra. @*Results@#The mean volume of the pancreas was 62.648 ± 19.094 cm3. The results indicated a negative correlation between the PV and age. There was a positive correlation between the PV and BMI for both sexes, females, and males (r = 0.343, p < 0.001; r = 0.461, p < 0.001; and r = 0.244, p < 0.001, respectively). Additionally, there was a positive correlation between the PV and sarcopenia for females (r = 0.253, p < 0.001) and males (r = 0.200, p < 0.001). @*Conclusions@#CT pancreas volumetry results may help physicians follow up or predict conditions of the pancreas after interventions for pancreatic-related disease in the future.

Effects of Preoperative Malnutrition on Postoperative Surgical Outcomes and Quality of Life of Elderly Patients with Periampullary Neoplasms: A Single-Center Prospective Cohort Study

BACKGROUND/AIMS: We investigated the effect of preoperative malnutrition on postoperative surgical outcomes in elderly patients undergoing pancreatoduodenectomy for periampullary neoplasms. METHODS: This prospective cohort study enrolled 154 patients aged ≥65 years with periampullary neoplasms. Using the Mini Nutritional Assessment tool, patients were categorized into three groups according to their preoperative nutritional status: well-nourished (13.0%), at-risk-of-malnutrition (59.7%), and malnourished (27.3%). RESULTS: Significant intergroup differences were observed in preoperative body mass index (25.6±2.4 kg/m² [well-nourished] vs 23.4±2.6 kg/m² [at-risk-of-malnutrition] vs 21.1±2.8 kg/m² [malnourished], p<0.001). The overall morbidity significantly differed between the well-nourished and malnourished groups (20% vs 50.0%, p=0.024). The rates of clinically significant postoperative pancreatic fistula were significantly different among groups (p=0.035). Univariate and multivariate analyses showed that the at-risk-of-malnutrition or malnourished status (hazard ratio [HR], 3.45; p=0.037) and intraoperative blood loss (HR, 1.01; p=0.040) significantly affected the overall postoperative morbidity in elderly patients. CONCLUSIONS: Before surgery, 87.0% of patients were classified into the at-risk-of-malnutrition or malnourished group. Compared with well-nourished patients, patients with nutritional issues showed a higher overall surgical morbidity. Improved preoperative nutritional status leads to favorable surgical outcomes in elderly patients.

Clinical significance and characteristics of left-sided gallbladder: case series study of 10 patients

PURPOSE: The aims of this case series study were to review the 10 patients who were diagnosed with left-sided gallbladder and analyze their anatomic variations in the bile duct, portal vein, and hepatic vessels. METHODS: In this case series study, 10 patients with left-sided gallbladder were retrospectively analyzed at 2 tertiary referral centers between April 2004 and May 2019. RESULTS: Mean age was 61.1 years; there were 7 women and 3 men. Ten patients underwent laparoscopic cholecystectomy for acute cholecystitis or symptomatic gallbladder stone. The mean operation time was 77.2 minutes. Three ports were used in laparoscopic cholecystectomy procedures. The mean postoperative hospital stay was 3.5 days, and there were no cases of surgery-related morbidity. Two patients had type 1 bile duct and 3 had type 3 bile duct (2 type 3B and 1 type 3A). The right posterior portal vein as the first branch of the main portal vein was observed in all patients. Segment IV branches of the left portal vein crossing over to the segment VIII territory were observed in 7 of the 10 patients. CONCLUSION: Although left-sided gallbladder is a very rare disease, it is possible to diagnose it preoperatively and perform laparoscopic cholecystectomy safely by adjusting port position. The common important features of left-sided gallbladder include distribution of the left portal vein crossing over to the right side of the liver and increased size of the left portal vein. These variations may have important clinical implications in the management of hepatic resection including donor hepatectomy.

Comparison of Single-Incision Robotic Cholecystectomy, Single-Incision Laparoscopic Cholecystectomy and 3-Port Laparoscopic Cholecystectomy - Postoperative Pain, Cosmetic Outcome and Surgeon's Workload

PURPOSE: Robotic-associated minimally invasive surgery is a novel method for overcoming some limitations of laparoscopic surgery. This study aimed to evaluate the outcomes (postoperative pain, cosmesis, surgeon's workload) of single-incision robotic cholecystectomy (SIRC) vs. single-incision laparoscopic cholecystectomy (SILC) vs. conventional three-port laparoscopic cholecystectomy (3PLC). METHODS: 134 patients who underwent laparoscopic or robotic cholecystectomy at a single center during 2016~2017 were enrolled. Prospectively collected data included demographics, operative outcomes, questionnaire regarding pain and cosmesis, and NASA-Task Load Index (NASA-TLX) scores for surgeon's workload. RESULTS: 55 patients underwent SIRC, 29 SILC, and 50 3PLC during the same period. 3PLC patient group was older than the others (SIRC vs. SILC vs. 3PLC: 48.1 vs. 42.2 vs. 54.1 years, p < 0.001). Operative time was shortest with 3PLC (44.1 vs. 38.8 vs. 25.4 min, p < 0.001). Estimated blood loss, postoperative complications, and postoperative stay were similar among the groups. Pain control was lowest in the 3PLC group (98.2% vs. 100% vs. 84.0%, p=0.004), however, at 2 weeks postoperatively there were no differences among the groups (p=0.374). Cosmesis scores were also worst after 3PLC (17.5 vs. 18.4 vs. 13.3, p < 0.001). NASA-TLX score was highest in the SILC group (21.9 vs. 44.3 vs. 25.2, p < 0.001). CONCLUSION: Although SIRC and SILC take longer than 3PLC, they produce superior cosmetic outcomes. Compared with SILC, SIRC is more ergonomic, lowering the surgeon's workload. Despite of higher cost, SIRC could be an alternative for treating gallbladder disease in selected patients.

Effect of Hand-free “Chin Tuck against Resistance (CTAR)” Exercise on Hyoid Bone Movement and the Degree of Aspiration in Stroke Patients with Dysphagia: A Report of 2 Cases / 대한연하장애학회지

This study recruited two men with dysphagia after stroke, aged 57 and 62 years. They had difficulty using both hands properly due to paralysis of the left upper extremity and rheumatoid arthritis of the right hand in patient 1 and paralysis of both upper extremities in patient 2. This study examined the effects of 4 weeks of hand-free chin-tuck-resistance exercise on the hyoid movement and aspiration. The exercises involved isotonic and isometric parts. In isometric CTAR, the patients were asked to chin tuck against the device 3 times for 60 s each with no repetition. In isotonic CTAR, the patient performed 30 consecutive repetitions by strongly pressing against the resistance device and then releasing it. Based on a video fluoroscopic swallowing study, the degree of aspiration was measured using the Penetration-Aspiration Scale (PAS) and two-dimensional motion analysis of the hyoid bone. Post-intervention, the hyoid movements in both patients improved by 0.16 and 0.22 cm (anterior movement), and 0.26 and 0.28 cm (superior movement), and the PAS scores decreased by 2 and 2 points, respectively. This study confirms that hands-free chin-tuck resistance exercise is applicable and helpful for improving the hyoid movement and reducing aspiration in patients with dysphagia after stroke. Therefore, this exercise can be introduced as an intervention for improving the swallowing function in patients with dysphagia who have difficulty using both hands.

Survival outcome and prognostic factors of neoadjuvant treatment followed by resection for borderline resectable pancreatic cancer

PURPOSE: Neoadjuvant treatment may provide improved survival outcomes for patients with borderline resectable pancreatic cancer (BRPC). The purpose of this study is to evaluate the clinical outcomes of neoadjuvant treatment and to identify prognostic factors. METHODS: Forty patients who met the National Comprehensive Cancer Network definition of BRPC and received neoadjuvant treatment followed by surgery between 2007 and 2015 were evaluated. Prospectively collected clinicopathological outcomes were analyzed retrospectively. RESULTS: The mean age was 61.7 years and the male-to-female ratio was 1.8:1. Twenty-six, 3, and 11 patients received gemcitabine-based chemotherapy, 5-fluorouracil, and FOLFIRINOX, respectively. The 2-year survival rate (2YSR) was 36.6% and the median overall survival (OS) was 20 months. Of the 40 patients, 34 patients underwent resection and the 2YSR was 41.2% while the 2YSR of patients who did not undergo resection was 16.7% (P = 0.011). The 2YSR was significantly higher in patients who had partial response compared to stable disease (60.6% vs. 24.3%, P = 0.038), in patients who did than did not show a CA 19-9 response after neoadjuvant treatment (40.5% vs. 0%, P = 0.039) and in patients who did than did not receive radiotherapy (50.8% vs. 25.3%, P = 0.036). Five patients had local recurrence and 17 patients had systemic recurrence with a median disease specific survival of 15 months. CONCLUSION: Neoadjuvant treatment followed by resection is effective for BRPC. Pancreatectomy and neoadjuvant treatment response may affect survival. Effective systemic therapy is needed to improve long-term survival since systemic metastasis accounts for a high proportion of recurrence.

Initiating Liver Transplantation at a Public Hospital in Korea / 대한이식학회지

BACKGROUND: Although there more than 1,000 liver transplantations (LTs) are performed in Korea annually, their immense cost remains a great hurdle. Hence, in an attempt to reduce the medical costs of LT, a program was initiated at a public hospital affiliated with the Seoul National University Hospital. METHODS: A total of 11 LTs have been successfully executed since the first LT performed at Seoul Metropolitan Government Seoul National University Boramae Medical Center in July 2011 through December 2014. RESULTS: Nine patients (81.8%) were male and two (18.2%) were female. The mean age of patients was 53.4±11.4 years. Hepatitis B virus-related liver disease (n=6, 54.5%) was the most common causative disease, followed by alcoholic liver disease (ALD) (n=4,36.4%). The actuarial 3-year survival rate was 90.9%. The median total medical cost of LTs was US $41,583 (calculated from operation to discharge), but only $11,860 was actually charged for patients with health insurance coverage. One female patient who had undergone deceased donor LT for alcoholic liver cirrhosis died during follow-up. This patient was non-compliant with the medical instructions after discharge, and finally expired due to septic shock at 10 months post-LT. CONCLUSIONS: In the public hospital, LT was successfully performed at a much lower cost. However, LT guidelines and peritransplant management protocols for patients with ALD must be established before escalating LT at public hospitals since ALD with poor compliance is one of the most common causes of complications at public hospitals.

Prevalence and characteristics of clinically significant retained common bile duct stones after laparoscopic cholecystectomy for symptomatic cholelithiasis

PURPOSE: To investigate the prevalence and clinical features of retained symptomatic common bile duct (CBD) stone detected after laparoscopic cholecystectomy (LC) in patients without preoperative evidence of CBD or intrahepatic duct stones. METHODS: Of 2,111 patients who underwent cholecystectomy between September 2007 and December 2014 at Seoul Metropolitan Government-Seoul National University Boramae Medical Center, 1,467 underwent laparoscopic cholecystectomy for symptomatic gallbladder stones and their medical records were analyzed. We reviewed the clinical data of patients who underwent postoperative endoscopic retrograde cholangiopancreatography (ERCP) for clinically significant CBD stones (i.e., symptomatic stones requiring therapeutic intervention). RESULTS: Overall, 27 of 1,467 patients (1.84%) underwent postoperative ERCP after LC because of clinical evidence of retained CBD stones. The median time from LC to ERCP was 152 days (range, 60–1,015 days). Nine patients had ERCP-related complications. The median hospital stay for ERCP was 6 days. CONCLUSION: The prevalence of clinically significant retained CBD stone after LC for symptomatic cholelithiasis was 1.84% and the time from LC to clinical presentation ranged from 2 months to 2 years 9 months. Therefore, biliary surgeons should inform patients that retained CBD stone may be detected several years after LC for simple gallbladder stones.

Metastatic mucinous adenocarcinoma of the distal common bile duct, from transverse colon cancer presenting as obstructive jaundice

The patient was a 70-year-old male whose chief complaints were obstructive jaundice and weight loss. Abdominal imaging studies showed a 2.5 cm sized mass at the distal common bile duct, which was suggestive of bile duct cancer. Eccentric enhancing wall thickening in the transverse colon was also shown, suggesting concomitant colon cancer. A colonoscopy revealed a lumen-encircling ulcerofungating mass in the transverse colon, that was pathologically proven to be adenocarcinoma. The bile duct pathology was also adenocarcinoma. Pylorus-preserving pancreaticoduodenectomy and extended right hemicolectomy were performed under the diagnosis of double primary cancers. Postoperative histopathologic examination revealed moderately differentiated mucinous adenocarcinoma of transverse colon cancer, and mucinous adenocarcinoma of the distal common bile duct. Immunohistochemical staining studies showed that the bile duct cancer had metastasized from the colon cancer. The patient recovered uneventfully from surgery and will be undergoing chemotherapy for three months.

Laparoscopic treatment of hepatic cysts located in the posterosuperior segments of the liver

PURPOSE: Laparoscopy is considered the treatment of choice for hepatic cysts, especially those located in anterolateral segments (AL; segments II, III, IVb, V, and VI) because of the ease of laparoscopic access. Here, we evaluated the feasibility and safety of laparoscopic treatment of hepatic cysts in posterosuperior segments (PS; segments I, IVa, VII, and VIII). METHODS: We retrospectively analyzed clinical data for 34 patients who underwent laparoscopic treatment of hepatic cysts between September 2004 and December 2012. Patients were divided into two groups depending on whether the main largest cyst was located in AL (n = 20) or PS (n = 14). Laparoscopic cyst unroofing was performed in 29 patients with symptomatic simple cysts. Laparoscopic resection was performed in 5 patients with suspected cystic neoplasms. RESULTS: There were no deaths or major complications. The mean operation time was 110 minutes and the mean hospital stay was 4.4 days. The mean cyst size was not significantly different (P = 0.511) but the frequency of multiple cysts was significantly greater in group PS (P = 0.003). The predominant type of resection was unroofing in both groups (P = 0.251). The mean blood loss (P = 0.747), mean hospital stay (P = 0.812), mean operation time (P = 0.669), morbidity rate (P = 0.488), and relapse rate (P = 0.448) were not significantly different. Relapse occurred in one patient who underwent reunroofing 17 months later. The median follow-up is 62 months. CONCLUSION: Laparoscopy is a safe procedure for hepatic cysts located in posterosuperior segments.