2014–2017 Nationwide Bariatric and Metabolic Surgery Report in Korea

PURPOSE: The information committee of the Korean Society for Metabolic and Bariatric Surgery (KSMBS) performed the nationwide survey of bariatric and metabolic operations to report IFSO (International Federation for the Surgery of Obesity and Metabolic Disorders) worldwide survey annually. This study aimed to report the trends of bariatric and metabolic surgery in Korea in 2014–2017. MATERIALS AND METHODS: We analyzed the accumulated nationwide survey data conducted for annual ISFO survey from 2014 to 2017. Trends such as the number of operations by hospital type and the number of operations by surgical method were analyzed. RESULTS: The number of operations has decreased sharply in 2015 comparing to 2014 (913⇒550). The number of operations performed in private hospitals dropped sharply from 529 to 250, 198, and 103 cases. The number of revisional surgeries increased to 223 in 2015. The primary surgery number fell from 757 in 2014 to 327 in 2015. In primary surgery, sleeve gastrectomy was gradually increased from 2014 to 143 (18.9%), 105 (32.1%), 167 (47.2%) and 200 (56.3%) and became the most frequently performed surgery. On the other hand, the incidence of adjustable gastric band decreased gradually from 439 (58.0%) to 117 (35.8%), 112 (31.6%) and 59 (16.6%). CONCLUSION: The overall number of obesity metabolic operations has decreased since 2014, especially the number of adjustable gastric band, and the number of operations in private hospitals declined sharply. On the other hand, the number of operations in university hospitals did not change much, and the number of sleeve gastrectomy increased.

Clinical Analysis of Recurrent Inguinal Hernias

PURPOSE: Recurrent inguinal hernia repairs provide a considerable technical challenge and greater risk of further recurrence. The purpose of this study was to establish a preventive method and management plan for recurrent inguinal hernia. METHODS: The medical records of adult having undergone an inguinal hernia operation at the Dankook university hospital, between June 1994 and December 2004, were analyzed. The patients' characteristics, types of hernia and operation methods were recorded. In the recurrent cases, the numbers and names of previous operation, types of recurrent hernia, and times to reoperation were analyzed. RESULTS: Of the 470 inguinal hernia cases, 35 were operated on for a recurrent hernia. With the recurrent hernias, the operation times were longer and the use of general anesthesia was more frequent. Of the recurrent hernia types, direct hernias were the most frequent. More than half the recurrent hernias were operated on 5 years after the primary hernia repairs. The recurrent hernia was treated with or without a mesh in 33 (94.3%) and 2 cases (5.7%), respectively. In the previous operations, mesh had or had not been used in 30 (85.7%) and 5 cases (14.3%), respectively. CONCLUSION: In the recurrent hernia group, the most frequent type of previous repair was an operation without a mesh. A direct hernia was the most frequent type of recurrence. The recurrent hernias were mostly repaired using a mesh.

Actual Long-term Outcome of Klatskin's Tumor after Surgical Resection

PURPOSE: To analyze the actual long-term outcomes of Klatskin's tumors after surgical resection and identify the factors affecting the long-term survival. METHODS: We reviewed the medical records of 145 Klatskin's tumor cases, who underwent an operation between 1991 and 1999, and analyzed the actual outcomes and prognostic factors. The mean age of the subjects was 55, with a male to female ratio of 2.8: 1. Seventy-six patients underwent resection with curative intent (resection rate 52.4%), including hilar resection (n=23), extended right hepatectomy (n=25), extended left hepatectomy (n=26) and hepatopancreatoduodenectomy (n=4). The operative mortality was 2.6%. The resection margin involvement rate was 21%. We also compared the clinicopathological characteristics between the long- term and short-term survivors. RESULTS: Twenty-one patients survived more than 5 years, with an actual 5-year survival rate of 28%. Among the survivors, 4 had a recurrent disease at 5 years and 3 developed a recurrence after 5 years. Some patients with well-known poor prognostic factors, such as lymph node metastasis and resection margin involvement, survived longer than 5 years. Lymph node metastasis was identified as a significant prognostic factor in a multivariate analysis. The long-term survivors had favorable T and N stages compared with the short-term survivors. CONCLUSION: The actual 5-year survival rate was 28%. Lymph node metastasis was found to be a significant prognostic factor. Long-term follow up is mandatory, as recurrences occurred later than 5 years after surgery. Aggressive surgical resection should be attempted to gain a chance for survival, even in patients with poor prognostic factors.

Determination of Resectability for Pancreatic Head Cancer: Based on the Suspected Vascular Invasion in Abdominal Computed Tomography

PURPOSE: To determine the resectability of pancreatic head cancer by correlating the surgical findings with those of a suspected vascular invasion by abdominal computed tomography (CT). METHODS: The portal vein, superior mesenteric vein, celiac artery, common hepatic artery and superior mesenteric artery were investigated in 100 pancreatic cancer patients who underwent two-phase CT of the pancreas. The degree of vascular encasement, luminal narrowing and the length of the involved segment were analyzed in order to correlate the surgical results. The CT findings and associated unresectable causes were analyzed in those patients who underwent the non-operative treatment. RESULTS: A surgical correlation was available in 66 patients, whose 116 vessels were examined. Vascular encasement was categorized into 5 groups (0: none, 1: < or =90 degree, 2: 91~180 degree, 3: 181~270 degree, 4: 271~360 degree). If category 0, 1 and 2 was determined to be vascular invasion (-), the positive predictive value and negative predictive value were 91.7% and 80% in the veins, and 100% and 75.4% in the arteries. If category 0, 1, 2 and 3 in the vein were determined to be vascular invasion (-), the respective values were 100% and 75.4%. While all the arteries with narrowing were unresectable, some veins with narrowing less than 2/3 of the diameter were resectable. The mean length of the segment involved in the resectable veins was significantly shorter than that of the unresectable veins. CONCLUSION: A non-operative treatment is recommended when vascular encasement exceeds 270degree in the veins or 180 degree in the arteries, when the arteries show narrowing, or when the veins show narrowing more than 2/3 of the original diameter. A curative resection should be attempted when the vascular encasement reaches < 180degree and when the arterial narrowing is absent.

Clinical Application of FDG-PET in Biliary- pancreatic Malignancy

PURPOSE: This study was done to review our clinical experience of fluorodeoxyglucose (FDG)-positron emission tomography (PET) in biliary-pancreatic malignancies, and evaluated its diagnostic accuracy and usefulness. METHODS: FDG-PET was performed in 15 patients with biliary-pancreatic malignancies, to determine the extent of the disease (n=9) and to detect the recurrence (n=6). RESULTS: Of the 9 patients with a suspected loco-regional spread, 6 patients were disclosed by FDG-PET as having multiple metastasis to the regional lymph nodes and extraperitoneal organs, but the other 3 showed no evidence of regional or distant metastasis. Thus, FDG-PET performed preoperatively to estimate the extent of the disease, showed sensitivity and specificity of 100%, respectively. However, for the detection of a recurrent disease only 3 out of 5 with recurrent diseases were detected by FDG-PET (sensitivity: 60%). FDG-PET revealed one suspected recurrent lesion, but a computed tomography (CT) scan showed no evidence of a recurrence. Due to the 2 false-negative results, the overall sensitivity and specificity of this study were 81.8 (9/11) and 100% (4/4), respectively. CONCLUSION: Unnecessary surgical procedures were avoided in 6 cases, and 3 curative surgeries aborted through the use of FDG-PET. Despite the lack of cases, FDG-PET was useful in estimating the extent of a disease, but was unsatisfactory in detecting a recurrent disease compared to CT. Coupled with conventional imaging, FDG-PET may also provide more helpful information for biliary-pancreatic malignancies as well.

Mutations of DPC4/Smad4 Gene in Gallbladder Carcinoma

PURPOSE: The DPC4/Smad4 gene is known to perform a key role in the TGF-beta group protein signaling pathway, which regulates cell proliferation, differentiation and death. DPC4/ Smad4 gene mutation has been studied in cancers of the breast, ovary, esophagus, colo-rectum, bile duct, as well as the pancreas. The mutation rates depend on the kind of carcinoma sites, and range from 10% to around 50%, but no study has been performed on gallbladder carcinomas. This study was performed to search for mutation of the DPC4/Smad4 gene in the gallbladder carcinomas. METHODS: Eighteen surgically resected gallbladder cancers were screened for mutation of the exons; 8, 9, 10 and 11 of the DPC4/Smad4 gene using dideoxyfingerprinting (ddF), and single strand conformational polymorphism (SSCP). The results were confirmed using automatic DNA sequencing, and the expressions examined by immunohistochemical staining with the monoclonal anti-DPC4/Smad4 protein antibody, B8. RESULTS: DdF revealed 3 mutations in two of the exons, which were confirmed by direct sequencing. In one case, a single-base substitution mutation existed in exon 11 with codon change (missense mutation), whereas in two cases such mutations were detected in exon 9 without codon change (silent mutation). Immunohistochemical staining showed negative to weakly positive expression for all three mutated cases, but had high false-positive rates (7/11). CONCLUSION: DPC4/Smad4 gene mutation exists in a certain proportion of gallbladder carcinomas, but the mutation rate seems to be low compared to organogenetically related pancreas or bile duct carcinomas. This suggests somewhat different mechanisms may operate on the carcinogenesis of these organs.

Hemorrhage Following Pancreatoduodenectomy

PURPOSE: Hemorrhage following pancreatoduodenectomy is a severe, life-threatening complication. This study was conducted to suggest methods of the prevention and management of hemorrhagic complications. METHODS: We reviewed medical records of 456 patients who had undergone pancreatoduodenectomy at Seoul National University Hospital between January 1991 and December 2000. RESULTS: Postoperative bleeding occurred in 21 patients. Early hemorrhage within the postoperative 5th day amounted 5 cases, which were caused by improper intra-operative hemostasis. Three of these patients were saved by prompt surgery and, in one patient, conservative management. Late hemorrhage after the postoperative 5th day included 16 cases, of which 12 patients (75%) were associated with pancreas anastomotic leaks and 8 patients displayed pseudoaneurysm. "Sentinel bleeding" was evident in 8 cases. Angiographic embolization was performed in 8 cases, achieving hemostasis in 7 cases. Reoperations were attempted in 7 cases with complete hemostasis in 2 cases. As a result, 15 of 21 patients obtained complete hemostasis and mortality rate from postoperative hemorrhage was 28.6% (6/21). CONCLUSION: Successful hemostasis was achieved by surgery in case of early hemorrhage and by angiographic embolization in late hemorrhage. In order to prevent hemorrhage following pancreatoduodenectomy, meticulous hemostasis and considerate operative techniques for avoiding pancreatic anastomotic leaks or vascular injury are essential.

Analysis of Long-term Survivors after Pancreatoduodenectomy in the Patients with Pancreatic Cancer

PURPOSE: Pancreatic ductal adenocarcinoma is known to be very dismal. Although some publications reported marked improved survival data after surgical resection recently, many clinicians have pessimistic views on the treatment of pancreatic cancer. So we set the objectives of this study to evaluate the clinical results of pancreatoduodenectomy in pancreatic cancer and investigate what constitutes long term survival after pancreatoduodenectomy for pancreatic cancer. METHODS: We analyzed 286 patients with pancreatic head ductal adenocarcinoma hospitalized in Seoul National University Hospital between 1985 and 1995, retrospectively. We excluded the patients with cystic pancreatic tumor and solid pseudo-papillary tumor in this study. Of them, 67 patients received pancreatoduodenectomy. We re-reviewed the histologic specimens of resected cases and tried to find clinico- pathological features in long-term survivors after pancreatoduodenectomy. RESULTS: Median survival of total patients with pancreatic head cancer was 8 months. Significant survival difference could be found between resected cases (15 months) and non-resected cases (6 months) (p<0.001). Of the patients who underwent pancreatoduodenectomy, there were nine patients who survived more than three years. In the patients who underwent pancreatoduodenectomy, depth of invasion, lymph node metastasis, UICC stage, CEA level, adjuvant chemotherapy were the prognostic factors. After histologic re-review in the long-term survivors, there were only 4 typical ductal adenocarcinoma, and 2 cases of variant ductal adenocarcinoma (mucinous noncystic adenocarcinoma, undifferentiated adenocarcinoma), the others were re-diagnosed with bile duct cancer, papillary mucinous carcinoma, and pancreatoblastoma. When we excluded the patients with non ductal adenocarcinoma according to the pathologic review, the median survival of the patients with pancreatoduodenectomy (n=64) decreased (14 months). CONCLUSION: Only the 2% of all the pancreatic cancer and 11% of the resected cases could be considered as 'cure'. In the long-term survivors, there were various types of pathology associated with good prognosis, so typical ductal adenocarcinoma of pancreas would have poorer prognosis than expected. Careful pathologic review must be preceded in the analyzing the survival data.

Clinical Usefulness of Percutaneous Choledochoscopy in Biliary Tract Diseases

PURPOSE: This study was conducted to evaluate the clinical significance of choledochoscopy in biliary tract diseases. METHODS: We conducted a retrospective study of 291 patients who received choledochoscopy from October 1993 to December 1999. The indications of choledochoscopy were 259 cases of bile duct stones and 32 cases of benign and malignant biliary diseases: Klatskin tumor (n=10), intrahepatic cholangiocarcinoma (n=8), common bile duct cancer (n=6), hepatocellular carcinoma with bile duct invasion (n=2), and benign biliary stricture (n=6). The purpose of the choledochoscopy was 1) removal of bile duct stones, 2) differentiation between benign and malignant biliary diseases and 3) preoperative assessment of the extent and resectability of bile duct carcinoma. RESULTS: The success rate of complete stone removal was 80.1%, and the rate of recurrent biliary stones after a mean follow-up period of 24 months was 13.1%. The most common cause of a failure to remove the stones was biliary stricture. Differentiating between benign and malignant lesions, and the preoperative assessment of the extent and resectability of a bile duct carcinoma were accomplished by choledochoscopic observation followed by biopsy. The sensitivity in the diagnosis of malignant biliary diseases was 87%. The morbidity and mortality rates of choledochoscopy were 3.4% and 0%, respectively. With the exception of bile peritonitis due to tract rupture, any complications, such as cholangitis, bleeding, and pain, were conservatively managed. CONCLUSION: Our experience shows that choledochoscopyhas an important role in the diagnosis and therapy for benign and malignant biliary diseases and can be applied if indicated.