Incidence of bactibilia and related factors in patients who undergo cholecystectomy

Purpose@#In general, bile is normally sterile. However, there are reports bactibilia may occur in certain instances, though the causal factors are unclear. We analyzed possible preoperative predictors of bactibilia upon cholecystectomy. @*Methods@#Bile samples were collected during cholecystectomies from November 2018 to November 2019. A total of 428 open or laparoscopic cholecystectomies were performed. Preoperative, intraoperative, and postoperative variables were compared between the culture-positive and culture-negative groups. @*Results@#One hundred fifty-seven patients (36.7%) were culture-positive. Gram-negative bacteria (95 [61.0%]) were more common. Escherichia coli (38 [40.0%]) and Enterobacter (22 [23.2%]) were the most common species. In univariate analysis, age of ≥70 years (P < 0.001), male sex (P < 0.001), high American Society of Anesthesiologists physical status grades (P = 0.001), diabetes mellitus (P = 0.002), jaundice (P = 0.007), high Tokyo Guideline grades (P = 0.008), percutaneous transhepatic gallbladder drainage (PTGBD; P < 0.001), endoscopic retrograde cholangiopancreatography (ERCP; P < 0.001) were identified as a risk factors for bactibilia. In multivariate analysis, age of ≥70 years (hazard ratio [HR], 2.874; 95% confidence interval [CI], 1.769–4.670; P = 0.001), ERCP (HR, 9.001; 95% CI, 4.833–16.75; P < 0.001), and PTGBD (HR, 2.866; 95% CI, 1.440–4.901; P = 0.002) were independent risk factors for bactibilia. @*Conclusion@#Among patients who underwent cholecystectomy, those who were elderly, symptomatic, and underwent preoperative drainage were more likely to have bactibilia. In such cases, surgeons should take care to prevent bile leakage during surgery and consider administering appropriate antibiotics.

Comparison between percutaneous transhepatic gallbladder drainage and upfront laparoscopic cholecystectomy in patients with moderate-to-severe acute cholecystitis: a propensity score-matched analysis

Purpose@#In the Tokyo Guidelines 2018 (TG18), emergency laparoscopic cholecystectomy is recognized as a crucial early treatment option for acute cholecystitis. However, early laparoscopic intervention in patients with moderate-to-severe acute cholecystitis or those with severe comorbidities may increase the risk of complications. Therefore, in the present study, we investigated the association between early laparoscopic cholecystectomy and percutaneous transhepatic gallbladder drainage (PTGBD) in moderate-to-severe acute cholecystitis patients. @*Methods@#We retrospectively analyzed 835 TG18 grade II or III acute cholecystitis patients who underwent laparoscopic cholecystectomy at 4 tertiary medical centers in the Republic of Korea. Patients were classified into 2 groups according to whether PTGBD was performed before surgery, and their short-term postoperative outcomes were analyzed retrospectively. @*Results@#The patients were divided into 2 groups, and 1:1 propensity score matching was conducted to establish the PTGBD group (n = 201) and the early laparoscopic cholecystectomy group (n = 201). The PTGBD group experienced significantly higher rates of preoperative systemic inflammatory response syndrome (24.9% vs. 6.5%, P < 0.001), pneumonia (7.5% vs.3.0%, P = 0.045), and cardiac disease (67.2% vs. 57.7%, P = 0.041) than the early operation group. However, there was no difference in biliary complication (hazard ratio, 1.103; 95% confidence interval, 0.519–2.343; P = 0.799) between the PTGBD group and early laparoscopic cholecystectomy group. @*Conclusion@#In most cases of moderate-to-severe cholecystitis, early laparoscopic cholecystectomy was relatively feasible.However, PTGBD should be considered if patients have the risk factor of underlying disease when experiencing general anesthesia.

External validation of risk prediction platforms for pancreatic fistula after pancreatoduodenectomy using nomograms and artificial intelligence

Purpose@#Postoperative pancreatic fistula (POPF) is a life-threatening complication following pancreatoduodenectomy (PD).We previously developed nomogram- and artificial intelligence (AI)-based risk prediction platforms for POPF after PD. This study aims to externally validate these platforms. @*Methods@#Between January 2007 and December 2016, a total of 1,576 patients who underwent PD in Seoul National University Hospital, Ilsan Paik Hospital, and Boramae Medical Center were retrospectively reviewed. The individual risk scores for POPF were calculated using each platform by Samsung Medical Center. The predictive ability was evaluated using a receiver operating characteristic curve and the area under the curve (AUC). The optimal predictive value was obtained via backward elimination in accordance with the results from the AI development process. @*Results@#The AUC of the nomogram after external validation was 0.679 (P < 0.001). The values of AUC after backward elimination in the AI model varied from 0.585 to 0.672. A total of 13 risk factors represented the maximal AUC of 0.672 (P < 0.001). @*Conclusion@#We performed external validation of previously developed platforms for predicting POPF. Further research is needed to investigate other potential risk factors and thereby improve the predictability of the platform.

Development and External Validation of Survival Prediction Model for Pancreatic Cancer Using Two Nationwide Databases: Surveillance, Epidemiology and End Results (SEER) and Korea Tumor Registry System-Biliary Pancreas (KOTUS-BP)

Background/Aims@#Several prediction models for evaluating the prognosis of nonmetastatic resected pancreatic ductal adenocarcinoma (PDAC) have been developed, and their performances were reported to be superior to that of the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. We developed a prediction model to evaluate the prognosis of resected PDAC and externally validated it with data from a nationwide Korean database. @*Methods@#Data from the Surveillance, Epidemiology and End Results (SEER) database were utilized for model development, and data from the Korea Tumor Registry System-Biliary Pancreas (KOTUS-BP) database were used for external validation. Potential candidate variables for model development were age, sex, histologic differentiation, tumor location, adjuvant chemotherapy, and the AJCC 8th staging system T and N stages. For external validation, the concordance index (C-index) and time-dependent area under the receiver operating characteristic curve (AUC) were evaluated. @*Results@#Between 2004 and 2016, data from 9,624 patients were utilized for model development, and data from 3,282 patients were used for external validation. In the multivariate Cox proportional hazard model, age, sex, tumor location, T and N stages, histologic differentiation, and adjuvant chemotherapy were independent prognostic factors for resected PDAC. After an exhaustive search and 10-fold cross validation, the best model was finally developed, which included all prognostic variables. The C-index, 1-year, 2-year, 3-year, and 5-year time-dependent AUCs were 0.628, 0.650, 0.665, 0.675, and 0.686, respectively. @*Conclusions@#The survival prediction model for resected PDAC could provide quantitative survival probabilities with reliable performance. External validation studies with other nationwide databases are needed to evaluate the performance of this model.

The Implication of Cytogenetic Alterations in Pancreatic Ductal Adenocarcinoma and Intraductal Papillary Mucinous Neoplasm Identified by Fluorescence In Situ Hybridization and Their Potential Diagnostic Utility

Background/Aims@#We investigated chromosomal aberrations in patients with pancreatic ductal adenocarcinoma (PDAC) and intraductal papillary mucinous neoplasm (IPMN) by fluorescence in situ hybridization (FISH) to identify cytogenetic changes and molecular markers that may be useful for preoperative diagnosis. @*Methods@#Tissue samples from 48 PDAC and 17 IPMN patients were investigated by FISH analysis using probes targeting chromosomes 7q, 17p, 18q, 20q, and 21q and the pericentromeric region of chromosome 18 (CEP18). @*Results@#The PDAC samples harbored 17p deletion (95.8%), 18q deletion (83.3%), CEP18 deletion (81.2%), 20q gain (81.2%), 21q deletion (77.1%), and 7q gain (70.8%). The IPMN samples had 17p deletion (94.1%), CEP18 deletion (94.1%), 21q deletion (70.6%), 18q deletion (58.8%), 20q gain (58.8%), and 7q gain (58.8%). A significant difference in CEP18 gain was identified between the PDAC and IPMN groups (p=0.029). Detection of 17p or 18q deletion had the highest diagnostic accuracy (80.0%) for PDAC. @*Conclusions@#Chromosomal alterations were frequently identified in both PDAC and IPMN with similar patterns. CEP18 gain and 17p and 18q deletions might be involved in the later stages of PDAC tumorigenesis. Chromosome 17p and 18q deletions might be excellent diagnostic markers.

Risk factors of elderly patients with postoperative delirium following major abdominal surgery for cancer

Purpose@#Postoperative delirium (POD) is a common complication in elderly patients after major abdominal surgery for cancer. Although POD is related with a poor outcome, there have not been many reports about POD after abdominal surgery in Korea. The aims of study were to analyze the characteristics and surgical outcomes of elderly patients with POD and to identify the risk factors of POD. @*Methods@#From November 2016 to January 2019, we prospectively enrolled 63 patients who were aged ≥75 years and underwent major abdominal surgery for cancer. POD was daily assessed for up to 10 days postoperatively with the Confusion Assessment Method and a validated chart review. @*Results@#POD occurred in eight patients (12.7%). Univariate analysis showed that the occurrence of POD was related to sodium <135 mEq/L (P=0.037), combined resection (P=0.023), longer surgery/anesthesia time (P=0.023 and P=0.037, respectively), increased blood loss (P=0.004), postoperative admission to intensive care unit (ICU) (P=0.023), and duration of Foley catheter (P=0.011), however, multivariate analysis identified no significant risk factors of POD. There was no difference in postoperative outcomes such as hospital stay, mortality, reoperation, and morbidity between patients with POD and without POD. @*Conclusion@#Elderly patients with hyponatremia, combined resection, longer operation/anesthesia time and admission to ICU had tendencies to develop POD after major abdominal surgery. Surgeons should pay more attention to prevent POD, and a large-scale prospective study is needed to identify the risk factors of POD.

Risk factors of elderly patients with postoperative delirium following major abdominal surgery for cancer

Purpose@#Postoperative delirium (POD) is a common complication in elderly patients after major abdominal surgery for cancer. Although POD is related with a poor outcome, there have not been many reports about POD after abdominal surgery in Korea. The aims of study were to analyze the characteristics and surgical outcomes of elderly patients with POD and to identify the risk factors of POD. @*Methods@#From November 2016 to January 2019, we prospectively enrolled 63 patients who were aged ≥75 years and underwent major abdominal surgery for cancer. POD was daily assessed for up to 10 days postoperatively with the Confusion Assessment Method and a validated chart review. @*Results@#POD occurred in eight patients (12.7%). Univariate analysis showed that the occurrence of POD was related to sodium <135 mEq/L (P=0.037), combined resection (P=0.023), longer surgery/anesthesia time (P=0.023 and P=0.037, respectively), increased blood loss (P=0.004), postoperative admission to intensive care unit (ICU) (P=0.023), and duration of Foley catheter (P=0.011), however, multivariate analysis identified no significant risk factors of POD. There was no difference in postoperative outcomes such as hospital stay, mortality, reoperation, and morbidity between patients with POD and without POD. @*Conclusion@#Elderly patients with hyponatremia, combined resection, longer operation/anesthesia time and admission to ICU had tendencies to develop POD after major abdominal surgery. Surgeons should pay more attention to prevent POD, and a large-scale prospective study is needed to identify the risk factors of POD.

Incidence of gallstones after gastric resection for gastric cancer: a nationwide claims-based study

PURPOSE: Gallstone formation is one of the most common problems after gastrectomy. This retrospective cohort study used the South Korean nationwide claims database to evaluate the incidence and risk factors of gallstone after gastrectomy for gastric cancer. METHODS: All consecutive patients who underwent gastrectomy for gastric cancer in South Korea in 2008–2010 were identified. Incidence of gallstone formation 5 years after gastrectomy in males and females, in various age groups, and after different types of gastrectomy was determined. Multivariate logistic regression analysis served to identify gallstone risk factors. RESULTS: Of the 47,752 patients, 2,506 (5.2%) developed gallstone during the 5-year follow-up period. At 12, 24, 36, and 48 months, the cumulative incidences were 1.2%, 2.2%, 3.3%, and 4.3%, respectively. Males had a higher incidence than females (5.8% vs. 4.1%, P < 0.001). Older patients (60–89 years) had a higher incidence than younger patients (30–59 years) (6.1% vs. 4.3%, P < 0.001). Gallstone was most common after total gastrectomy (6.6%), followed by proximal gastrectomy (5.4%), distal gastrectomy (4.8%), and pylorus-preserving distal gastrectomy (4.0%) (P < 0.001). Multivariate analysis showed that male sex (odds ratio [OR], 1.39), an older age (OR, 1.44), and total gastrectomy (OR, 1.40 vs. distal gastrectomy) were significant independent risk factors for postgastrectomy gallstone. CONCLUSION: The cumulative incidence of gallstone 5 years after gastrectomy for gastric cancer was 5.2%. Male sex, an older age, and total gastrectomy were significant risk factors. More careful monitoring for gallstone may be necessary in patients with such risk factors.

Unexpected Appendiceal Pathologies and Their Changes With the Expanding Use of Preoperative Imaging Studies

PURPOSE: The preoperative diagnosis of acute appendicitis is often challenging. Sometimes, pathologic results of the appendix embarrass or confuse surgeons. Therefore, more and more imaging studies are being performed to increase the accuracy of appendicitis diagnoses preoperatively. However, data on the effect of this increase in preoperative imaging studies on diagnostic accuracy are limited. We performed this study to explore unexpected appendiceal pathologies and to delineate the role of preoperative imaging studies in the diagnosis of acute appendicitis. METHODS: The medical records of 4,673 patients who underwent an appendectomy for assumed appendicitis between 1997 and 2012 were reviewed retrospectively. Pathological results and preoperative imaging studies were surveyed, and the frequencies of pathological results and preoperative imaging studies were investigated. RESULTS: The overall rate of pathology compatible with acute appendicitis was 84.4%. Unexpected pathological findings, such as normal histology, specific inflammations other than acute appendicitis, neoplastic lesions, and other pathologies, comprised 9.6%, 3.3%, 1.2%, and 1.5%, respectively. The rate of unexpected pathological results was significantly reduced because of the increase in preoperative imaging studies. The decrease in normal appendices contributed the most to the reduction while other unexpected pathologies did not change significantly despite the increased use of imaging studies. This decrease in normal appendices was significant in both male and female patients under the age of 60 years, but the differences in females were more prominent. CONCLUSION: Unexpected appendiceal pathologies comprised 15.6% of the cases. Preoperative imaging studies reduced them by decreasing the negative appendectomy rate of patients with normal appendices.

Outcomes of Surgical Resection for Ruptured Hepatocellular Carcinoma

BACKGROUND/AIMS: Many recent studies have shown excellent outcomes of surgical resection for ruptured hepatocellular carcinoma (HCC). In addition, there are several reports suggesting that a ruptured HCC did not increase the risk for peritoneal dissemination of a tumor after surgical resection. However, the impact of HCC rupture on recurrence and patient survival has not yet been clarified. METHODS: The medical data of patients who underwent surgical resection for ruptured HCC in our center between January 2011 and December 2015 were retrospectively reviewed. The outcomes of the patients were investigated. RESULTS: Among 128 patients who underwent surgical resection for HCC, 5 patients (3.9%) had a ruptured HCC. All patients underwent elective operation in a stable condition. Transarterial chemoembolization (TACE) was performed for achieving hemostasis in four patients except one who achieved spontaneous hemostasis. Two patients had tumor recurrence and one patient died due to HCC recurrence during the median follow-up duration of 28.3 months (range, 24.3–62.3 months). One patient who developed late intrahepatic recurrence at 40.0 months after resection was managed well by means of radiofrequency ablation and TACE and is now alive for 5 years without any evidence of viable tumor. However, the other patient who showed early peritoneal seeding at 1.9 months after resection finally died despite aggressive treatments. CONCLUSIONS: Rupture of HCC might result in peritoneal seeding of the tumor in the early postoperative stage, which could lead to a poor result. Nonetheless, surgical resection may be the best treatment option yielding good survival, even for a ruptured HCC.

Hepatectomy, combined with intraoperative radiofrequency ablation in patients with multiple hepatocellular carcinomas

BACKGROUNDS/AIMS: We compared the efficacy and safety of a hepatectomy, combined with intraoperative radiofrequency ablation to those of wider extent hepatectomy, alone, in patients with multiple hepatocellular carcinomas (HCCs). METHODS: Between January 2004 and December 2013, 78 patients with multiple HCCs underwent surgery. 25 patients were treated by hepatectomy, combined with intraoperative radiofrequency ablation (RFA) (group A), and 53 underwent hepatectomy only (group B). We retrospectively analyzed medical records to compare the clinical features of these two groups. RESULTS: Patients in group A had more limited resections (less than 2 segments) than those in group B (p<0.001). Patients in group A also tended to have fewer red blood cell transfusions than those in group B (p=0.060). Liver function- and surgery-related complications occurred only in group B. There were no in-hospital mortalities in both groups. The overall survival and disease-free survival outcomes were not significantly different between groups A and B (p=0.177 and p=0.305, respectively). CONCLUSIONS: Hepatectomy combined with intraoperative RFA could be a safe and effective treatment option for patients with multiple HCCs, comparable to extended hepatectomy alone.

Differential Diagnosis of Colorectal Polyps with Narrow Band Imaging Colonoscopy without Magnification / 대한소화기학회지

BACKGROUND/AIMS: Narrow band imaging (NBI) endoscopy can be used for gross differentiation between the types of colonic polyps. This study was conducted as a retrospective study for estimation of the interobserver and intra-observer agreement of the pit pattern of the mucosal surface and the accuracy of histology prediction. METHODS: A total of 159 patients underwent complete colonoscopy and 219 polyps examined by NBI endoscopy without magnification were assessed. Interobserver and intra-observer agreement were calculated by investigators in each group for determination of the surface pattern and prediction of histology based on the modified Kudo's classification using intraclass correlation coefficient. RESULTS: Interobserver agreement for the surface pit pattern and prediction of polyp type was 0.84 and 0.73 in experienced endoscopists, and 0.86 and 0.62 in trainees, respectively. Intra-observer agreement for the surface pit patterns and prediction of polyp type was 0.81, 0.83, 0.85, 0.83, 0.56, 0.84, 0.51, 0.83, and 0.71; and 0.71, 0.70, 0.82, 0.54, 0.72, 0.37, 0.51, 0.34, and 0.30, respectively. The diagnostic accuracy for prediction of polyp type was 69.4% for experienced endoscopists and 72.9% for trainees. CONCLUSIONS: NBI endoscopy without magnification showed fairly good inter and intra-observer agreement for the pit pattern of the mucosal surface and the accuracy of histology prediction; however, it had some limitation for differentiation of colon polyp histologic type. Training and experience with NBI is needed for improvement of accuracy.

A Rare Case of Free Bowel Perforation Associated with Infliximab Treatment for Stricturing Crohn's Disease / 대한소화기학회지

Crohn's disease is characterized by chronic transmural inflammation of the bowel and is associated with serious complications, such as bowel strictures, abscesses, fistula formation, and perforation. As neither medical nor surgical therapy provides a cure for Crohn's disease, the primary goals of therapy are to induce and maintain remission and prevent complications. As a biologic agent, infliximab, a monoclonal antibody to tumor necrosis factor, is indicated for refractory luminal and fistulizing Crohn's disease that does not respond to other medical therapies or surgery. Infliximab has proven to be very effective for inducing and maintaining remission in Crohn's disease; however, infliximab treatment has several potential complications. Here, we report a case of free perforation following a therapeutic response after an initial dose of infliximab for Crohn's disease. This is the first case report describing a free perforation in a Crohn's disease patient after an initial dose of infliximab.

Hepatic Resection for Hepatic Metastases from Gastric Adenocarcinoma

PURPOSE: The effects of hepatic resection on patients with metastatic tumors from gastric adenocarcinomas are unclear. Therefore, we analyzed early clinical outcomes in patients who underwent surgical resection for hepatic metastases from gastric adenocarcinomas. MATERIALS AND METHODS: From January 2003 to December 2010, 1,508 patients with primary gastric cancers underwent curative gastric resections at the Korea Cancer Center Hospital. Of these patients, 12 with liver-only metastases underwent curative hepatic resection. Their clinical data were analyzed retrospectively. RESULTS: The median follow-up period was 12.5 months (range, 1~85 months); no operative mortalities or major complications were observed. Three patients underwent synchronous resections, and 9 underwent metachronous resections. In the latter group, the median interval between gastrectomy and hepatectomy for hepatic metastasis was 10.5 months (range, 5~47 months). The overall 1- and 5-year survival rates of these 12 patients were 65% and 39%, respectively, with a median overall survival of 31.0 months; 2 patients survived for >5 years. CONCLUSIONS: Hepatic resection can be a feasible procedure for treating hepatic metastases from gastric adenocarcinomas. Although this study was small and involved only selected cases, the outcomes of the hepatic resections were comparable and long-term (>5 years) survivors were identified. Surgical resection of the liver can be considered a feasible option in managing hepatic metastases from gastric adenocarcinomas.

How Should Azathioprine Be Dosed in Crohn's Disease? A Novel Strategy of Maximum Dose-titration Based on the Lower Limit of Leukocyte Count and Tolerability / 대한소화기학회지

BACKGROUND/AIMS: Although general guidelines have suggested weight-based dosing of azathioprine (AZA, 2.5 mg/kg/day) for Crohn's disease (CD), a substantial number of patients develop bone marrow suppression. The aim of this study was to evaluate the maximum dose of AZA not based on weight but titrated according to the lower limit of leukocyte count for maintaining remission in patients with CD. METHODS: Among a total of seventy-eight patients with CD, who had been followed-up at Kosin University Gospel Hospital (Busan, Korea) from 2010 to 2011, those treated with the maximum dose of AZA meeting both drug-tolerability and leukocytes count of more than 4,000/mm3 for steroid-free maintaining remission were enrolled. The titrated maximum AZA dose and its relationship with weight were evaluated. RESULTS: A total of 42 patients (male, 32 patients; mean age, 31 years) were enrolled. The maximum dose of AZA was 49.1 mg/day. The dose per weight was 0.87 mg/kg/day and negatively correlated with body weight (gamma=-0.51, p=0.01) and BMI (gamma=-0.33, p=0.034). AZA dose per weight in the below 40 years old group was significantly higher than that in the above 40 years old group (p=0.039). CONCLUSIONS: Dose decision of AZA based only on weight could put the patients to inappropriately low or high dose resulting in need of additional therapy or serious side effect, respectively. Therefore, the maximum dose-titration based on the lower limit of leukocyte count and tolerability is a novel and a valuable strategy in deciding the dose of thiopurines.

Successful Endoscopic Mucosal Resection of a Low Esophageal Carcinoid Tumor

Esophageal carcinoid tumors remain some of the rarest of all carcinoid tumors, with only several cases previously reported in the literature. The endoscopic mucosal resection of selected carcinoid tumors has been shown to be a valid, safe, and effective method of treatment. Endoscopic ultrasonography is the technique of choice to select patients eligible for endoscopic resection. Here, we report successful endoscopic mucosal resection of a low esophageal carcinoid tumor and review the relevant literature. The present case is the first reported case of esophageal carcinoid tumor in Korea.

Determination of Malignant and Invasive Predictors in Branch Duct Type Intraductal Papillary Mucinous Neoplasms of the Pancreas: A Suggested Scoring Formula

Prediction of malignancy or invasiveness of branch duct type intraductal papillary mucinous neoplasm (Br-IPMN) is difficult, and proper treatment strategy has not been well established. The authors investigated the characteristics of Br-IPMN and explored its malignancy or invasiveness predicting factors to suggest a scoring formula for predicting pathologic results. From 1994 to 2008, 237 patients who were diagnosed as Br-IPMN at 11 tertiary referral centers in Korea were retrospectively reviewed. The patients' mean age was 63.1 +/- 9.2 yr. One hundred ninty-eight (83.5%) patients had nonmalignant IPMN (81 adenoma, 117 borderline atypia), and 39 (16.5%) had malignant IPMN (13 carcinoma in situ, 26 invasive carcinoma). Cyst size and mural nodule were malignancy determining factors by multivariate analysis. Elevated CEA, cyst size and mural nodule were factors determining invasiveness by multivariate analysis. Using the regression coefficient for significant predictors on multivariate analysis, we constructed a malignancy-predicting scoring formula: 22.4 (mural nodule [0 or 1]) + 0.5 (cyst size [mm]). In invasive IPMN, the formula was expressed as invasiveness-predicting score = 36.6 (mural nodule [0 or 1]) + 32.2 (elevated serum CEA [0 or 1]) + 0.6 (cyst size [mm]). Here we present a scoring formula for prediction of malignancy or invasiveness of Br-IPMN which can be used to determine a proper treatment strategy.

Recent Treatment Modalities for Hepatolithiasis and Long-term Outcomes

PURPOSE: Treatment of hepatolithiasis is difficult because of the high recurrence rate, and the long-term outcome is not satisfactory. We reviewed clinical outcomes to determine the optimal treatment modalities for hepatolithiasis. METHODS: Between 1981 and 2005, 648 patients with hepatolithiasis were treated at our institute. Changing patterns of treatment modalities and outcomes were analyzed for the periods: 1st (1981~1985; n=159), 2nd (1986~1990; n=100), 3rd (1991~1995; n=111), 4th (1996~2000; n=141), and 5th (2001~2005; n=137). Clearance and recurrence rates according to the treatment modalities and associated malignancies were analyzed in patients for the most recent 10 years. RESULTS: During the past 25 years, hepatectomy as a treatment for hepatholithiasis has increased in frequency and become the major treatment modality in the recent 10 years, while choledocholithotomy and drainage procedures have decreased in frequency. With improvement in operative clearance and post-operative lithotripsy, the final clearance rate improved from 79.0% to 91.3%. In the most recent 10 years, the final clearance rate of hepatectomy, choledocholithotomy, cholangioenterostomy, and PTCS was 97.1%, 82.0%, 78.8%, and 100%, respectively, and the recurrence rate was 34.7%, 15.4%, 17.0%, and 42.9%, respectively. Twenty-six patients (47.2%) had recurrences within 2 years, and 12 patients (21.8%) had recurrences after 5 years. Cholangiocarcinomas occurred in 10 patients (3.6%). The diagnosis of cholangiocarcinoma was established pre-operatively in 2 patients, post-operatively in 4 patients, and during the follow-up period in 4 patients. CONCLUSION: In the treatment of hepatolithiasis, hepatectomy has a high clearance rate and a low recurrence rate. To reduce the recurrence rate, complete stone clearance without residual stones seems to be of utmost importance. Suspicion of malignancy and long-term follow-up are needed in the management of patients with hepatolithiasis.

Clinical Characteristics of Biliary Tract Cancer Associated with Choledochal Cyst

PURPOSE: Choledochal cysts are rare congenital or acquired cystic dilatations of the intra- or extra-hepatic bile ducts. The mechanism of carcinogenesis in choledochal cyst has not been clearly elucidated, although stasis of bile and reflux of pancreatic juice appear to be important factors. The aim of this study was to identify the clinical risk factors predicting development of biliary tract cancers in patients with choledochal cyst. METHODS: The study subjects included 170 consecutive patients who underwent surgery for choledochal cysts at Seoul National University Hospital between December 1980 and May 2008. We analyzed the demographic characteristics, clinical symptoms, laboratory findings, type of choledochal cysts, pathologic characteristics, and long-term outcomes of the patients with associated biliary tract cancers. RESULTS: Out Of 170 patients with choledochal cysts, combined biliary tract cancers ware identified in 29 patients, which included extrahepatic bile duct (n=15; 51.7%), gallbladder (n=12; 41.4%), and ampulla of Vater cancers (n=2; 6.9%). There were no significant differences in gender, clinical symptoms (abdominal pain, jaundice, and abdominal masses), laboratory findings (leukocytosis, hyperbilirubinemia, and increased alkaline phosphatase), and Todani classification of choledochal cysts between the two groups with or without combined biliary tract cancer. Multivariate analysis revealed that age > or =41 years and pancreatico-choledochal type APBDU were associated with the development of biliary tract cancers in patients with choledochal cysts. CONCLUSION: Age > or =41 years and pancreatico-choledochal type APBDU were associated with the development of biliary tract cancers in patients with choledochal cysts. Therefore, the possibility of associated biliary tract cancers should be considered when planning surgical management for patients with these risk factors.

Clinical Characteristics of Biliary Tract Cancer Associated with Choledochal Cyst

PURPOSE: Choledochal cysts are rare congenital or acquired cystic dilatations of the intra- or extra-hepatic bile ducts. The mechanism of carcinogenesis in choledochal cyst has not been clearly elucidated, although stasis of bile and reflux of pancreatic juice appear to be important factors. The aim of this study was to identify the clinical risk factors predicting development of biliary tract cancers in patients with choledochal cyst. METHODS: The study subjects included 170 consecutive patients who underwent surgery for choledochal cysts at Seoul National University Hospital between December 1980 and May 2008. We analyzed the demographic characteristics, clinical symptoms, laboratory findings, type of choledochal cysts, pathologic characteristics, and long-term outcomes of the patients with associated biliary tract cancers. RESULTS: Out Of 170 patients with choledochal cysts, combined biliary tract cancers ware identified in 29 patients, which included extrahepatic bile duct (n=15; 51.7%), gallbladder (n=12; 41.4%), and ampulla of Vater cancers (n=2; 6.9%). There were no significant differences in gender, clinical symptoms (abdominal pain, jaundice, and abdominal masses), laboratory findings (leukocytosis, hyperbilirubinemia, and increased alkaline phosphatase), and Todani classification of choledochal cysts between the two groups with or without combined biliary tract cancer. Multivariate analysis revealed that age > or =41 years and pancreatico-choledochal type APBDU were associated with the development of biliary tract cancers in patients with choledochal cysts. CONCLUSION: Age > or =41 years and pancreatico-choledochal type APBDU were associated with the development of biliary tract cancers in patients with choledochal cysts. Therefore, the possibility of associated biliary tract cancers should be considered when planning surgical management for patients with these risk factors.