Hepatic hemangioma: proportion and predictor of surgical treatment with emphasis on its growth rate

Background/Aims@#There are limited studies on the management of hepatic hemangiomas (HHs). We investigated the proportion and predictors of surgical resection and analyzed HH growth rates in addition to associated factors. @*Methods@#A retrospective case-control study of patients treated in 2 centers was conducted. Thirty-six patients who underwent surgical resection were assigned to the case group. Patients who did not undergo surgical treatment were randomly sigselected at a 1:10 ratio and assigned to the control group (n = 360). Baseline characteristics, clinical course and surgical outcomes were analyzed. @*Results@#The proportion of surgically treated HH patients was 0.3% (36 per 11,049). The longest diameter at diagnosis (mean ± standard deviation) was 7.7 ± 5.2 cm in the case group and 2.4 ± 1.8 cm in the control group (p 10 cm (OR 10.50, 95% CI 1.06–103.77, p = 0.04). The subgroup analysis showed substantial growth in 41.3% with an overall mean annual growth rate of 0.14 cm. @*Conclusions@#Approximately one in 300 patients with an HH underwent surgical treatment. Multiple HHs and a growth rate of more than 4.8%/year were indications for surgical treatment. Nearly half of the HHs showed growing pattern in our study.

Four-Tier Pathologic Tumor Regression Grading System Predicts the Clinical Outcome in Patients Who Undergo Surgical Resection for Locally Advanced Pancreatic Cancer after Neoadjuvant Chemotherapy

Background/Aims@#Neoadjuvant chemotherapy is increasingly utilized in patients with borderline or locally advanced pancreatic cancer (LAPC). However, the pathologic evaluation of tumor regression is not routinely performed or well established. We aimed to evaluate the prognostic value of three tumor regression grading systems frequently used in LAPC and to determine the correlation between pathologic and clinical response. @*Methods@#We included a total of 38 patients with LAPC who were treated with neoadjuvant chemotherapy and subsequent resection. Pathologic tumor regression was graded based on the College of American Pathologists (CAP), Evans, and MD Anderson grading systems. @*Results@#One out of 38 patients (2.6%) achieved a pathologic complete response. Unlike other grading systems (Evans, p=0.063; MD Anderson, p=0.110), the CAP grading system was a significant prognostic factor for overall survival (p=0.043). Pathologic N stage (p=0.023), margin status (p=0.044), and radiologic response (p=0.016) correlated with overall survival. In the multivariate analysis, CAP 3 was an independent predictor of shorter overall survival (p=0.026). The CAP grading system correlated with the radiologic response (p=0.007) but not the carbohydrate antigen 19-9 level (p=0.333). @*Conclusions@#The four-tier CAP pathologic tumor regression grading system predicted the clinical outcome in LAPC patients who underwent resection after neoadjuvant chemotherapy. Therefore, a more comprehensive pathologic evaluation is warranted in these patients.

Diagnostic Accuracy of CT for Evaluating Circumferential Resection Margin Status in Resectable or Borderline Resectable Pancreatic Head Cancer: A Prospective Study Using Axially Sliced Surgical Pathologic Correlation

Objective@#CT plays a central role in determining the resectability of pancreatic cancer, which directs the use of neoadjuvant therapy. This study aimed to assess the diagnostic accuracy of CT in predicting circumferential resection margin (CRM) involvement in patients with resectable or borderline resectable pancreatic head cancer. @*Materials and Methods@#Seventy-seven patients who were scheduled for upfront surgery for resectable or borderline resectable pancreatic head cancer were prospectively enrolled, and 75 patients (38 male and 37 female; mean age ± standard deviation, 68 ± 11 years) were finally analyzed. The CRM status was evaluated separately for the superior mesenteric artery (SMA) and posterior and superior mesenteric vein/portal vein (SMV/PV) margins. Three independent radiologists reviewed the preoperative CT images and evaluated the resection margin status. The reference standard for CRM status was pathologic examination of pancreaticoduodenectomy specimens in an axial plane perpendicular to the axis of the second portion of the duodenum. The diagnostic accuracy of CT was assessed for overall CRM involvement, defined as involvement of the SMA or posterior margins (per-patient analysis), and involvement of each of the three resection margins (per-margin analysis). The data were pooled using a crossed random effects model. @*Results@#Forty patients had pathologically confirmed overall CRM involvement in pancreatic cancer, while CRM involvement was not seen in 35 patients. For overall CRM involvement, the pooled sensitivity and specificity were 15% (95% confidence interval: 7%–49%) and 99% (96%–100%), respectively. For each of the resection margins, the pooled sensitivity and specificity were 14% (9%–54%) and 99% (38%–100%) for the SMA margin, 12% (8%–46%) and 99% (97%–100%) for the posterior margin; and 37% (29%–53%) and 96% (31%–100%) for the SMV/PV margin, respectively. @*Conclusion@#CT showed very high specificity but low sensitivity in predicting pathological CRM involvement in pancreatic cancer.

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.

Real-World Efficacy and Safety of Everolimus with Low Dose Tacrolimus in Liver Transplantation Recipients

Background@#Post-transplant immunosuppression with calcineurin inhibitors (CNIs) is associated with kidney function impairment while mammalian target of rapamycin (mTOR) inhibitors, such as everolimus, can be used for its renal-sparing effects. In this study, we compared the efficacy and safety of everolimus with low dose tacrolimus (EVR+Low TAC) and conventional dose tacrolimus (TAC) in liver transplantation recipients. @*Methods@#Medical records of recipients who received liver transplantation at Seoul National University Bundang Hospital from January 1st 2009 to December 31st 2018 were retrospectively reviewed. Cohort entry date was defined as the day everolimus was initiated and tacrolimus dosage was reduced. All patients were followed up for 1 year. Indicator of efficacy was the incidence of rejection and safety was evaluated by incidence of drug adverse events including renal function. @*Results@#Among 118 patients, there were 40 patients (33.9%) in EVR+Low TAC group. Incidence of rejection, including both biopsy proven acute rejection and clinical rejection, was similar in two groups [7.5% (n=3) vs. 6.4% (n=5), p=1.000]. Renal dysfunction was less frequent in EVR+Low TAC [17.5% (n=7) vs. 35.9% (n=28), p=0.038]. However, incidence rates of dyslipidemia, oral ulcer were more frequent in EVR+Low TAC [45.0% (n=18) vs. 21.8% (n=17), p=0.009; 15.0% (n=6) vs. 1.3% (n=1), p=0.006]. @*Conclusions@#In terms of prevention of rejection, EVR+Low TAC was as effective as TAC and had renal-sparing effect but was associated with increased risk of dyslipidemia and oral ulcer. This study demonstrates that EVR+Low TAC could be an alternative to liver transplant recipients with nephrotoxicity after administration of conventional dose tacrolimus.

Real-World Efficacy and Safety of Everolimus with Low Dose Tacrolimus in Liver Transplantation Recipients

Background@#Post-transplant immunosuppression with calcineurin inhibitors (CNIs) is associated with kidney function impairment while mammalian target of rapamycin (mTOR) inhibitors, such as everolimus, can be used for its renal-sparing effects. In this study, we compared the efficacy and safety of everolimus with low dose tacrolimus (EVR+Low TAC) and conventional dose tacrolimus (TAC) in liver transplantation recipients. @*Methods@#Medical records of recipients who received liver transplantation at Seoul National University Bundang Hospital from January 1st 2009 to December 31st 2018 were retrospectively reviewed. Cohort entry date was defined as the day everolimus was initiated and tacrolimus dosage was reduced. All patients were followed up for 1 year. Indicator of efficacy was the incidence of rejection and safety was evaluated by incidence of drug adverse events including renal function. @*Results@#Among 118 patients, there were 40 patients (33.9%) in EVR+Low TAC group. Incidence of rejection, including both biopsy proven acute rejection and clinical rejection, was similar in two groups [7.5% (n=3) vs. 6.4% (n=5), p=1.000]. Renal dysfunction was less frequent in EVR+Low TAC [17.5% (n=7) vs. 35.9% (n=28), p=0.038]. However, incidence rates of dyslipidemia, oral ulcer were more frequent in EVR+Low TAC [45.0% (n=18) vs. 21.8% (n=17), p=0.009; 15.0% (n=6) vs. 1.3% (n=1), p=0.006]. @*Conclusions@#In terms of prevention of rejection, EVR+Low TAC was as effective as TAC and had renal-sparing effect but was associated with increased risk of dyslipidemia and oral ulcer. This study demonstrates that EVR+Low TAC could be an alternative to liver transplant recipients with nephrotoxicity after administration of conventional dose tacrolimus.

Effect of Enhanced Recovery After Surgery program on hospital stay and 90-day readmission after pancreaticoduodenectomy: a single, tertiary center experience in Korea

Purpose@#Despite increasing number of reports on Enhanced Recovery After Surgery program (ERAS) and readmission after pancreaticoduodenectomy (PD) from Western countries, there are very few reports on this topic from Asian countries.This study aimed to evaluate the effects of ERAS on hospital stay and readmission and to identify reasons and risk factors for readmission after PD. @*Methods@#This retrospective cohort study included 670 patients who underwent open PD from January 2003 to December 2017. The patients were classified into ERAS (n = 352) and non-ERAS (n = 318) groups. Patients’ characteristics, perioperative outcomes, and readmission rates were compared. @*Results@#There were no significant differences in the postoperative complication rates between the groups. The mean postoperative hospital stay was significantly shorter in the ERAS group (24.5 vs. 18.0 days, P < 0.001), but the 90-day readmission rate was similar in the 2 groups (9.1% vs. 8.5%, P = 0.785). Complications associated with pancreatic fistula (42.4%) were the most common cause for readmission. In the multivariate analysis, diabetes mellitus (odds ratio [OR], 1.84;95% confidence interval [CI], 1.05–3.24; P = 0.034), preoperative non-jaundice (OR, 0.45; 95% CI, 0.25–0.82; P = 0.009) and severe postoperative complications (OR, 4.12; 95% CI, 2.34–7.26; P < 0.001) were identified as risk factors for readmission. @*Conclusion@#The results confirmed that the ERAS program for PD was beneficial in reducing postoperative stay without increasing readmission risks. To decrease readmission rates, prudent discharge planning and medical support should be considered in patients who experience severe complications.

Risk factors and long-term implications of unplanned conversion during laparoscopic liver resection for hepato­c cellular carcinoma located in anterolateral liver segment

Purpose@#The impact of conversion on perioperative and long-term oncologic outcomes is controversial. Thus, we compared these outcomes between laparoscopic (Lap), unplanned conversion (Conversion), and planned open (Open) liver resection for hepatocellular carcinoma (HCC) located in anterolateral (AL) liver segments and aimed to identify risk factors for unplanned conversion. @*Methods@#We retrospectively studied 374 patients (Lap, 299; Open, 62; Conversion, 13) who underwent liver resection for HCC located in AL segments between 2004 and 2018. @*Results@#Compared to the Lap group, the Conversion group showed greater values for operation time (p < 0.001), blood loss (p = 0.021), transfusion rate (p = 0.009), postoperative complication rate (p = 0.008), and hospital stay (p = 0.040), with a lower R0 resection rate (p < 0.001) and disease-free survival (p = 0.001). Compared with the Open group, the Conversion group had a longer operation time (p = 0.012) and greater blood loss (p = 0.024). Risk factors for unplanned conversion were large tumor size (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.05–1.74; p = 0.020), multiple tumors (OR, 5.95; 95% CI, 1.45–24.39; p = 0.013), and other organ invasion (OR, 15.32; 95% CI, 1.80–130.59; p = 0.013). @*Conclusion@#In conclusion, patients who experienced unplanned conversion during LLR for HCC located in AL segments showed poor perioperative and long-term outcomes compared to those who underwent planned laparoscopic and open liver resection. Therefore, open liver resection should be considered in patients with risk factors for unplanned conversion.

Neutrophil-to-lymphocyte ratio predicts early acute cellular rejection in living donor liver transplantation

Purpose@#The aim of this study was to evaluate the predictive value of neutrophil-to-lymphocyte ratio (NLR) in acute cellular rejection (ACR) after living donor liver transplantation (LDLT). @*Methods@#All consecutive patients who underwent ABO-compatible (ABOc) LDLT from September 2014 to December 2017 were retrospectively reviewed. NLR was calculated on 3 occasions; (1) 4 weeks prior to liver transplantation (LT), (2) the day of LT, and (3) the day before liver biopsy. @*Results@#Among 66 patients who underwent ABOc LDLT, ACR was identified in 15 patients (22.7%) on protocol liver biopsy performed routinely on the postoperative day 7. There was no significant difference in NLR at 4 weeks prior to LT and the day of LT between no-ACR and ACR group (2.98 ± 1.92 vs. 2.54 ± 1.15, P = 0.433; 17.9 ± 8.31 vs. 20.5 ± 13.4, P = 0.393). However, NLR was significantly lower in ACR group compared to non-ACR group just prior to liver biopsy (5.82 ± 3.42 vs. 18.4 ± 17.2, P = 0.035). NLR tends to decrease 3.5 days before the onset of ACR. The area under the receiver operating characteristic curve for optimal cut-off value of NLR was 6.49, with sensitivity and specificity of 80.4% and 73.3% respectively. @*Conclusion@#NLR has a potential as a noninvasive predictor of early ACR in ABOc LDLT.

Implementation of a resident night float system in a surgery department in Korea for 6 months: electronic medical record-based big data analysis and medical staff survey

PURPOSE: To evaluate superiority of a night float (NF) system in comparison to a traditional night on-call (NO) system for surgical residents at a single institution in terms of efficacy, safety, and satisfaction. METHODS: A NF system was implemented from March to September 2017 and big data analysis from electronic medical records was performed for all patients admitted for surgery or contacted from the emergency room (ER). Parameters including vital signs, mortality, and morbidity rates, as well as promptness of response to ER calls, were compared against a comparable period (March to September 2016) during which a NO system was in effect. A survey was also performed for physicians and nurses who had experienced both systems. RESULTS: A total of 150,000 clinical data were analyzed. Under the NO and NF systems, a total of 3,900 and 3,726 patients were admitted for surgery. Mortality rates were similar but postoperative bleeding was significantly higher in the NO system (0.5% vs. 0.2%, P = 0.031). From the 1,462 and 1,354 patients under the NO and NF systems respectively, that required surgical consultation from the ER, the time to response was significantly shorter in the NF system (54.5 ± 70.7 minutes vs. 66.8 ± 83.8 minutes, P < 0.001). Both physicians (90.4%) and nurses (91.4%) agreed that the NF system was more beneficial. CONCLUSION: This is the first report of a NF system using big data analysis in Korea, and potential benefits of this new system were observed in both ward and ER patient management.

Spleen Preservation in Laparoscopic Distal Pancreatectomy for Solid Pseudopapillary Neoplasm is Oncologically Safe

PURPOSE: Laparoscopic distal pancreatectomy (LDP) has been widely performed for solid pseudopapillary neoplasm (SPN) involving the body or tail of the pancreas. However, it has not been established whether spleen preservation in LDP is oncologically safe for the treatment of SPN with malignant potential. In this study, we compared the short- and long-term outcomes between patients with SPN who underwent laparoscopic spleen-preserving distal pancreatectomy (LSPDP) vs laparoscopic distal pancreatectomy with splenectomy (LDPS). METHODS: We retrospectively reviewed the medical records of 46 patients with SPN who underwent LDP between January 2005 and November 2016. Patients were divided into 2 groups according to spleen preservation: the LSPDP group (n=32) and the LDPS group (n=14). Clinicopathologic characteristics and perioperative outcomes were compared between groups. RESULTS: There were no significant differences in pathologic variables, including tumor size, tumor location, node status, angiolymphatic invasion, or perineural invasion between groups. Median operating time was significantly longer in the LSPDP group vs the LDPS group (243 vs 172 minutes; p=0.006). Estimated intraoperative blood loss was also significantly greater in the LSPDP group (310 vs 167 ml; p=0.063). There were no significant differences in incidence of postoperative complications (≥ Clavien-Dindo class IIIa) or pancreatic fistula between groups. After a median follow-up of 35 months (range, 3S153 months), there was no recurrence or disease-specific mortality in either group. CONCLUSION: The results show that LSPDP is an oncologically safe procedure for SPN involving the body or tail of the pancreas.

Donor Specific Antibody Negative Antibody-Mediated Rejection after ABO Incompatible Liver Transplantation / 대한이식학회지

Antibody-mediated rejection (AMR) is a major complication after ABO-incompatible liver transplantation. According to the 2016 Banff Working Group on Liver Allograft Criteria for the diagnosis of acute AMR, a positive serum donor specific antibody (DSA) is needed. On the other hand, the clinical significance of the histological findings of AMR in the absence of DSA is unclear. This paper describes a 57-year-old man (blood type, O+) who suffered from hepatitis B virus cirrhosis with hepatocellular carcinoma. Pre-operative DSA and cross-matching were negative. After transplantation, despite the improvement of the liver function, acute AMR was observed in the protocol biopsy on postoperative day 7; the cluster of differentiation 19+ (CD19+) count was 0% and anti-ABO antibody titers were 1:2. This paper presents the allograft injury like AMR in the absence of DSA after ABOi living donor liver transplantation with low titers of anti-ABO antibody and depleted serum CD19+ B cells.

Surgical Strategy for T2 Gallbladder Cancer: Nationwide Multicenter Survey in Korea

BACKGROUND: Although all guidelines suggest that T2 gallbladder (GB) cancer should be treated by extended cholecystectomy (ECx), high-level scientific evidence is lacking because there has been no randomized controlled trial on GB cancer. METHODS: A nationwide multicenter study between 2000 and 2009 from 14 university hospitals enrolled a total of 410 patients with T2 GB cancer. The clinicopathologic findings and long-term follow-up results were analyzed after consensus meeting of Korean Pancreas Surgery Club. RESULTS: The 5-year cumulative survival rate (5YSR) for the patients who underwent curative resection was 61.2%. ECx group showed significantly better 5YSR than simple cholecystectomy (SCx) group (65.4% vs. 54.0%, P = 0.016). For N0 patients, there was no significant difference in 5YSR between SCx and ECx groups (68.7% vs. 73.6%, P = 0.173). Systemic recurrence was more common than locoregional recurrence (78.5% vs. 21.5%). Elevation of cancer antigen 19-9 level preoperatively and lymph node (LN) metastasis were significantly poor prognostic factors in a multivariate analysis. CONCLUSION: ECx including wedge resection of GB bed should be recommended for T2 GB cancer. Because systemic recurrence was more common and recurrence occurred more frequently in patients with LN metastasis, postoperative adjuvant therapy should be considered especially for the patients with LN metastasis.

Living-donor liver transplantation for giant hepatic hemangioma with diffuse hemangiomatosis in an adult: a case report

Hepatic hemangioma represents the most common benign primary hepatic neoplasm. Although most such tumors are small and asymptomatic, giant hepatic hemangioma is frequently symptomatic, and requires intervention. Moreover, diffuse multiple hepatic hemangiomatosis occupying almost the entire liver is extremely rare in adults, and the optimal management for this condition is unclear. We report a case of a rapidly growing, symptomatic giant hepatic hemangioma with diffuse hepatic hemangiomatosis in a 50-year-old female patient who was treated by living-donor liver transplantation. This case shows malignant behavior of a benign hemangioma that required liver transplantation. Although this case could not meet the criteria for transplantation according to the MELD (model for end-stage liver disease) score system, it should be considered as an exceptional indication for deceased-donor liver allocation. Further studies of the mechanism underlying hemangioma growth are warranted.

Single incision laparoscopic cholecystectomy for patients with Mirizzi syndrome

Since multiport laparoscopic cholecystectomy has become a standard treatment for gallbladder (GB) disease, a single incision laparoscopic surgical technique has been tried to decrease the surgical site pain and achieve a better cosmetic out come in selected patients. The development of devices dedicated for single incision laparoscopic cholecystectomy (SILC) is expanding the indication of this single incision laparoscopic technique to more complicated GB diseases. Mirizzi syndrome (MS) is one of the complex uncommon gallstone diseases in patients undergoing cholecystectomy. Because the laparoscopic procedure has become a routine treatment for cholecystectomy, several studies have reported their experience with the laparoscopic technique for the treatment of MS with a comparable outcome in Csendes type I or II. Because the indication for SILC cholecystectomy is expanded to more complicated GB conditions, and the desire of patients for a less painful, better cosmetic surgical outcome has increased, our medical center used this single incision laparoscopic surgical technique for MS Csendes types I and II patients. Here, we report 2 successful cases of SILC for patients with MS types I and II without significant morbidity.

Solo Reduced Port Laparoscopic Left Lateral Sectionectomy

Laparoscopic approach for left lateral sectionectomy became the standard procedure. With increasing demand for minimizing of the access ports and with the advancement in surgical technique, reduced port laparoscopic surgery is introducing itself to the fields of hepatic surgery. We report a case of solo reduced port laparoscopic left lateral sectionectomy for a 25-year-old patient with a 1.7 cm sized tumor implant of growing teratoma syndrome. She underwent salpingo-oophorectomy and 3 cycles of chemotherapy with bleomycin, etoposide and cisplatin 2 prior to the operation. Her BMI was 18.3 kg/m². The total operation time was 85 minutes and estimated blood loss was scanty. The patient was discharged without a significant complication on postoperative day 5. In the video, we demonstrate the surgical procedure of the solo reduced port laparoscopic left lateral sectionectomy using a laparoscopic scope holder.

The Clinicopathological and Prognostic Significance of the Gross Classification of Hepatocellular Carcinoma

BACKGROUND: We aimed to determine the clinicopathological significance of the gross classification of hepatocellular carcinoma (HCC) according to the Korean Liver Cancer Association (KLCA) guidelines. METHODS: A retrospective analysis was performed on 242 cases of consecutively resected solitary primary HCC between 2003 and 2012 at Seoul National University Bundang Hospital. The gross classification (vaguely nodular [VN], expanding nodular [EN], multinodular confluent [MC], nodular with perinodular extension [NP], and infiltrative [INF]) was reviewed for all cases, and were correlated with various clinicopathological features and the expression status of “stemness”-related (cytokeratin 19 [CK19], epithelial cell adhesion molecule [EpCAM]), and epithelial-mesenchymal transition (EMT)–related (urokinase plasminogen activator receptor [uPAR] and Ezrin) markers. RESULTS: Significant differences were seen in overall survival (p=.015) and disease-free survival (p = .034) according to the gross classification; INF type showed the worst prognosis while VN and EN types were more favorable. When the gross types were simplified into two groups, type 2 HCCs (MC/NP/INF) were more frequently larger and poorly differentiated, and showed more frequent microvascular and portal venous invasion, intratumoral fibrous stroma and higher pT stages compared to type 1 HCCs (EN/VN) (p < .05, all). CK19, EpCAM, uPAR, and ezrin expression was more frequently seen in type 2 HCCs (p < .05, all). Gross classification was an independent predictor of both overall and disease-free survival by multivariate analysis (overall survival: p=.030; hazard ratio, 4.118; 95% confidence interval, 1.142 to 14.844; disease-free survival: p=.016; hazard ratio, 1.617; 95% confidence interval, 1.092 to 2.394). CONCLUSIONS: The gross classification of HCC had significant prognostic value and type 2 HCCs were associated with clinicopathological features of aggressive behavior, increased expression of “stemness”- and EMT-related markers, and decreased survival.

Fatigue and weakness hinder patient social reintegration after liver transplantation

BACKGROUND/AIMS: With improvements in the survival of liver transplantation (LT) recipients, the focus is shifting to patient quality of life (QOL), and employment is an important factor in aiding the social reintegration of LT patients. This study aims to evaluate the current employment status of liver graft recipients and various factors that may hinder reemployment. METHODS: Fifty patients above age 18 who underwent either living or deceased donor LT at a single center from March 2009 to July 2016 were interviewed during their visit to the outpatient clinic. The internally developed questionnaire consisted of 10 items. The Karnofsky Performance Scale and EQ-5D were used to evaluate patient function and QOL. RESULTS: A total of 25 (50%) patients returned to work after transplantation (the working group), and 21 (84%) patients in the working group returned to work within the first year after transplantation. In the non-working group (n=25), 17 (68%) answered that their health was the reason for unemployment. Fatigue and weakness were the most frequent symptoms. CONCLUSIONS: The data shows that as many as 50% of total patients returned to work after receiving LT. Fatigue and weakness were the most common complaints of the unemployed group, and resolving the causes of these symptoms may help to increase the employment rate.

Current Status of Laparoscopic Liver Resection: Experiences from Tertiary Center

Laparoscopic liver resection has been widely accepted nowadays for selective cases of liver diseases. Laparoscopic left lateral sectionectomy and minor LLR are considered standard practice worldwide and cautious introduction of major laparoscopic liver resections like hemihepatectomies, central sectionectomy etc.. in institutions having experienced liver surgeons. Because of increasing young liver donor, laparoscopic donor hepatectomy is becoming popular, which gives better cosmetic outcomes. Many clinical trials compared laparoscopic liver resection safety, long term outcomes with open procedures. More recently, advances in laparoscopic instruments and techniques encouraged Korean surgeons to choose a laparoscopic procedure as one of the treatment options for benign or malignant diseases of liver.

Single Incision Laparoscopic Cholecystectomy without a Camera Operator

PURPOSE: This study aimed to evaluate the implementation of solo surgery using a laparoscopic scope holder for single incision laparoscopic cholecystectomy (SILC). METHODS: With a glove port and a flexible high-definition scope, SILC was performed through a single trans-umbilical incisional site with CO2 pneumoperitoneum at a pressure of 12 mmHg. Fifty-eight patients who underwent solo SILC using a scope holder (Solo-SILC) were compared to 15 patients who underwent camera operator-assisted SILC (Ca-SILC) in terms of intraoperative and postoperative outcomes. RESULTS: The mean BMI and operation time were 23.0±3.6 kg/m² and 64.4±16.6 min in Ca-SILC and 25.0±3.8 kg/m² and 58.2±27.1 min in Solo-SILC, respectively (p=0.067 and p=0.410). Estimated blood loss was negligible and an additional assistant port was not required in either groups. A case of gallbladder perforation and bile leak was noted in the Ca-SILC group, and 13 cases of bile leak in the Solo-SILC group, with no significant differences (p=0.167) during the surgery. Postoperative outcomes including surgical complications, diet restriction, diarrhea and hospital stay were not significantly different except for shoulder pain (p<0.001). CONCLUSION: Even with the limitations of a small number of patients, Solo-SILC proved to be a feasible technique. To confirm the safety of solo-SILC, further studies with a larger sample size are required.