Long-term survival after CCRT and HAIC followed by ALPPS for hepatocellular carcinoma with portal vein invasion: a case report

There are various methods for treating advanced hepatocellular carcinoma with portal vein invasion, such as systemic chemotherapy, transarterial chemoembolization, transarterial radioembolization, and concurrent chemoradiotherapy. These methods have similar clinical efficacy but are designed with a palliative aim. Herein, we report a case that experienced complete remission through “associating liver partition and portal vein ligation for staged hepatectomy (ALPPS)” after concurrent chemoradiotherapy and hepatic artery infusion chemotherapy. In this patient, concurrent chemoradiotherapy and hepatic artery infusion chemotherapy induced substantial tumor shrinkage, and hypertrophy of the nontumor liver was sufficiently induced by portal vein ligation (stage 1 surgery) followed by curative resection (stage 2 surgery). Using this approach, long-term survival with no evidence of recurrence was achieved at 16 months. Therefore, the optimal use of ALPPS requires sufficient consideration in cases of significant hepatocellular carcinoma shrinkage for curative purposes.

Obesity and the risk of primary liver cancer: A systematic review and meta-analysis

Background/Aims@#In this systematic review and meta-analysis, we aimed to clarify the effect of obesity on the occurrence of and mortality from primary liver cancer. @*Methods@#This study was conducted using a systematic literature search of MEDLINE, EMBASE, and the Cochrane Library until November 2018 using the primary keywords “obesity,” “overweight,” “body mass index (BMI),” “body weight,” “liver,” “cancer,” “hepatocellular carcinoma,” “liver cancer,” “risk,” and “mortality.” Studies assessing the relationship between BMI and occurrence of or mortality from primary liver cancer in prospective cohorts and those reporting hazard ratios (HRs) or data that allow HR estimation were included. @*Results@#A total of 28 prospective cohort studies with 8,135,906 subjects were included in the final analysis. These included 22 studies with 6,059,561 subjects for cancer occurrence and seven studies with 2,077,425 subjects for cancerrelated mortality. In the meta-analysis, an increase in BMI was associated with the occurrence of primary liver cancer (HR, 1.69; 95% confidence interval, 1.50–1.90, I2=56%). A BMI-dependent increase in the risk of occurrence of primary liver cancer was reported. HRs were 1.36 (95% CI, 1.02–1.81), 1.77 (95% CI, 1.56–2.01), and 3.08 (95% CI, 1.21–7.86) for BMI >25 kg/m2, >30 kg/m2, and >35 kg/m2, respectively. Furthermore, increased BMI resulted in enhanced liver cancer-related mortality (HR, 1.61; 95% CI, 1.14–2.27, I2=80%). @*Conclusions@#High BMI increases liver cancer mortality and occurrence of primary liver cancer. Obesity is an independent risk factor for the occurrence of and mortality from primary liver cancer.

IgG4-Related Hepatic Inflammatory Pseudotumor Complicated by Actinomycosis during Steroid Therapy

For a 67-year-old man with diabetes mellitus, a 9-cm liver mass was found on CT during the diagnostic work-up for weight loss and fever. Dynamic CT and MRI showed a layered pattern of contrast enhancement suggesting the imaging features of the solid inflammatory mass. After tissue diagnosis of immunoglobulin G4 (IgG4)-related disease by gun needle biopsy, steroid therapy induced partial shrinkage of the mass on the follow-up CT at 4 weeks. On the 5-month follow-up CT with the maintenance of low-dose oral steroid medication, disease progression with invasion to diaphragm brought surgical intervention of right hemihepatectomy considering the possibility of combined malignancy. In the area of diaphragmatic destruction, focal actinomycosis was complicated in the main mass of IgG4-related disease. We are the first to describe a rare case of IgG4-related inflammatory pseudotumor, complicated by actinomycosis, showing an invasive nature that mimicked malignancy during steroid therapy in a diabetic patient.

Protective effect of Korean red ginseng on oxaliplatin-mediated splenomegaly in colon cancer

PURPOSE: This study investigated how adding Korean red ginseng extract (KRG) to folinic acid, fluorouracil and oxaliplatin (FOLFOX) chemotherapy affected the rate of splenomegaly in colon cancer. METHODS: This retrospective study analyzed 42 patients who were randomly assigned to receive a FOLFOX regimen with or without KRG. Spleen volume change was assessed by computed tomography scans measured before surgery (presurgery volume) and 3 weeks after cessation of the 12th cycle of FOLFOX (postchemotherapy volume). RESULTS: All patients showed increased spleen volume. No difference was observed in median presurgery and postchemotherapy volume between the KRG and control groups. However, a ratio defined as postchemotherapy volume divided by presurgery volume was significantly lower in the KRG group than the control group (median, 1.38 [range, 1.0–2.8] in KRG group vs. median, 1.89 [range, 1.1–3.0] in control group, P = 0.028). When splenomegaly was defined as a >61% increase in spleen volume, the rate of splenomegaly was significantly lower in the KRG group than the control group (28.6% vs. 61.9%, P = 0.03). KRG consumption was inversely associated with developing splenomegaly in multivariate analysis. CONCLUSION: Adding KRG during FOLFOX chemotherapy for colon cancer might protect against oxaliplatin-induced splenomegaly. The protective effect of Korean red ginseng should be investigated with further research.

Robotic Cholecystectomy Using the Newly Developed Korean Robotic Surgical System, Revo-i: A Preclinical Experiment in a Porcine Model

One Korean company recently successfully produced a robotic surgical system prototype called Revo-i (MSR-5000). We, therefore, conducted a preclinical study for robotic cholecystectomy using Revo-i, and this is a report of the first case of robotic cholecystectomy performed using the Revo-i system in a preclinical porcine model. Revo-i consists of a surgeon console (MSRC-5000), operation cart (MSRO-5000) and vision cart (MSRV-5000), and a 40 kg-healthy female porcine was prepared for robotic cholecystectomy with general anesthesia. The primary end point was the safe completion of these procedures using Revo-i: The total operation time was 88 minutes. The dissection time was defined as the time from the initial dissection of the Calot area to the time to complete gallbladder detachment from the liver bed: The dissection time required 14 minutes. The surgical console time was 45 minutes. There was no gallbladder perforation or significant bleeding noted during the procedure. The porcine survived for two weeks postoperatively without any complications. Like the da Vinci surgical system, the Revo-i provides a three-dimensional operative view and allows for angulated instrument motion (forceps, needle-holders, clip-appliers, scissors, bipolar energy, and hook monopolar energy), facilitating an effective laparoscopic procedure. Our experience suggests that robotic cholecystectomy can be safely completed in a porcine model using Revo-i.

Aggressive surgical resection for concomitant liver and lung metastasis in colorectal cancer

BACKGROUNDS/AIMS: Aggressive surgical resection for hepatic metastasis is validated, however, concomitant liver and lung metastasis in colorectal cancer patients is equivocal. METHODS: Clinicopathologic data from January 2008 through December 2012 were retrospectively reviewed in 234 patients with colorectal cancer with concomitant liver and lung metastasis. Clinicopathologic factors and survival data were analyzed. RESULTS: Of the 234 patients, 129 (55.1%) had synchronous concomitant liver and lung metastasis from colorectal cancer and 36 (15.4%) had metachronous metastasis. Surgical resection was performed in 33 patients (25.6%) with synchronous and 6 (16.7%) with metachronous metastasis. Surgical resection showed better overall survival in both groups (synchronous, p=0.001; metachronous, p=0.028). In the synchronous metastatic group, complete resection of both liver and lung metastatic lesions had better survival outcomes than incomplete resection of two metastatic lesions (p=0.037). The primary site of colorectal cancer and complete resection were significant prognostic factors (p=0.06 and p=0.003, respectively). CONCLUSIONS: Surgical resection for hepatic and pulmonary metastasis in colorectal cancer can improve complete remission and survival rate in resectable cases. Colorectal cancer with concomitant liver and lung metastasis is not a poor prognostic factor or a contraindication for surgical treatments, hence, an aggressive surgical approach may be recommended in well-selected resectable cases.

Mirizzi Syndrome: A Single Center Experience

PURPOSE: Mirizzi syndrome is caused by extrinsic compression of the common hepatic duct by stones impacted in the cystic duct or the gallbladder neck. The standard treatment for Mirizzi syndrome has been open cholecystectomy. The aim of this study was to review our experience of Mirizzi syndrome and consider its surgical treatment. METHODS: Data were collected retrospectively through chart review of 9,360 patients who underwent cholecystectomy between April 1983 and August 2016. RESULTS: Mirizzi syndrome was identified in 21 of 9,360 patients (0.22%). The mean age at diagnosis was 56 years. The most common symptom was abdominal pain (85.7%). A total of 16 patients (76.2%) were diagnosed with McSherry type I and 5 patients (23.8%) with McSherry type II. Laparoscopic cholecystectomy (LC) was initiated in 13 patients and open cholecystectomy (OC) in 8 patients. Conversion from LC to OC was reported for 3 patients (conversion rate 18.8%). In 4 patients with McSherry type II, an additional procedure (T tube insertion or hepaticojejunostomy) was required. CONCLUSION: Preoperative diagnosis of Mirizzi syndrome is very important in order to plan surgical strategy. LC is possible in selected patients with Mirizzi syndrome. However, OC is suitable in patients with McSherry type II. In the near future, laparoscopic procedures may be adaptable in patients with McSherry type II.

The role of prophylactic antibiotics on surgical site infection in elective laparoscopic cholecystectomy

BACKGROUNDS/AIMS: Although laparoscopic cholecystectomy is a common and widely accepted technique, the use of prophylactic antibiotics in elective laparoscopic cholecystectomy still remains controversial. The aim of this study is to determine whether prophylactic antibiotics could prevent surgical site infection after elective laparoscopic cholecystectomy and to identify any risk factors for surgical site infection. METHODS: This study included 471 patients undergoing laparoscopic cholecystectomy between January 2009 and May 2012. Period 1 patients (279) received second generation cephalosporin 1 g intravenously after induction of anesthesia, and Period 2 patients (192) were not given prophylactic antibiotics. The characteristics and surgical site infections of the patients were compared and analyzed. RESULTS: The overall rate of surgical site infection was 1.69% for the total of 471 patients. The incidence of surgical site infection was similar for the two Periods: 5 of 279 patients (1.79%) in Period 1, 3 of 192 patients (1.56%) in Period 2 (p=0.973). All of the patients with surgical site infections were well treated under conservative treatments without any sequelae. The preoperative albumin level (p=0.023) contributed to surgical site infection. CONCLUSIONS: Prophylactic antibiotics are not necessary for elective laparoscopic cholecystectomy but patients in poor nutritional state with low albumin level should consider prophylactic antibiotics.

Volume-reserving Surgery after Photodynamic Therapy for Biliary Papillomatosis: A Case Report / 대한소화기학회지

Biliary papillomatosis is rare, and its pathogenic mechanisms are not yet clear. Because of its high risk for malignancy transformation, surgical resection is regarded as a standard treatment. Photodynamic therapy (PDT) has been used by the intravenous administration of hematoporphyrin derivative followed by laser exposure. A photochemical process causes disturbance of the microvascular structure and degradation of membrane. Cholangitis is a major complication after PDT. A healthy 56-year-old man was diagnosed with biliary papillomatosis involving the common hepatic duct, both proximal intrahepatic bile ducts (IHD), and the right posterior IHD. After biliary decompression by endoscopic nasobiliary drainage, PDT was performed to avoid extensive liver resection and recurrence using endoscopic retrograde cholangiographic guidance. After portal vein embolization, the patient underwent extended right hemihepatectomy. Following administration of chemoradiation therapy with tegafur-uracil and 45 Gy due to local recurrence at postoperative 13 months, there was no local recurrence or distant metastases. This is the first case report on PDT for biliary papillomatosis in Korea. Preoperative PDT is beneficial for reducing the lesion in diffuse or multifocal biliary papillomatosis and may lead to curative and volume reserving surgery. Thus, PDT could improve the quality of life and prolong life expectation for biliary papillomatosis patients.

Feasible Factors to Reduce Hospital Days after Laparoscopic Cholecystectomy

PURPOSE: Under the proper program, day-case laparoscopic cholecystectomy is feasible in the aspect of postoperative recovery consisting of patient's satisfaction and postoperative complication. In this study, we plan a new protocol for laparoscopic cholecystectomy by analyzing factors that can reduce hospital days. METHODS: A total of 175 patients who underwent three-day laparoscopic cholecystectomy were initially selected. Out of 175 patients, secondary selection was executed using inclusion criteria. The selected patients were scheduled for new two-day laparoscopic cholecystectomy, and 89 patients were included in the data analysis. This study elucidated the comparative analysis between the discharged in the postoperative day 0 group and the postoperative day 1 group. RESULTS: The clinical characteristics were not significantly different between discharged in the postoperative day 0 group and the postoperative day 1 group. The combined diseases were not significantly different between the two groups. Post-operative complications in both groups were analyzed on the seventh day after the operation. No significant difference was observed between the two groups. Members of the patient group who were discharged on postoperative day 0 were given a survey regarding post-operative pain, desirability of discharge, and the level of satisfaction with patient education. The average score was 8.3 out of 10 points. In comparison of the total hospital cost between the two groups, the group discharged on postoperative day 0 had lower cost in all factors. CONCLUSION: We conclude that day-case laparoscopic cholecystectomy is as safe and effective as routine clinical pathway applied laparoscopic cholecystectomy in stable cardiovascular disease, uncomplicated pulmonary disease, and controlled DM patients.

Duodenum-preserving pancreatic head resection in benign and low-grade malignant pancreatic tumors

BACKGROUNDS/AIMS: With development of imaging techniques, pancreatic tumors are being diagnosed more frequently. Applying the standard surgical procedures for pancreatic head tumors, such as pancreaticoduodenectomy and pylorus-preserving pancreaticoduodenectomy may seem too extensive for benign or low-grade malignant pancreas head tumors. Duodenum-preserving pancreatic head resection (DPPHR) has been safely performed in patients with chronic pancreatitis. Recently, DPPHR has been used as a limited surgical procedure to remove benign or low-grade malignant pancreatic head lesions. This study is aimed to evaluate the results of DPPHR in benign or low-grade malignant tumors. METHODS: Between 2004 and 2012, six patients underwent DPPHR due to benign or low-grade malignant pancreas tumor. We performed this retrospective analysis based on the medical records. RESULTS: Five of six patients were diagnosed as intraductal papillary mucinous neoplasms. Remaining one patient was diagnosed as solid pseudopapillary neoplasm. The median age of patients was 60.3 (27-75) years, and the median follow-up period was 24 months. The operation time, blood loss and length of stay were 442.5 minutes, 680 ml and 19.2 days, respectively. There was no mortality. Five patients experienced complications including 1 delayed gastric empting, 2 bile duct strictures, 1 pancreatic fistula and 1 duodenal stricture. No recurrence or metastasis was found during follow-up. CONCLUSIONS: In benign and low-grade malignant lesions of pancreatic head, DPPHR could be alternative to traditional surgery. For applying DPPHR in pancreas tumor, a thorough preoperative examination and utilization of frozen section for sufficient resection margin are required.

Is close monitoring in the intensive care unit necessary after elective liver resection? / 대한외과학회지

PURPOSE: Many surgical patients are admitted to the intensive care unit (ICU), resulting in an increased demand, and possible waste, of resources. Patients who undergo liver resection are also transferred postoperatively to the ICU. However, this may not be necessary in all cases. This study was designed to assess the necessity of ICU admission. METHODS: The medical records of 313 patients who underwent liver resections, as performed by a single surgeon from March 2000 to December 2010 were retrospectively reviewed. RESULTS: Among 313 patients, 168 patients (53.7%) were treated in the ICU. 148 patients (88.1%) received only observation during the ICU care. The ICU re-admission and intensive medical treatment significantly correlated with major liver resection (odds ratio [OR], 6.481; P = 0.011), and intraoperative transfusions (OR, 7.108; P = 0.016). Patients who underwent major liver resection and intraoperative transfusion were significantly associated with need for mechanical ventilator care, longer postoperative stays in the ICU and the hospital, and hospital mortality. CONCLUSION: Most patients admitted to the ICU after major liver resection just received close monitoring. Even though patients underwent major liver resection, patients without receipt of intraoperative transfusion could be sent to the general ward. Duration of ICU/hospital stay, ventilator care and mortality significantly correlated with major liver resection and intraoperative transfusion. Major liver resection and receipt of intraoperative transfusions should be considered indicators for ICU admission.

Introduction of 7th AJCC Cancer Staging: Gallbladder, Perihilar Bile Duct and Distal Common Bile Duct

The American Joint Committee on Cancer (AJCC) Cancer staging system has been revised every 6~8 years since the first edition of the cancer staging system was introduced in 1977. The latest edition, the 7th, was published in 2009 and has been used since January, 2010. In case of gallbladder cancer, perihilar cancer and distal common bile duct cancer, there are several changes compared to the 6th edition (revised in 2002). In gallbladder cancer, there is no difference in lymph node location from the 6th edition, but in the 7th edition disease is divided into hilar nodes and other regional lymph nodes. This has been reclassified in terms of the possibility of surgical resection and patient outcome. In perihilar cancer, we had to follow cancer staging for extrahepatic bile duct cancer because there was no classification previously; but now a new staging guideline has been introduced. There is no difference from the 6th edition in cancer staging of the distal common bile duct. However, the classification of the primary site has changed according to involvement of the celiac axis or superior mesenteric artery in invasion of adjacent organs. Explanations for the differences between the 5th, 6th and 7th editions are introduced and the helpfulness of the new system in clinical applications is examined.

Effect of Operative Wound Protection on Surgical Wound Complications

PURPOSE: Surgical wound complications remain a cause of morbidity and mortality among postoperative patients, and the cost of caring for patients with a surgical wound complication is substantial. The purpose of this study was to evaluate the ability of a vinyl wound protector to reduce the rate of wound complications when used in clean-contaminated surgery. MATERIALS AND METHODS: Between May 2006 and September 2006, 295 patients with a gastric cancer that underwent gastric surgery were studied prospectively, and the patients were randomized into one of two groups: the no wound protector group (n=137) or the polyethylene protector group (n=132). RESULTS: The demographics and operation type and operation time were similar for patients in both groups. The rate of wound complication was different between patients in the no protector group (n=42) and the polyethylene protector group (n=12) (P=0.001) and the rates of seroma (P=0.001), infection (P=0.030) and dehiscence (P=0.282) were different for the two groups. The postoperative hospital stay was significantly shorter in the polyethylene protector group of patients (P=0.040). CONCLUSION: The use of a polyethylene protector resulted in a reduction of the surgical wound complication rate, and the cost of caring for patients, and morbidity and mortality among postoperative patients could be reduced.