Survival Benefit of Adjuvant Chemotherapy in Patients with Pancreatic Ductal Adenocarcinoma Who Underwent Surgery Following Neoadjuvant FOLFIRINOX / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#The benefit of adjuvant chemotherapy following curative-intent surgery in pancreatic ductal adenocarcinoma (PDAC) patients who had received neoadjuvant FOLFIRINOX is unclear. This study aimed to assess the survival benefit of adjuvant chemotherapy in this patient population. @*Materials and Methods@#This retrospective study included 218 patients with localized non-metastatic PDAC who received neoadjuvant FOLFIRINOX and underwent curative-intent surgery (R0 or R1) between January 2017 and December 2020. The association of adjuvant chemotherapy with disease-free survival (DFS) and overall survival (OS) was evaluated in overall patients and in the propensity score matched (PSM) cohort. Subgroup analysis was conducted according to the pathology-proven lymph node status. @*Results@#Adjuvant chemotherapy was administered to 149 patients (68.3%). In the overall cohort, the adjuvant chemotherapy group had significantly improved DFS and OS compared to the observation group (DFS: median, 13.8 months [95% confidence interval (CI), 11.0 to 19.1] vs. 8.2 months [95% CI, 6.5 to 12.0]; p < 0.001; and OS: median, 38.0 months [95% CI, 32.2 to not assessable] vs. 25.7 months [95% CI, 18.3 to not assessable]; p=0.005). In the PSM cohort of 57 matched pairs of patients, DFS and OS were better in the adjuvant chemotherapy group than in the observation group (p < 0.001 and p=0.038, respectively). In the multivariate analysis, adjuvant chemotherapy was a significant favorable prognostic factor (vs. observation; DFS: hazard ratio [HR], 0.51 [95% CI, 0.36 to 0.71; p < 0.001]; OS: HR, 0.45 [95% CI, 0.29 to 0.71; p < 0.001]). @*Conclusion@#Among PDAC patients who underwent surgery following neoadjuvant FOLFIRINOX, adjuvant chemotherapy may be associated with improved survival. Randomized studies should be conducted to validate this finding.

Adjuvant Chemotherapy for Resected Ampulla of Vater Carcinoma: Retrospective Analysis of 646 Patients / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#This study evaluated the efficacy of adjuvant chemotherapy (AC) in patients with resected ampulla of Vater (AoV) carcinoma. @*Materials and Methods@#Data from 646 patients who underwent surgical resection at Asan Medical Center between 2000 and 2017 were retrospectively reviewed. @*Results@#The median age of the patients was 62 years, and 54.2% were male. Patients were classified into AC group (n=165, 25.5%) and no AC group (n=481, 74.5%). With a median follow-up duration of 88 months, in patients with stage I, II, III, median recurrence-free survival (RFS) was not reached, 44 months, and 15 months, respectively, and the median overall survival (OS) were not reached, 88 months and 35 months, respectively. Despite no statistical significance, RFS and OS were better in stage II patients with AC than in those without AC (median RFS, 151 months vs. 38 months; p=0.156 and median OS, 153 months vs. 74 months; p=0.299). In multivariate analysis for RFS and OS, TNM stage, R1 resection status, presence of lymphovascular invasion, and perineural invasion remained significant factors, whereas AC (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.54 to 1.00; p=0.052) was marginally related with RFS. After propensity score matching in only stage II/III patients, RFS and OS with AC were numerically longer than those without AC (HR, 0.80; 95% CI, 0.60 to 1.06; p=0.116 and HR, 0.77; 95% CI, 0.56 to 1.06; p=0.111). @*Conclusion@#AC with fluoropyrimidine did not improve survival of patients with resected AoV carcinoma. However, multivariate analysis with prognostic factors showed a marginally significant survival benefit with AC.

Adjuvant Chemotherapy for Resected Ampulla of Vater Carcinoma: Retrospective Analysis of 646 Patients / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#This study evaluated the efficacy of adjuvant chemotherapy (AC) in patients with resected ampulla of Vater (AoV) carcinoma. @*Materials and Methods@#Data from 646 patients who underwent surgical resection at Asan Medical Center between 2000 and 2017 were retrospectively reviewed. @*Results@#The median age of the patients was 62 years, and 54.2% were male. Patients were classified into AC group (n=165, 25.5%) and no AC group (n=481, 74.5%). With a median follow-up duration of 88 months, in patients with stage I, II, III, median recurrence-free survival (RFS) was not reached, 44 months, and 15 months, respectively, and the median overall survival (OS) were not reached, 88 months and 35 months, respectively. Despite no statistical significance, RFS and OS were better in stage II patients with AC than in those without AC (median RFS, 151 months vs. 38 months; p=0.156 and median OS, 153 months vs. 74 months; p=0.299). In multivariate analysis for RFS and OS, TNM stage, R1 resection status, presence of lymphovascular invasion, and perineural invasion remained significant factors, whereas AC (hazard ratio [HR], 0.74; 95% confidence interval [CI], 0.54 to 1.00; p=0.052) was marginally related with RFS. After propensity score matching in only stage II/III patients, RFS and OS with AC were numerically longer than those without AC (HR, 0.80; 95% CI, 0.60 to 1.06; p=0.116 and HR, 0.77; 95% CI, 0.56 to 1.06; p=0.111). @*Conclusion@#AC with fluoropyrimidine did not improve survival of patients with resected AoV carcinoma. However, multivariate analysis with prognostic factors showed a marginally significant survival benefit with AC.

Prognostic Predictability of American Joint Committee on Cancer 8th Staging System for Perihilar Cholangiocarcinoma: Limited Improvement Compared with the 7th Staging System / Journal of the Korean Cancer Association, 대한암학회지

Purpose@#This study was conducted to evaluate the prognostic values of the 7th and 8th American Joint Committee on Cancer (AJCC) staging systems for patients with resected perihilar cholangiocarcinoma (PHCC). @*Materials and Methods@#A total of 348 patients who underwent major hepatectomy for PHCC between 2008 and 2015 were identified from a single center. Overall survival (OS) was estimated using the Kaplan-Meier method and compared across stage groups with the log-rank test. The concordance index was used to evaluate the prognostic predictability of the 8th AJCC staging system compared with that of the 7th. @*Results@#In the 8th edition, the stratification of each group of T classification improved compared to that in the 7th, as the survival rate of T4 decreased (T2, 31.2%; T3, 13.9%; T4, 15.1%; T1- T2, p=0.260; T2-T3, p=0.001; T3-T4, p=0.996). Both editions showed significant survival differences between each N category, except between N1 and N2 (p=0.063) in 7th edition. Differences of point estimates between the 8th and 7th T and N classification and overall stages were +0.028, +0.006, and +0.039, respectively (T, p=0.005; N, p=0.115; overall stage, p=0.005). In multivariable analysis, posthepatectomy liver failure, T category, N category, distant metastasis, histologic differentiation, intraoperative transfusion, and resection margin status were associated with OS. @*Conclusion@#The prognostic predictability of 8th AJCC staging for PHCC improved slightly, with statistical significance, compared to the 7th edition, but its overall performance is still unsatisfactory.

Laparoscopic Repair of Diastasis Recti: A Case Report and Literature Review

Diastasis recti is a state with separated aponeurosis between two recti caused by weakening of the intercrossing fibers in the linea alba and it causes abdominal protrusion. Common causes comprised of increased intraabdominal pressure, or congenital weakening of myoaponeurotic layer. We describe a patient who underwent laparoscopic repair of diastasis recti. A 30-year-old woman was referred to our outpatient department for an abdominal mass that had appeared 1 year earlier. Physical examination revealed an abdominal wall defect along the midline and computed tomography showed thinning and stretching of the linea alba. The patient underwent laparoscopic repair for diastasis recti. The stretched linea alba was approximated using interrupted sutures from the epigastrium to the suprapubic area. A dual mesh was applied below the peritoneum to prevent recurrence. The patient was discharged without complications, and was followed up for 1 year without recurrence. Laparoscopic repair could be a considerable is a treatment modality for diastasis recti.

Laparoscopic Cholecystectomy in Two Patients with Situs Inversus Totalis: A Case Report

Situs inversus totalis (SIT) is a rare condition in which the viscera are transposed in a mirror image reversal. We report two cases of laparoscopic cholecystectomy (LC) performed for SIT patients. A 63-year old male patient with SIT was diagnosed with symptomatic gallstones. We performed LC by 3-port method. The patient was discharged uneventfully on postoperative day 2. A 57-year old female patient with SIT underwent LC for acute cholecystitis. Due to severe inflammation an assistant was needed. The patient was discharged uneventfully on postoperative day 3. Over 80 cases of LCs in SIT patients have been reported so far and LC has become the standard treatment. The current report confirms the safety of laparoscopy in such cases. Laparoscopic cholecystectomy can be performed safely in SIT patients if care is taken. Surgeons need to be careful of reversed anatomy and unaccustomed working hand.

Laparoscopic Approach for Pancreatic Leiomyosarcoma with Metachronous Liver Metastasis

Although pancreatic leiomyosarcoma (PLM) is a rare malignant pancreatic cancer, it usually shows aggressive biological features such as invasion to an adjacent organ or distant metastasis at the time of diagnosis. Radical resection is the best treatment modality but effective chemotherapies have not been identified. A 58-year-old female was referred to us complaining of intermittent left upper quadrant abdominal discomfort. Imaging studies revealed a 10-cm mass in the pancreatic tail. The patient underwent laparoscopic distal pancreatectomy with splenectomy, and the pathological findings were consistent with PLM. Imaging studies 14 months after surgery revealed multiple liver metastases. Because the patient was young with a sufficient remnant liver, we performed laparoscopic metastatectomy without any postoperative complications. Patients with PLM need frequent check-ups, even after curative resection. The role of laparoscopic resection should be confirmed in the future.

Unsuspected Duplicated Gallbladder in a Patient Presenting with Acute Cholecystitis

Duplicated gallbladder (GB) is a rare congenital disease. Surgical management of a duplicated GB needs special care because of concurrent bile duct anomalies and the risk of injuring adjacent arteries during surgery. An 80-year-old man visited an emergency room with right upper quadrant abdominal pain. Computed tomography (CT) revealed cholecystitis with a 2-bodied GB. Because of this unusual finding, magnetic resonance choledochopancreatography was performed to detect possible biliary anomalies. The 2 GB bodies were unified at the neck with a common cystic duct, a so-called V-shaped duplicated GB. The patient's right posterior hepatic duct joined the common bile duct (CBD) near the cystic duct. The patient underwent laparoscopic cholecystectomy without adjacent organ injury, and was discharged uneventfully. Surgeons should carefully evaluate the patient preoperatively and select adequate surgical procedures in patients with suspected duplicated GB because of the risk of concurrent biliary anomalies.

Laparoscopic resection of hilar cholangiocarcinoma

Laparoscopic resection of hilar cholangiocarcinoma is technically challenging because it involves complicated laparoscopic procedures that include laparoscopic hepatoduodenal lymphadenectomy, hemihepatectomy with caudate lobectomy, and hepaticojejunostomy. There are currently very few reports describing this type of surgery. Between August 2014 and December 2014, 5 patients underwent total laparoscopic or laparoscopic-assisted surgery for hilar cholangiocarcinoma. Two patients with type I or II hilar cholangiocarcinoma underwent radical hilar resection. Three patients with type IIIa or IIIb cholangiocarcinoma underwent extended hemihepatectomy together with caudate lobectomy. The median (range) age, operation time, blood loss, and length of hospital stay were 63 years (43-76 years), 610 minutes (410-665 minutes), 650 mL (450-1,300 mL), and 12 days (9-21 days), respectively. Four patients had a negative margin, but 1 patient was diagnosed with high-grade dysplasia on the proximal resection margin. The median tumor size was 3.0 cm. One patient experienced postoperative biliary leakage, which resolved spontaneously. Laparoscopic resection is a feasible surgical approach in selected patients with hilar cholangiocarcinoma.

The role of de novo variants in complex and rare diseases pathogenesis

De novo variants (DNVs) can arise during parental germ cell formation, fertilization, and the processes of embryogenesis. It is estimated that each individual carries 60-100 such spontaneous variants in the genome, most of them benign. However, a number of recent studies suggested that DNVs contribute to the pathogenesis of a variety of human diseases. Applications of DNVs include aiding in clinical diagnosis and identifying disease-causing genetic factors in patients with atypical symptoms. Therefore, understanding the roles of DNVs in a trio, with healthy parents and an affected offspring, would be crucial in elucidating the genetic mechanism of disease pathogenesis in a personalized manner.

Result of using a biologic collagen implant (Permacol) for mesenteric defect repair after excision of a huge mesenteric lymphangioma in a child

Mesenteric lymphangiomas, which involve near total mesentery, are extremely rare. A mesenteric lymphangioma should be treated through excision because they can cause invasion of vital structures, bleeding, or infection. After excision of a huge mesenteric lymphangioma, internal herniation may occur through a large mesenteric defect leading to intestinal volvulus, obstruction, and other life-threatening circumstances. We report a case in which a biologic collagen implant (Permacol) was used for mesenteric defect repair after excision of a huge mesenteric lymphangioma. The implant did not cause any symptoms or complications during follow-up for 4 years. When encountering large defects of mesentery, closure with implant can be a feasible choice, and Permacol could be a possible implant for closing the defect.

A case of gallbladder cancer combined with ectopic individual opening of pancreatic and bile ducts to the duodenal bulb

Ectopic opening of the pancreatic and bile ducts (EOPBD) into the duodenal bulb is an extremely rare congenital anomaly with unknown clinical implications. We presented a case of gallbladder cancer with EOPBD into the duodenal bulb. A 57-year-old male was referred to our hospital with intermittent right upper abdominal pain. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography showed individual EOPBD into the duodenal bulb with no papillary structure, and a focal nodular lesion in the gallbladder. A follow-up abdominal computed tomography scan 9 months later revealed a slight increase in the size of the fundal nodule, which was suspected as gallbladder cancer. An intraoperative frozen biopsy identified the nodular lesion as adenocarcinoma involving the cystic duct, and the patient underwent radical cholecystectomy including bile duct resection with hepaticojejunostomy. EOPBD is an extremely rare condition that can be associated with gallbladder malignancy as well as benign disease. Clinicians should follow up carefully and consider surgical treatment for suspected malignant lesions.

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

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

Implementation of a Critical Pathway for Patients with Acute Cholecystitis

PURPOSE: Since introduction of the laparoscopic procedure for cholecystectomy, it has become the treatment of choice for symptomatic gallbladder diseases. Previous studies have demonstrated that implementation of critical pathway (CP) in laparoscopic cholecystectomy (LC) is effective in reducing cost in terms of length of stay (LOS) and revisit rates. However, few studies have proven the effectiveness of critical pathway specifically in patients with acute cholecystitis (AC). METHODS: CP was introduced for LC for chronic cholecystitis (CC) in April 2008. Then, indication for CP was extended to AC in May 2010. We compared outcomes of LC for patients with AC between two eras, including Pre-CP (Jan 2007 to Mar 2008) and Post-CP (May 2010 to Jun 2011). Among 78 patients with AC, 70 patients (90%) were enrolled for the critical pathway. Among them, 55 patients (79%) were discharged with full application of CP; however, it was suspended in 15 patients (21%). RESULTS: No differences in demographics and clinical characteristics were observed between Pre-CP (n=97) and Post-CP (n=70) patients. The mean LOS before surgery was shorter in the Post-CP group (2.6 vs. 4.0 days, p=.012). In addition, the mean total LOS was shorter in the Post-CP group (5.5 vs. 8.7 days, p<.001). However no differences in postoperative complications were observed between the two groups (10 vs. 5 cases, p=.483). CONCLUSION: Implementation of CP in AC resulted in a decrease in the LOS in total and before surgery, without increasing morbidity. Therefore, critical pathway can be safely implemented for selected patients with AC.

Metastatic follicular struma ovarii complicating pregnancy: a case report and review of the literature

A 35-year-old woman was determined to have an ovarian cyst and underwent a right ovarian cystectomy at 10 weeks of gestation. A histopathological examination revealed follicular carcinoma arising in a teratoma. No evidence of metastasis was found after delivery. She underwent a total thyroidectomy, followed by radioactive iodine (RAI) therapy. However, her serum thyroglobulin level increased to 1,437 ng/ml (normal range: 0-52 ng/ml) after 10 months. Radioiodine scintigraphy and abdominal computed tomography revealed liver metastasis and peritoneal seeding. She underwent debulking surgery of the liver, right salpinx, and peritoneal seeding nodules. A pathological examination showed metastatic follicular carcinoma with focal poorly differentiated features. Adjuvant RAI therapy was restarted, and her serum thyroglobulin levels returned to normal. In conclusion, metastatic lesions were successfully treated with a combination of debulking surgery and RAI therapy. Close medical follow-up monitoring serum thyroglobulin levels is mandatory in such patients.

Bouveret's syndrome: a case report and a review of the literature

Bouveret's syndrome is a gastric outlet obstruction caused by an impacted gallstone that passes through a cholecysto-gastric or cholecysto-duodenal fistula. An elderly woman visited a local clinic with nausea and abdominal pain. Abdominal computed tomography revealed a stone that was impacted in the duodenal lumen and a fistula between the gallbladder and duodenum. Malignancy could not be excluded due to the mass in the cystic duct showing enhancement and the presence of enlarged lymph nodes on computed tomography, and increased fludeoxyglucose uptake in the cystic duct on positron emission tomography. The patient underwent simultaneous cholecystectomy, segmental duodenectomy and gastro-jejunostomy. Pathological examination exhibited chronic inflammation and no primary cancer of the gallbladder and fistula.

A case of anaphylactic shock attributed to latex allergy during gastric cancer surgery / 대한외과학회지

Latex allergy is a known cause of allergic contact dermatitis. It produces mild symptoms, including skin rash and itching, which usually subside in a few days. However, latex allergy can also induce anaphylaxis, a severe type I hypersensitivity reaction that can cause urticaria, angioedema, hypotension, tachycardia, and bronchospasm. We report a case of anaphylactic shock during gastric cancer surgery in a patient with no previous allergic history. Surgery was suspended when hypotension, tachycardia, and wheezing developed. A thorough workup revealed that the patient had a latex allergy. The patient subsequently underwent curative gastrectomy performed with latex-free procedures.