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.

Determining the etiology of small bowel obstruction in patients without intraabdominal operative history: a retrospective study

Purpose@#Most of the causes of small bowel obstruction (SBO) in patients without a history of abdominal surgery are unclear at initial assessment. This study was conducted to identify the etiology and clinical characteristics of SBO in virgin abdomens and discuss the proper management. @*Methods@#A retrospective review involving operative cases of SBO from a single institute, which had no history of abdominal surgery, was conducted between January 2010 and December 2020. Clinical information, including radiological, operative, and pathologic findings, was investigated to determine the etiology of SBO. @*Results@#A total of 55 patients were included in this study, with a median age of 57 years and male sex (63.6%) constituting the majority. The most frequently reported symptoms were abdominal pain and nausea or vomiting. Neoplasm as an underlying cause accounted for 34.5% of the cases, of which 25.5% were malignant cases. In patients aged ≥60 years (n=23), small bowel neoplasms were the underlying cause in 12 (52.2%), of whom 9 (39.1%) were malignant cases. Adhesions and Crohn disease were more frequent in patients aged <60 years. Coherence between preoperative computed tomography scans and intraoperative findings was found in 63.6% of the cases. @*Conclusion@#There were various causes of surgical cases of SBO in virgin abdomens. In older patients, hidden malignancy should be considered as a possible cause of SBO in a virgin abdomen. Patients with symptoms of recurrent bowel obstruction who have no history of prior abdominal surgery require thorough medical history and close follow-up.

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.

The Management of Retained Rectal Foreign Body

Purpose@#Because insertion of a foreign body (FB) into the anus is considered a taboo practice, patients with a retained rectal FB may hesitate to obtain medical care, and attending surgeons may lack experience with removing these FBs. We performed this study to evaluate the clinical characteristics of Korean patients with a retained rectal FB and propose management guideline for such cases based on our experience. @*Methods@#We retrospectively investigated 14 patients between January 2006 and December 2018. We assessed demographic features, mechanism of FB insertion, clinical course between diagnosis and management, and outcomes. @*Results@#All patients were male (mean age, 43 years) and presented with low abdominal pain (n = 2), anal bleeding (n = 2), or concern about a retained rectal FB without symptoms (n = 10). FB insertion was most commonly associated with sexual gratification or anal eroticism (n = 11, 78.6%). All patients underwent general anesthesia for anal sphincter relaxation with the exception of 2 who underwent FB removal in the emergency department. FBs were retrieved transanally using a clamp (n = 2), myoma screw (n = 1), clamp application following abdominal wall compression (n = 2), or laparotomy followed by rectosigmoid colon milking (n = 2). Colotomy and primary repair were performed in four patients, and Hartmann operation was performed in one patient with fecal peritonitis. No morbidity or mortality was reported. All patients refused postextraction anorectal functional and anatomical evaluation and psychological counseling. @*Conclusion@#Retained rectal FB is rare; however, colorectal surgeons should be aware of the various methods that can be used for FB retrieval and the therapeutic algorithm applicable in such cases.

Single-Incision, Two-Port Laparoscopic Appendectomy as an Alternative to Transumbilical Single-Port Laparoscopic Appendectomy

PURPOSE: We designed a modified technique to perform an advanced procedure using conventional instruments and did not employ specialized single-incision laparoscopic surgery (SILS) port equipment. We compared postoperative results for transumbilical, single-port laparoscopic appendectomy (TUSPLA) and single-incision, 2-port laparoscopic appendectomy (SITPLA). METHODS: This retrospective study enrolled 77 patients who underwent TUSPLA or SITPLA to provide more minimally invasive surgery between May 2017 and April 2018. TUSPLA was performed in 39 patients and 38 underwent SITPLA. In the SITPLA group, two 5-mm trocars were inserted through the umbilicus and an extra puncture site was used for a left-handed instrument. Demographic characteristics, operative data, and postoperative outcomes were collected and compared between the groups. RESULTS: The mean total operative time in the SITPLA group was shorter than in the TUSPLA group (p=0.003). The mean laparoscopic instrumental time was also shorter (p<0.001) in the SITPLA. The number of postoperative analgesics in the SITPLA group was less than in the TUSPLA group (p=0.002). The length of hospital day after surgery was shorter in the SITPLA group than in the TUSPLA group (p=0.008). There were no other significant differences between the groups. CONCLUSION: SITPLA had a shorter operative time, required less pain management, and had a similar cosmetic outcome when compared with TUSPLA.

Primary Neuroendocrine Tumor of the Extrahepatic Bile Duct / 대한소화기학회지

No abstract available.

Clinical Manifestations of Superior Mesenteric Venous Thrombosis in the Era of Computed Tomography

PURPOSE: Thrombosis of the portal vein, known as pylephlebitis, is a rare and fatal complication caused by intraperitoneal infections. The disease progression of superior mesenteric venous thrombosis (SMVT) is not severe. This study aimed to determine the clinical features, etiology, and prognosis of SMVT. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 41 patients with SMVT from March 2000 to February 2017. We obtained a list of 305 patients through the International Classification of Disease-9 code system and selected 41 patients with SMVT with computed tomography. Data from the medical records included patient demographics, comorbidities, review of system, laboratory results, clinical courses, and treatment modalities. RESULTS: The causes of SMVT were found to be intraperitoneal inflammation in 27 patients (65.9%), malignancy in 7 patients (17.1%), and unknown in 7 patients (17.1%). Among the patients with intraperitoneal inflammation, 14 presented with appendicitis (51.9%), 7 with diverticulitis (25.9%), and 2 with ileus (7.4%). When comparing patients with and without small bowel resection, the differences in symptom duration, bowel enhancement and blood culture were significant (P=0.010, P=0.039, and P=0.028, respectively). CONCLUSION: SMVT, caused by intraperitoneal inflammation, unlike portal vein thrombosis including pylephlebitis, shows mild prognosis. In addition, rapid symptom progression and positive blood culture can be the prognostic factors related to extensive bowel resection. Use of appropriate antibiotics and understanding of disease progression can help improve the outcomes of patients with SMVT.

Difficult diagnosis and localization of focal nesidioblastosis: clinical implications of ⁶⁸Gallium-DOTA-D-Phe¹-Tyr³-octreotide PET scanning

Focal nesidioblastosis is a rare cause of endogenous hyperinsulinemic hypoglycemia in adults. Because it is difficult to localize and detect with current imaging modalities, nesidioblastosis is challenging for biliary-pancreatic surgeons. ⁶⁸Gallium-DOTA-D-Phe¹-Tyr³-octreotide PET scanning and ¹¹¹indium-pentetreotide diethylene triamine pentaacetic acid octreotide scanning may be superior to conventional imaging modalities in determining the localization of nesidioblastosis. We report the successful surgical treatment of a 54-year-old woman with focal hyperplasia of the islets of Langerhans, who experienced frequent hypoglycemic symptoms and underwent various diagnostic examinations with different results.

Difficult diagnosis and localization of focal nesidioblastosis: clinical implications of ⁶⁸Gallium-DOTA-D-Phe¹-Tyr³-octreotide PET scanning

Focal nesidioblastosis is a rare cause of endogenous hyperinsulinemic hypoglycemia in adults. Because it is difficult to localize and detect with current imaging modalities, nesidioblastosis is challenging for biliary-pancreatic surgeons. ⁶⁸Gallium-DOTA-D-Phe¹-Tyr³-octreotide PET scanning and ¹¹¹indium-pentetreotide diethylene triamine pentaacetic acid octreotide scanning may be superior to conventional imaging modalities in determining the localization of nesidioblastosis. We report the successful surgical treatment of a 54-year-old woman with focal hyperplasia of the islets of Langerhans, who experienced frequent hypoglycemic symptoms and underwent various diagnostic examinations with different results.

Effects of Surgical Methods and Tumor Location on Survival and Recurrence Patterns after Curative Resection in Patients with T2 Gallbladder Cancer

BACKGROUND/AIMS: Extended cholecystectomy is generally recommended for patients with T2 gallbladder cancer. However, few studies have assessed the extent of resection relative to T2 gallbladder tumor location. This study analyzed the effects of surgical methods and tumor location on survival outcomes and tumor recurrence in patients with T2 gallbladder cancer. METHODS: Clinicopathological characteristics, extent of resection, survival rates, and recurrence patterns were retrospectively analyzed in 88 patients with pathologically confirmed T2 gallbladder cancer. RESULTS: The 5-year disease-free survival rate was 65.0%. Multivariate analysis showed that lymph node metastasis was the only independent risk factor for poor 5-year disease-free survival rate. Survival outcomes were not associated with tumor location. Survival tended to be better in patients who underwent extended cholecystectomy than in those who underwent simple cholecystectomy. Recurrence rate was not affected by surgical method or tumor location. Systemic recurrence was more frequent than local recurrence without distant recurrence. Gallbladder bed recurrence and liver recurrence were relatively rare, occurring only in patients with liver side tumors. CONCLUSIONS: Extended cholecystectomy is the most appropriate treatment for T2 gallbladder cancer. However, simple cholecystectomy with regional lymph node dissection may be appropriate for patients with serosal side tumors.

Atypical Varicose Veins in the Popliteal Fossa Unrelated to Small Saphenous Vein Reflux

PURPOSE: To analyze the causes, clinical features, and computed tomography (CT) images of atypical varicose veins in the popliteal fossa unrelated to small saphenous vein (SSV) reflux by three-dimensional CT venography (3D-CTV). METHODS: A total of 1,476 limbs in 794 consecutive patients with varicose veins who underwent surgery from 2005 to 2009 were enrolled. The medical records, duplex ultrasound, and 3D-CTV images were analyzed retrospectively. RESULTS: Varicose veins in the popliteal fossa (PFV) were found in 438 of 1,476 limbs; the PFV in 428 limbs (97.5%) were caused by SSV insufficiency. Ten limbs (2.5%) had atypical PFV unrelated to the SSV. Incompetent perforator of the PPF was found in six of ten limbs (four women and two men; median age, 58-years). The CEAP clinical classes were C2 in four limbs and C4 in two limbs. The PPF drained to the popliteal vein in five limbs and to the gastrocnemial vein in one limb. A perforator ligation was performed in all patients, and additional sclerotherapy was performed in one patient. Thigh or calf perforator insufficiency was found in three limbs (two women and one man; median age, 62.7-years). The CEAP clinical classes were C2 in two limbs and C3 in one limb. Great saphenous vein insufficiency with Giacomini vein reflux was found in one limb (woman, 67-years). CONCLUSION: An exact preoperative understanding of the anatomy and flow dynamics is essential for the proper treatment of rare atypical PFV. A preoperative evaluation with 3D-CTV can provide accurate anatomical information for the surgery.

A case of Congenital patent urachus / 대한비뇨기과학회지

The complex group of changes which occurs during the intrauterine maturation of the urinary tract gives rise to several anomalies including those of the urachus. The occurrence of patent urachus is very rare and 67 cases has been reported by world literature since 1550, first description of patent urachus by Bartholomaeus Gabriolus A brief discussion of embryology, diagnosis and treatment is included for completeness. And a case of congenital patent urachus was seen at Han Ill Hospital.