Treatment strategies of drain after complicated laparoscopic cholecystectomy for acute cholecystitis

Acute cholecystitis (AC) is the most common biliary tract disease, and laparoscopic cholecystectomy (LC) is recognized as the treatment of choice. The present study in this issue compared the surgical outcomes, particularly the occurrence of postoperative surgical site infections (SSIs) in patients with and without drain placement following complicated LC for AC. It showed that late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications, postoperative hospital stay, and SSIs. Drain placement is not routinely recommended, even after complicated LC for AC. When placing a drain, early drain removal is recommended for postoperative outcomes such as SSIs

A new formula for estimation of standard liver volume using liver height and thoracic width

Purpose@#Precise estimation of the standard liver volume (SLV) is crucial in decision making regarding major hepatectomy and living donor liver transplantation. This study aimed to propose an accurate and efficient formula for estimating the SLV in the Korean population. @*Methods@#We created a regression model for SLV estimation using a data set of 230 Korean patients with healthy livers. The proposed model was cross validated using a different data set of 37 patients with healthy livers. The total liver volume (TLV), except for the volume of liver blood vessels, was measured through computed tomography volumetry as the dependent variable. Various anthropometric variables, liver height (LH), thoracic width (TW), age, and sex (0, female and 1, male) were considered as candidates for independent variables. We conducted stepwise regression analysis to identify variables to be included in the proposed model. @*Results@#A new formula was established; SLV = −1,275 + 9.85 × body weight (BW, kg) + 19.95 × TW (cm) + 7.401 × LH (mm). The proposed formula showed the best performance among existing formulas over the cross-validation data set. @*Conclusion@#The proposed formula derived using BW, TW, and LH estimated the TLV in the cross-validation data set more accurately than existing formulas.f

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.

Is cholecystectomy safe in extremely elderly patients?

Gallstone disease is the most common global indication for abdominal surgery. Especially acute cholecystitis in the elderly is frequently encountered due to an increasingly elderly population. Although cholecystectomy is the gold standard treatment for acute cholecystitis, the surgical management in the elderly presents specific challenges due to associated comorbidities, the severity of their presenting disease, and a greater likelihood of suffering postoperative complications and prolonged hospital stay. Further effort to provide firm evidence to clarify the safety and feasibility of cholecystectomy for acute cholecystitis in extremely elderly patients such as octogenarians and even nonagenarians.

Is cholecystectomy safe in extremely elderly patients?

Gallstone disease is the most common global indication for abdominal surgery. Especially acute cholecystitis in the elderly is frequently encountered due to an increasingly elderly population. Although cholecystectomy is the gold standard treatment for acute cholecystitis, the surgical management in the elderly presents specific challenges due to associated comorbidities, the severity of their presenting disease, and a greater likelihood of suffering postoperative complications and prolonged hospital stay. Further effort to provide firm evidence to clarify the safety and feasibility of cholecystectomy for acute cholecystitis in extremely elderly patients such as octogenarians and even nonagenarians.

Prospective Control Study of Clinical Effectivenessof Prophylactic Antibiotics in LaparoscopicCholecystectomy on Infection Rate

Purpose@#This study evaluated the effectiveness of prophylactic antibiotics in elective laparoscopic cholecystectomy (LCC) for the reduction of postoperative infection rate. @*Materials and Methods@#Elective LCC was performed on 529 patients at Jeonbuk National University Hospital between April 2015 and August 2017. A total of 509 patients were enrolled based on the inclusion criteria. This prospective study compared the results for antibiotic group (AG) (n=249, cefotetan 1 g, 1 dose/prophylactic) and non-antibiotic group (NAG) (n=260). @*Results@#There were no significant differences in clinical characteristics between the two groups: AG and NAG (p=0.580, 0.782, and 0.325, respectively). Levels of C-reactive protein were higher in NAG compared to AG at postoperative day 2 (16.6±24.2 vs. 24.2±40.6; p=0.033). There were no significant differences in white blood cell counts and erythrocyte sedimentation rate. Fever ≥38℃ on postoperative day 2 occurred in 3 (1.2%) and 9 (3%) patients in AG and NAG, respectively. One patient in each group had subhepatic fluid collection by abdominal computed tomography, but there was no evidence of infection. Two patients in NAG (3%) had serous wound drainage on postoperative day 14. @*Conclusion@#Our results showed no significant differences in patients receiving or not receiving prophylactic antibiotics during LCC. Therefore, it is not necessary to use prophylactic antibiotics during elective LCC in patients who meet the inclusion criteria.

Validation of the 8th AJCC Cancer Staging System for Pancreas Neuroendocrine Tumors Using Korean Nationwide Surgery Database / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The 8th edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic neuroendocrine tumor (PNET) included several significant changes. We aim to evaluate this staging system compared to the 7th edition AJCC staging system and European Neuroendocrine Tumors Society (ENETS) system. MATERIALS AND METHODS: We used Korean nationwide surgery database (2000-2014). Of 972 patients who had undergone surgery for PNET, excluding patients diagnosed with ENETS/World Health Organization 2010 grade 3 (G3), only 472 patients with accurate stage were included. RESULTS: Poor discrimination in overall survival rate (OSR) was noted between AJCC 8th stage III and IV (p=0.180). The disease-free survival (DFS) curves of 8th AJCC classification were well separated between all stages. Compared with stage I, the hazard ratio of II, III, and IV was 3.808, 13.928, and 30.618, respectively (p=0.007, p < 0.001, and p < 0.001). The curves of OSR and DFS of certain prognostic group in AJCC 7th and ENETS overlapped. In ENETS staging system, no significant difference in DFS between stage IIB versus IIIA (p=0.909) and IIIA versus IIIB (p=0.291). In multivariable analysis, lymphovascular invasion (p=0.002), perineural invasion (p=0.003), and grade (p < 0.001) were identified as independent prognostic factors for DFS. CONCLUSION: This is the first large-scale validation of the AJCC 8th edition staging system for PNET. The revised 8th system provides better discrimination compared to that of the 7th edition and ENETS TNM system. This supports the clinical use of the system.

Estimation of Standard Liver Volume Using CT Volume, Body Composition, and Abdominal Geometry Measurements

PURPOSE: The present study developed formulas for estimation of standard liver volume (SLV) with high accuracy for the Korean population. MATERIALS AND METHODS: SLV estimation formulas were established using gender-balanced and gender-unbalanced measurements of anthropometric variables, body composition variables, and abdominal geometry of healthy Koreans (n=790). Total liver volume excluding blood volume, was measured based on CT volumetry. RESULTS: SLV estimation formulas as preferred in various conditions of data availability were suggested in the present study. The suggested SLV estimation formulas in the present study were found superior to existing formulas, with an increased accuracy of 4.0–217.5 mL for absolute error and 0.2–18.7% for percentage of absolute error. CONCLUSION: SLV estimation formulas using gender-balanced measurements showed better performance than those using gender-unbalanced measurements. Inclusion of body composition and abdominal geometry variables contributed to improved performance of SLV estimation.

Donor Complication in Living Donor Liver Transplantation / 대한이식학회지

Living donor liver transplantation (LDLT) has become an inevitable procedure due a shortage of deceased donors under the influence of religious and native cultures. The most important concern in LDLT is donor safety. This study reviewed the safety of LDLT donors from reported studies of morbidity and mortality. Many studies have reported mortality and morbidity rates ranging from 0% to 33% for healthy liver donors. Use of laparoscopic surgery on LDLT donors has advantages of reduced blood loss, lower postoperative morbidity and shorter hospital stay relative to conventional open surgery. There is a consensus that remnant liver volume (RLV), degree of steatosis, and donor age are the most important factors influencing donor safety. In LDLT, donor hepatectomy can be performed successfully with minimal and easily controlled complications. However, a large-scale prospective cohort study is needed to better understand the risk factors and accurately determine the complication rates for LDLT.

Predictive Factors of Malignant Potential in Gallbladder Polyps / 대한췌담도학회지

BACKGROUND/AIMS: Although the incidence of GB polyps is increasing with improved surveillance, the study of predictive factors of malignant potential has not been sufficient. The aim of this retrospective study is to investigate the predictive factors of malignant potential in GB polyps. METHODS: Among 3,159 patients with laparoscopic cholecystectomy in Chonbuk National University hospital January 2009 to December 2013, 437 patients confirmed GB polyps pathologically were enrolled. The patients were divided into two groups; one with benign GB polyp and another with GB adenoma and incidental GB cancer. RESULTS: Group I with benign GB polyp was seen in 359 patients. On the other hand, 53 patients with GB adenoma and 25 patients with GB cancer in gourp II were identified. The patients in group II had shown a significantly higher incidence of age older than 50 years (53/78, 67.9% vs. 163/359, 45.4%, p=0.001), size larger than 10mm (40/78, 51.3% vs. 37/359, 10.3%, p<0.001), and GB wall thickening (36/78, 46.2% vs. 77/359, 21.5%, p<0.001). The presence of GB stone had not shown significant differences between two groups (26/78, 33.3% vs. 96/359, 26.7%, p=0.378). CONCLUSIONS: Cholecystectomy should be considered for the patients with GB polyp with these predictive factors.

Usefulness of Artificial Jump Graft to Portal Vein Thrombosis in Deceased Donor Liver Transplantation

Severe portal vein thrombosis (PVT) is often considered a relative contraindication for living donor liver transplantation due to high associated risks and morbidity. Meanwhile, improvement in operative techniques, resulting in higher success rates has removed PVT from the list of contraindications in deceased donor liver transplantation (DDLT). In this report, we describe a surgical technique for DDLT using polytetrafluoroethylene graft from the inferior mesenteric vein for portal inflow in patient with portomesenteric thrombosis.

SPA0355 attenuates ischemia/reperfusion-induced liver injury in mice

Hepatic ischemia/reperfusion (I/R) injury leads to oxidative stress and acute inflammatory responses that cause liver damage and have a considerable impact on the postoperative outcome. Much research has been performed to develop possible protective techniques. We aimed to investigate the efficacy of SPA0355, a synthetic thiourea analog, in an animal model of hepatic I/R injury. Male C57BL/6 mice underwent normothermic partial liver ischemia for 45 min followed by varying periods of reperfusion. The animals were divided into three groups: sham operated, I/R and SPA0355 pretreated. Pretreatment with SPA0355 protected against hepatic I/R injury, as indicated by the decreased levels of serum aminotransferase and reduced parenchymal necrosis and apoptosis. Liver synthetic function was also restored by SPA0355 as reflected by the prolonged prothrombin time. To gain insight into the mechanism involved in this protection, we measured the activity of nuclear factor-kappaB (NF-kappaB), which revealed that SPA0355 suppressed the nuclear translocation and DNA binding of NF-kappaB subunits. Concomitantly, the expression of NF-kappaB target genes such as IL-1beta, IL-6, TNF-alpha and iNOS was significantly downregulated. Lastly, the liver antioxidant enzymes superoxide dismutase, catalase and glutathione were upregulated by SPA0355 treatment, which correlated with the reduction in serum malondialdehyde. Our results suggest that SPA0355 pretreatment prior to I/R injury could be an effective method to reduce liver damage.

Clinicopathological characteristics and prognostic factors in combined hepatocellular carcinoma and cholangiocarcinoma

BACKGROUNDS/AIMS: Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is an uncommon subtype of primary liver cancer that has rarely been reported in detail. This study was performed in order to evaluate the clinicopathological characteristics and prognostic factors of cHCC-CC in single center. METHODS: The clinicopathological features of patients diagnosed and operated with cHCC-CC at Chonbuk National Hospital between July 1998 and July 2007 were retrospectively studied by comparing them with patients with only hepatocellular carcinoma (HCC) who had undergone a hepatic resection during the same period. RESULTS: Ten out of 152 patients who had undergone a hepatic resection were diagnosed with cHCC-CC and thus included in this study (M : F=8 : 2, median age: 52+/-11.1 years). According to the parameters of the 7th American Joint Committee on Cancer T staging, there were 76 (50.0%), 44 (28.9%), 9 (5.9%), 18 (11.8%) and 5 (3.3%) patients with T stages 1, 2, 3a, 3b and 4, respectively. The overall survival period was longer in the HCC only group (68+/-40.4 months) than in the combined cHCC-CC group (23+/-40.1 months) (p<0.0001). The 5-year survival rate was 10% in the cHCC-CC group and 60% in the HCC group (p<0.0001). The disease free survival for patients with cHCC-HCC and HCC were 16+/-37.4 and 51+/-44.3 months, respectively (p<0.0001). Univariate analysis revealed that age, gender, transarterial chemoembolization (TACE), and T stage were statistically significant in terms of patient's overall survival. However, there were no significant clinicopathological factors identified by the multivariate analysis. CONCLUSIONS: Even after the hepatic resection in the HCC, the prognosis is poorer if the patient has cholangiocellular components compared to the usual HCC.

Mucinous Non-neoplastic Cyst of the Pancreas

No abstract available.

Analyze the Patency Rates according to Risk Factors and Comorbidities in Patients with Chronic Arterial Occlusive Disease in Lower Extremity / 대한혈관외과학회지

PURPOSE: The aim of this study is to analyze the patency rates according to the risk factors and comorbidities in patients treated with endovascular treatments or arterial bypass surgery due to chronic arterial occlusive disease in the lower extremity. METHODS: Two hundred fifty-seven patients were treated for chronic arterial occlusive disease in lower extremity from January 2000 to December 2010 at Chonbuk National University Hospital; of the 257 patients, we retrospectively reviewed medical records of 142 patients who could be followed-up. We analyzed the patency rates according to the Trans-Atlantic Inter-Society Consensus (TASC) II classification, risk factors and comorbidities. RESULTS: One year, three year, and five year patency rates according to TASC classification had no statistical significance (P=0.301), and those risk factors and comorbidities associated with each other also had no statistical significance. However, the patency rates according to the number of risk factors and comorbidities demonstrated statistical significance (P=0.004), respectively. In addition, when sum of the total number was above 6, the patency rates were the poorest with statistical significance (P<0.001). Also, these analyses had statistical significance in the groups regarding TASC C, D (P<0.001), aorto-iliac lesions (P<0.001) and femoro-popliteal lesions (P<0.001). CONCLUSION: Analysis of risk factors and comorbidities in patients with chronic arterial occlusive disease in the lower extremity can be useful in predicting the patency rates prior to endovascular treatments or arterial bypass surgeries.

Development of the Rectus Abdominis and Its Sheath in the Human Fetus

PURPOSE: Although the rectus abdominis and its sheath are well known structures, their development in the human fetus is poorly understood. MATERIALS AND METHODS: We examined rectus abdominis and sheath development in semiserial horizontal sections of 18 fetuses at 5-9 weeks of gestation. RESULTS: Rectus muscle differentiation was found to commence above the umbilicus at 6 weeks and extend inferiorly. Until closure of the anterior chest wall via fusion of the bilateral sternal anlagen (at 7 weeks), the anterior rectal sheath originated from the external oblique and developed towards the medial margin of the rectus abdominis at all levels, including the supracostal part. After formation of the anterior sheath, fascial laminae from the internal oblique and transversus abdominis contributed to formation of the posterior rectus sheath. However, the posterior sheath was absent along the supracostal part of the rectus abdominis, as the transversus muscle fibers reached the sternum or the midline area. Therefore, it appeared that resolution of the physiological umbilical hernia (8-9 weeks) as well as chest wall closure was not required for development of the rectus abdominis and its sheath. Conversely, in the inferior part of the two largest fetal specimens, after resolution of the hernia, the posterior sheath underwent secondary disappearance, possibly due to changes in mechanical stress. CONCLUSION: Upward extension of the rectus abdominis suddenly stopped at the margin of the inferiorly developing pectoralis major without facing the external intercostalis. The rectus thoracis, if present, might correspond to the pectoralis.

Surgical outcomes and prognostic factors influencing long-term survival in patients with gallbladder cancer

BACKGROUNDS/AIMS: The aim of this study is to analyze surgical outcomes and prognostic factors affecting survival after surgical resection in patients with gallbladder cancer. METHODS: We retrospectively reviewed 86 patients treated surgically for gallbladder cancer from January 2000 to December 2009 at Chonbuk National University Hospital. Clinicopathologic factors, surgical treatment and outcome data were analyzed. RESULTS: Among the 86 patients (44 male, 42 female) with gallbladder cancer, the mean age was 62.9 years (range: 32-80) and the median survival was 42.4+/-3.5 month. The overall cumulative survival rates of 86 patients were for 1 year, 83.7%; 3 year, 67.4%; 5 year survival, 61.7%. Univariate analysis revealed that preoperative serum alanine aminotransferase, alkaline phosphatase, total bilirubin, carcinoembryonic antigen (CEA), T staging, N staging were statistically significantly associated with survival. CEA (p=0.004) and T staging (p=0.005) were associated with survival in multivariate analysis. Two-year survival rates were analyzed according to the methods of surgical resection, with simple cholecystectomy showing 100%, whereas extended cholecystectomy showed about 83% in T1b. We could not find out any adverse effect of the simple cholecystectomy for survival. CONCLUSIONS: CEA and T stage are independent significant prognostic factor associated with patient survival in our study. Simple cholecystectomy can be regarded as curative resection in stage T1b. Longer observation periods and more cases will be needed to confirm these conclusions.

Ciliated hepatic foregut cyst / 대한간학회지

No abstract available.

Endovascular Treatment of an Internal Iliac Artery Aneurysm Using Amplatzer Vascular Plug: 2 Case Reports / 대한혈관외과학회지

To report endovascular occlusion of an internal iliac artery aneurysm (IIAA) of two patients using Amplatzer vascular plug (AVP; AGA Medical Corporation, USA). A 69-year-old asymptomatic man had aneurysms of both internal iliac arteries. The size of the right (Rt) IIAA was 23 mm and that of the left (Lt) IIAA was 45 mm. We decided to induce vascular occlusion of the Lt internal iliac artery (IIA). We deployed an AVP in the proximal and distal Lt IIA. The patient was discharged after four days and showed no recurrence of aneurysm for one year. A 78-year-old women had lower abdominal pain for three days. Computed tomography scan showed a 43 mm Rt common iliac artery (CIA) aneurysm and a 38 mm Rt IIAA. We decided to insert a stent graft in the Rt CIA and to occlude the Rt IIA using AVP. We deployed the stent graft in the Rt CIA and the AVP in the distal Rt IIA. The patient was discharged after seven days and demonstrated no recurrence of aneurysm for four months. AVP is a feasible vascular occlusive device for internal iliac artery aneurysm.

Scoring of prognostic factors that influence long-term survival in patients with hepatic metastasis of colorectal cancer

BACKGROUNDS/AIMS: To find independent predictors that affect the survival in patients with hepatic metastasis of colorectal cancer after surgery and to devise a risk scoring system. METHODS: Among 150 patients who underwent hepatic resection after diagnosis of colorectal cancer with hepatic metastasis between March 1994 and February 2009, we analyzed clinical, pathologic and outcome data retrospectively. RESULTS: The 1-year survival rate was 83%, and the 5-year survival rate was 35%. Nine factors were found to be independent predictors of adverse outcome by univariate analysis: stage of primary tumor, CA19-9 >36 U/ml, extrahepatic disease, distribution of the hepatic tumor, number of hepatic tumors >3, largest hepatic tumor >5 cm, total size >10 cm, CEA >10 ng/ml, and metachronous cancer. The last two of these criteria were also significant risk factors on multivariate analysis. When these criteria were used as a risk scoring system, assigning one point for each criterion and dividing the cases into A, B and C groups, the total score was highly predictive of outcomes (p<0.001). No patients in group C (6 to 9 points) were long-term survivors. CONCLUSIONS: Long-term outcome can be predicted from nine criteria that are readily available for all patients. Patients meeting up to two criteria (group A) are more likely to have a favorable outcome compared to the three or over (groups B and C). This scoring system may offer an easy, rapid, and reliable prognostic indicator of survival outcome after hepatic resection in patients with hepatic metastasis from colorectal cancer.