Optimal drain management following complicated laparoscopic cholecystectomy for acute cholecystitis: a propensity-matched comparative study

Purpose@#This study was performed to investigate the effect of drain placement on complicated laparoscopic cholecystectomy (cLC) for acute cholecystitis (AC). @*Methods@#This single-center retrospective study reviewed patients with AC who underwent cLC between January 2010 and December 2020. cLC was defined as open conversion, subtotal cholecystectomy, adjacent organ injury during surgery, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL. One-toone propensity score matching was performed to compare the surgical outcomes between patients with and without drain on cLC. @*Results@#A total of 216 patients (mean age, 65.8 years; 75 female patients [34.7%]) underwent cLC, and 126 (58.3%) underwent intraoperative abdominal drainage. In the propensity score-matched cohort (61 patients in each group), early drain removal (≤postoperative day 3) was performed in 42 patients (68.9%). The overall rate of surgical site infection (SSI) was 10.7%. Late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications (13.1% vs. 21.4% vs. 47.4%, p = 0.006), postoperative hospital stay (3.8 days vs. 4.4 days vs. 12.7 days, p < 0.001), and SSI (4.9% vs. 11.9% vs. 31.6%, p = 0.006). In the multivariate analysis, late drain removal was the most significant risk factor for organ space SSI. @*Conclusion@#This study demonstrated that drain placement is not routinely recommended, even after cLC for AC. When placing a drain, early drain removal is recommended because late drain removal is associated with a higher risk of organ space SSI.

Efficacy of sentinel lymph node biopsy with radioisotope alone and the prediction of sentinel node status using PET-CT in breast cancer

Purpose@#Sentinel lymph node biopsy (SLNB) using both a radioactive isotope (RI) and blue dye is considered highly effective; however, there were limitations with the use of both agents in some hospitals, and blue dye has been shown to have some adverse effects. Additionally, preoperative prediction of sentinel lymph node (SLN) status using the maximum standardized uptake value (SUVmax) on positron emission tomography-computed tomography (PET-CT) can help avoid unnecessary axillary dissection or SLNB. Thus, we evaluated the efficacy and oncologic safety of SLNB using an RI alone in terms of long-term outcomes and determined the association between SLN metastasis and SUVmax of the primary tumor. @*Methods@#This retrospective study was conducted at Konyang University Hospital between March 2011 and May 2018. Overall, 142 patients with breast cancer who underwent SLNB using an RI alone were enrolled. Data on identification and false-negative rates were collected. The SUVmax of primary tumors on PET-CT were analyzed for their association with SLN metastasis. @*Results@#The identification and false-negative rates were 98.6% and 0%, respectively. There was no axillary local recurrence in patients with negative SLN findings. The correlation between the SUVmax of the primary tumor and SLN status was significant (r=0.249, P=0.005); the cutoff value for negative SLN metastasis was <2.15. @*Conclusion@#The single agent method using an RI is not inferior to other methods and serves as a feasible option for SLNB. And the number of excised SLNs could be minimized when the SUVmax of primary tumor is extremely low.

Efficacy of sentinel lymph node biopsy with radioisotope alone and the prediction of sentinel node status using PET-CT in breast cancer

Purpose@#Sentinel lymph node biopsy (SLNB) using both a radioactive isotope (RI) and blue dye is considered highly effective; however, there were limitations with the use of both agents in some hospitals, and blue dye has been shown to have some adverse effects. Additionally, preoperative prediction of sentinel lymph node (SLN) status using the maximum standardized uptake value (SUVmax) on positron emission tomography-computed tomography (PET-CT) can help avoid unnecessary axillary dissection or SLNB. Thus, we evaluated the efficacy and oncologic safety of SLNB using an RI alone in terms of long-term outcomes and determined the association between SLN metastasis and SUVmax of the primary tumor. @*Methods@#This retrospective study was conducted at Konyang University Hospital between March 2011 and May 2018. Overall, 142 patients with breast cancer who underwent SLNB using an RI alone were enrolled. Data on identification and false-negative rates were collected. The SUVmax of primary tumors on PET-CT were analyzed for their association with SLN metastasis. @*Results@#The identification and false-negative rates were 98.6% and 0%, respectively. There was no axillary local recurrence in patients with negative SLN findings. The correlation between the SUVmax of the primary tumor and SLN status was significant (r=0.249, P=0.005); the cutoff value for negative SLN metastasis was <2.15. @*Conclusion@#The single agent method using an RI is not inferior to other methods and serves as a feasible option for SLNB. And the number of excised SLNs could be minimized when the SUVmax of primary tumor is extremely low.

The Usefulness of Preoperative Colonoscopic Tattooing with Autologous Blood for Localization in Laparoscopic Colorectal Surgery

Purpose@#In colorectal cancer surgery, it is important to have accurate resection margins. However, it is challenging to localize lesions during laparoscopy. Therefore, to reduce surgical errors, many preoperative localizing methods have been introduced. In this study, we aimed to assess the preoperative feasibility and safety of autologous blood tattooing. @*Methods@#A total of 11 patients underwent preoperative colonoscopic autologous blood tattooing from August 2017 to February 2020. At the start of the surgery, the surgeon assessed the patients for the precision of visibility and other complications such as abscess or spillage. The patients’ characteristics, outcomes, and complications were collected retrospectively. @*Results@#The study comprised 8 men and 3 women, with an average age of 63 years. Ten patients showed precise visibility, and no localization errors were observed during surgery. No complication was observed in all patients. @*Conclusion@#Preoperative autologous blood tattooing is a very useful and safe technique because it has high visibility with no complications. This method does not require additional agents or facilities. A large-scale study will be required to develop standard guidelines.

Which Patients Are a Better Candidate of Laparoscopic Repair in Obturator Hernia Patients?

Purpose@#Obturator hernia is a difficult disease to diagnose. If a surgical treatment is delayed in obturator hernia, a bowel resection may be required due to strangulation. The surgical treatment of this disease is to use a classical laparotomy. Recently, the laparoscopic approach has been reported and reviewed for efficiency. We checked the indicators that determine the most appropriate surgical method according to the patient’s condition. @*Methods@#In the study, a single-institution, retrospective analysis of surgical patients undergoing an obturator hernia surgery between 2003 and 2018 was performed. The patients were divided into a laparoscopic group (5 patients underwent laparoscopic repair; no intestinal resection) and an open group (13 patients who underwent open repair; 10 with and 3 without intestinal resection). The outcomes were compared between the groups. We analyzed the relevant factors that could predict the proper method of surgery. @*Results@#A total 18 patients were included in the study. All patients were female, with body mass index (BMI) of under 21 kg/m2. Of the various factors, only the WBC and CRP counts were the factors that had shown significant differences between the two groups. It is noted that patients with open surgery had a higher WBC counts (10406 versus 6520/μl; p=0.011) and CRP counts (7.84 vs. 0.32 mg/dl; p=0.027). @*Conclusion@#Obturator hernia can be treated with a laparoscopic surgery. The choice of surgical treatment can be considered in advance through the review of the patient’s WBC count or CRP count.

Effects of remifentanil preconditioning on factors related to uterine contraction in WISH cells

BACKGROUND: Preterm labor and miscarriage may occur in stressful situations, such as a surgical operation or infection during pregnancy. Pharyngeal and buccal abscess and facial bone fractures are inevitable dental surgeries in pregnant patients. Remifentanil is an opioid analgesic that is commonly used for general anesthesia and sedation. Nonetheless, no study has investigated the effects of remifentanil on amniotic epithelial cells. This study evaluated the effects of remifentanil on the factors related to uterine contraction and its mechanism of action on amniotic epithelial cells.METHODS: Amniotic epithelial cells were preconditioned at various concentrations of remifentanil for 1 h, followed by 24-h lipopolysaccharide (LPS) exposure. MTT assays were performed to assess the cell viability in each group. The effects of remifentanil on factors related to uterine contractions in amniotic epithelial cells were assessed using a nitric oxide (NO) assay, western blot examinations of the expression of nuclear factor-kappa B (NF-κB), cyclooxygenase 2 (COX2), and prostaglandin E2 (PGE₂), and RT-PCR examinations of the expression of the proinflammatory cytokines interleukin (IL)-1β and tumor necrosis factor-alpha (TNF-α).RESULTS: Remifentanil did not affect viability and nitric oxide production of amniotic epithelial cells. Western blot analysis revealed that remifentanil preconditioning resulted in decreased expressions of NF-κB and PGE2 in the cells in LPS-induced inflammation, and a tendency of decreased COX2 expression. The results were statistically significant only at high concentration. RT-PCR revealed reduced expressions of IL-1β and TNF-α.CONCLUSION: Preconditioning with remifentanil does not affect the viability of amniotic epithelial cells but reduces the expression of factors related to uterine contractions in situations where cell inflammation is induced by LPS, which is an important inducer of preterm labor. These findings provide evidence that remifentanil may inhibit preterm labor in clinical settings.

Preliminary Findings on the Effectiveness of Meaning-Centered Psychotherapy in Patients with Pancreatobiliary Cancer

PURPOSE: This study investigated the effectiveness of meaning-centered psychotherapy (MCP), which is known to be a helpful psychotherapeutic intervention in distressing conditions, for patients with pancreatobiliary cancer. MATERIALS AND METHODS: We recruited 37 patients with pancreatobiliary cancer from three university general hospitals and assessed their psychological characteristics. Patients who reported clinically significant emotional distress were recommended to undergo MCP. Patients who consented to MCP were provided four sessions of the therapy. Patient psychological characteristics were assessed again 2 months after MCP. For statistical comparison, outcome variables included anxiety, depression, mental adjustment to cancer, and quality of life (QoL), as well as the degree of stress and physical symptoms. RESULTS: Sixteen patients completed the MCP and the final assessment 2 months later. In the initial assessment, the patients receiving MCP showed higher levels of anxiety and depression than those not receiving MCP, and QoL was also lower in terms of role function, emotional function, social function, and global QoL. At the 2-month follow-up, the MCP group showed a significant improvement in anxiety (p=0.007), depression (p=0.010), and anxious preoccupation (p < 0.001). In addition, QoL significantly improved in the MCP group, while there was no significant change in the non-MCP group. CONCLUSION: In this study, MCP showed potential therapeutic benefits against emotional distress in patients with pancreatobiliary cancer, improving their QoL.

Evolution of the Konyang Standard Method for single incision laparoscopic cholecystectomy: the result from a thousand case of a single center experience

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is increasingly performed worldwide. Accordingly, the Konyang Standard Method (KSM) for SILC has been developed over the past 6 years. We report the outcomes of our procedures. METHODS: Between April 2010 and December 2016, 1,005 patients underwent SILC at Konyang University Hospital. Initially 3-channel SILC with KSM was changed to 4-channel SILC using a modified technique with a snake retractor for exposure of Calot triangle; we called this a modified KSM (mKSM). Recently, we have used a commercial 4-channel (Glove) port for simplicity. RESULTS: SILC was performed in 323 patients with the KSM, in 645 with the mKSM, and in 37 with the commercial 4-channel port. Age was not significantly different between the 3 groups (P = 0.942). The postoperative hospital days (P = 0.051), operative time (P < 0.001) and intraoperative bleeding volume (P < 0.001) were significantly improved in the 3 groups. Drain insertion (P = 0.214), additional port insertion (P = 0.639), and postoperative complications (P = 0.608) were not significantly different in all groups. Postoperative complications were evaluated with the Clavien-Dindo classification. There were 3 cases (0.9%) over grade IIIb (bile duct injury, incisional hernia, duodenal perforation, or small bowel injury) with KSM and 3 (0.5%) with mKSM. CONCLUSION: We evaluated the evolution of the KSM for SILC. The use of the mKSM with a commercial 4-channel port may be the safest and most effective method for SILC.

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.

Effect of remifentanil on pre-osteoclast cell differentiation in vitro

BACKGROUND: The structure and function of bone tissue is maintained through a constant remodeling process, which is maintained by the balance between osteoblasts and osteoclasts. The failure of bone remodeling can lead to pathological conditions of bone structure and function. Remifentanil is currently used as a narcotic analgesic agent in general anesthesia and sedation. However, the effect of remifentanil on osteoclasts has not been studied. Therefore, we investigated the effect of remifentanil on pre-osteoclast (pre-OCs) differentiation and the mechanism of osteoclast differentiation in the absence of specific stimulus. METHODS: Pre-OCs were obtained by culturing bone marrow-derived macrophages (BMMs) in osteoclastogenic medium for 2 days and then treated with various concentration of remifentanil. The mRNA expression of NFATc1 and c-fos was examined by using real-time PCR. We also examined the effect of remifentanil on the osteoclast-specific genes TRAP, cathepsin K, calcitonin receptor, and DC-STAMP. Finally, we examined the influence of remifentanil on the migration of pre-OCs by using the Boyden chamber assay. RESULTS: Remifentanil increased pre-OC differentiation and osteoclast size, but did not affect the mRNA expression of NFATc1 and c-fos or significantly affect the expression of TRAP, cathepsin K, calcitonin receptor, and DC-STAMP. However, remifentanil increased the migration of pre-OCs. CONCLUSIONS: This study suggested that remifentanil promotes the differentiation of pre-OCs and induces maturation, such as increasing osteoclast size. In addition, the increase in osteoclast size was mediated by the enhancement of pre-OC migration and cell fusion.

Single Incision Laparoscopic Appendectomy for Management of Complicated Appendicitis: Comparison between Single-Incision and Conventional

PURPOSE: Single incision laparoscopic appendectomy (SILA) is a widely used surgical procedure for treatment of appendicitis with better cosmesis. However, many surgeons generally tend to choose conventional multiport laparoscopic appendectomy regarding with complicated appendicitis. The aim of this study is to demonstrate the safety and feasibility of SILA for treatment of complicated appendicitis by comparison with 3-ports conventional laparoscopic appendectomy (CLA). METHODS: Retrospective chart review of patients diagnosed appendicitis at single hospital during January 2015 to May 2017 collected 500 patients. Among 134 patients with complicated appendicitis, we compared outcomes for 29 patients who got SILA and 105 patients who got CLA. RESULTS: 179 and 321 patients were treated by SILA and CLA, respectively. 134 (26.8%) patients were treated for complicated appendicitis, 29 patients by SILA and 105 patients by CLA, respectively. There was no case converted to open or added additional trocar in both groups. There were no differences in demographics with regard to age, sex, body mass index (BMI), and American society of anesthesiologists (ASA) scores. There was no difference in mean operating time (58.97±18.53 (SILA) vs. 57.57±21.48 (CLA), p=0.751). The drain insertion rate (6.9% vs 37.1%, p=0.001) and the length of hospital stay (2.76±1.41 vs. 3.97±2.97, p=0.035) were lower in SILA group with significance. There was no significant difference in the rate of surgical site infection (6.9% vs. 6.7%, p=1.000). CONCLUSION: This study demonstrates that SILA is a feasible and safe procedure for treatment of complicated appendicitis.

Human epidermal growth factor receptor 2 expression in gastric cancer patients treated with curative intent gastrectomy

PURPOSE: This study aimed to clarify the association between human epidermal growth factor receptor 2 (HER-2) status and the clinicopathologic factors of patients who underwent curative intent gastrectomy.METHODS: From June 2011 to May 2015, curative intent gastrectomy was performed in 441 patients at Konyang University Hospital. Among them, we evaluated the HER-2 status in 113 patients. Data on clinicopathologic parameters such as age, sex, histological subtype, endoscopic Lauren classification, tumor location, size, presence of lymphovascular invasion, invasion depth, pathologic stage, HER-2 overexpression, recurrence and survival were obtained. In this study, pathological HER-2 intensity scores of 0, 1+, and 2+ were assumed to be negative, 3+ only was to be positive for overexpression.RESULTS: In a total of 113 cases who underwent curative intent gastrectomy with HER-2 testing, 16 (14.2%) cases had positivity of HER-2 overexpression. HER-2 overexpression had significant associations with tumor stage (19.0% in I-IIIb vs. 2.9% in IIIc-IV, P=0.036). Survival analysis of HER2 overexpression has no significant difference.CONCLUSION: In this study, HER-2 overexpression rate was 14.2% and patient tumor stage had significant association with HER-2 overexpression.

Predictive factor for excessive myelosuppression in patients receiving chemotherapy for breast cancer

PURPOSE: Myelosuppression, particularly neutropenia, is one of the most frequent and serious toxicity seen in patients with breast cancer undergoing systemic chemotherapy. However, the predictive factors for development of severe neutropenia in chemotherapy remain unknown. We therefore evaluated predictive factors for excessive myelosuppression.METHODS: We retrospectively analyzed 341 patients with breast cancer treated with chemotherapy from 2000 to 2012. Clinicopathological characteristics, number of using of granulocyte colony-stimulating factor (G-CSF), and pretreatment hematologic values were extracted from the electronic medical record system. Patients were sorted 2 groups by number of using G-CSF in each chemotherapeutic regimens; group 1 is more G-CSF (within high 20 percentile) and 2 less G-CSF using group (within lower 20 percentile).RESULTS: Number of using G-CSF was ranged 0–83 (mean 10.76). One hundred one patients were in group 1 and 65 patients were in group 2. Mean of number of G-CSF using was 0.21 in group 1 and 28.02 in group 2. Pretreatment white blood cell, hemoglobin and platelet count were lower in group 2 than in group 1 (6.88×10³/µL vs. 5.97×10³/µL, 12.63 g/dL vs. 11.90 g/dL, and 275.95×10⁴ µL vs. 227.37×10⁴ µL). There were no statistically differences in other clinicopathologic characteristics such as age, body mass index or comorbidities, hormonal receptor, stage, and other pretreatment hematologic values.CONCLUSION: Pretreatment white blood cell count, hemoglobin and platelet count can be used to identify patients at increased risk of significant myelosuppression undergoing chemotherapy with breast cancer. This information can be used to target high-risk patients for prophylactic treatment.

Risk factors for conversion to conventional laparoscopic cholecystectomy in single incision laparoscopic cholecystectomy

PURPOSE: The aim of this study was to investigate the risk factors for conversion to conventional laparoscopic cholecystectomy (CLC) in single incision laparoscopic cholecystectomy (SILC) along with the proposal for procedure selection guidelines in treating patients with benign gallbladder (GB) diseases. METHODS: SILC was performed in 697 cases between April 2010 and July 2014. Seventeen cases (2.4%) underwent conversion to conventional LC. We compared these 2 groups and analyzed the risk factors for conversion to CLC. RESULTS: In univariate analysis, American Society of Anesthesiologist score > 3, preoperative percutaneous transhepatic GB drainage status and pathology (acute cholecystitis or GB empyema) were significant risk factors for conversion (P = 0.010, P = 0.019 and P < 0.001). In multivariate analysis, pathology (acute cholecystitis or GB empyema) was significant risk factors for conversion to CLC in SILC (P < 0.001). CONCLUSION: Although SILC is a feasible method for most patients with benign GB disease, CLC has to be considered in patients with acute cholecystitis or GB empyema because it is likely to result in inadequate visualization of the Calot's triangle and greater bleeding risk.

Effects of propofol-induced autophagy against oxidative stress in human osteoblasts

BACKGROUND: Oxidative stress occurs during the aging process and other conditions such as bone fracture, bone diseases, and osteoporosis, but the role of oxidative stress in bone remodeling is unknown. Propofol exerts antioxidant effects, but the mechanisms of propofol preconditioning on oxidative stress have not been fully explained. Therefore, the aim of this study was to evaluate the protective effects of propofol against H2O2-induced oxidative stress on a human fetal osteoblast (hFOB) cell line via activation of autophagy. METHODS: Cells were randomly divided into the following groups: control cells were incubated in normoxia (5% CO2, 21% O2, and 74% N2) without propofol. Hydrogen peroxide (H2O2) group cells were exposed to H2O2 (200 µM) for 2 h, propofol preconditioning (PPC)/H2O2 group cells were pretreated with propofol then exposed to H2O2, 3-methyladenine (3-MA)/PPC/H2O2 cells were pretreated with 3-MA (1 mM) and propofol, then were exposed to H2O2. Cell viability and apoptosis were evaluated. Osteoblast maturation was determined by assaying bone nodular mineralization. Expression levels of bone related proteins were determined by western blot. RESULTS: Cell viability and bone nodular mineralization were decreased significantly by H2O2, and this effect was rescued by propofol preconditioning. Propofol preconditioning effectively decreased H2O2-induced hFOB cell apoptosis. However, pretreatment with 3-MA inhibited the protective effect of propofol. In western blot analysis, propofol preconditioning increased protein levels of collagen type I, BMP-2, osterix, and TGF-β1. CONCLUSIONS: This study suggests that propofol preconditioning has a protective effect on H2O2-induced hFOB cell death, which is mediated by autophagy activation.

Comparison of the Clinical Outcomes between Anti-thymocyte Globulin and Basiliximab Induction Therapy in Deceased Donor Kidney Transplantation: Single Center Experience / 대한이식학회지

BACKGROUND: The aim of this study is to evaluate the clinical outcomes between anti-thymocyte globulin (ATG) and basiliximab induction in deceased donor kidney transplantation (DDKT). METHODS: Between May 2006 and February 2015, 40 patients underwent DDKT at our institution. Three cases (7.5%) of them were lost during the following-up schedule. In this study, ATG induction criteria were donor age >50 years old or donor creatinine level >1.3 mg/dL except hepatitis B virus positive and hepatitis C virus positive recipients. Recipients were divided into two groups: the ATG group (n=20) and the basiliximab group (n=17). RESULTS: The 1-year patient survival in the ATG group was 89.4% compared to 93.8% in the basiliximab group (P=0.989). Graft survival for a 1 year in the ATG and the basiliximab group was 89.1% and 93.8%, respectively (P=0.967). Incidences of acute rejection episodes were more prevalent in the basiliximab group (15.0% vs. 29.4%, P=0.428). The glomerular filtration rate level by period of recipients was not different in both group (12th month, 64.60+/-16.17 mg/dL vs. 68.51+/-18.60 mg/dL, P=0.544). The overall complications during the follow-up were not significantly different in both groups (90.0% vs. 76.5%, P=0.383). CONCLUSIONS: The results showed that there was no difference in the patient survival and graft survival between induction of ATG and basiliximab of the DDKT were not different. Therefore, use of both induction agents led to a good patient and graft survival and ATG might be a safe and preferable agent for relatively poor renal function of donor in kidney transplantation.

Feasibility of implementing a surgical student internship program in South Korea

PURPOSE: Despite recommendations for introducing student internships (SI) in undergraduate medical education in Korea, the feasibility of surgical SIs has not been demonstrated in the Korean context. We thus identified tasks that could be performed by surgical student interns in a Korean education hospital. METHODS: The opinions of surgery clerkship directors of medical schools nationwide, regarding the tasks, symptoms and signs, disease entities, and procedures that student interns could perform in their hospitals, were subjected to descriptive analysis. RESULTS: Out of the 41 medical schools in Korea, 32 responded. Five implemented an optimal-quality SI program. Two schools considered third-year clerkship as SI. The respondents replied that student interns could be involved in basic nonspecific tasks such as history taking, physical examination, medial recording, reporting patients' status, and assisting during surgery. However, more surgery-specific tasks such as perioperative management or caring for a patient with acute abdominal pain were considered difficult for student interns to encounter in the Korean context. CONCLUSION: Surgical educators should determine a specific role for student interns and encourage them to perform surgery-specific tasks. We recommend societal and system support, and curriculum renovation to establish an SI program in Korea.

Risk factors for prolonged operative time in single-incision laparoscopic cholecystectomy

PURPOSE: We performed 3-channel single incision laparoscopic cholecystectomy (SILC) in earlier period of this study and modified our method to 4-channel SILC using a snake retractor for better operative field in later period. This study has been designed to evaluate the risk factors for prolonged operative time in SILC. METHODS: From April 2010 to August 2014, 323 cases of 3-channel SILC (Konyang standard method [KSM] group) and 399 cases of 4-channel SILC (modified KSM [mKSM] group) using a snake retractor were performed. RESULTS: The clinical characteristics were not significantly different between KSM and mKSM group except preoperative percutaneous transhepatic gallbladder drainage (PTGBD) treatment (9.6% vs. 16.5%, P 30 kg/m2 as well as the 4-channel SILC. CONCLUSION: Among patients with these risk factors, conventional laparoscopic cholecystectomy could be considered as well although SILC might be safe and feasible modality for benign gallbladder disease.

Four-channel single incision laparoscopic cholecystectomy using a snake retractor: comparison between 3- and 4-channel SILC 4-channel single incision cholecystectomy

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is a widely used method of performing cholecystectomy. A common technique used in SILC is a 3-channel method. However, exposure of Calot's triangle is limited in conventional 3-channel SILC. Therefore, we herein report the adequacy and feasibility of 4-channel SILC using a snake retractor. METHODS: Four hundred and fifteen SILC cases were performed between April 2010 and February 2013. We performed 326 SILC cases between April 2010 and September 2012 using the 3-channel method. We introduced a snake retractor for liver traction in October 2012, and 89 cases of 4-channel SILC using snake retractor have been performed since. RESULTS: Thirty patients (9.2%) in the 3-channel SILC group, and 23 patients (25.8%) in the 4-channel SILC group, were treated with percutaneous transhepatic gallbladder drainage insertion because of acute inflammation of the gallbladder (GB) before operation (P < 0.001). The mean operating time was 53.0 +/- 25.8 minutes in the 3-channel SILC group and 51.9 +/- 18.6 minutes in the 4-channel SILC group (P = 0.709). In the 3-channel SILC group, mean hospital stay was 3.0 +/- 3.3 days whereas it was 2.6 +/- 0.9 days in the 4-channel SILC group (P = 0.043). There were a total 9 cases (2.1%) of additional port usages, 6 cases (1.8%) in the 3-channel SILC group and 3 cases (3.4%) in the 4-channel SILC group (P = 0.411), due to cystic artery bleeding and bile leakage from gallbladder bed, but there were no open conversions. CONCLUSION: Benign diseases of the GB can be operated on using SILC with the 4-channel method using a snake retractor.

Research for Modification of Emergency Status in Deceased Donor Liver Allocation: Survival Analysis of Waiting Patients for Liver Transplantation / 대한이식학회지

Despite a remarkable increase of deceased donors, organ shortage is the main hurdle of organ transplantation in Korea. Therefore, liver transplantation priority is a major issue of liver allocation. We confront a situation that needs to change in order to achieve more adequate and objective allocation of the system. We considered the MELD system as an alternative to the CTP score and Status system. For application of the MELD system, comparison between two systems is required; and a national-based retrospective review of liver transplantation candidates (waiting list) was conducted as a multi-center collaborative study. Eleven transplant centers participated in this national study. From 2009 to 2012, 2,702 waiting lists were enrolled. After mean 349+/-412 days follow-up, 967 patients (35.8%) of liver transplantation, 750 patients (27.8%) of drop-out/mortality, and 719 patients (26.6%) on waiting were identified. In analysis of patient mortality during waiting time, status system showed significant difference of waiting mortality by status at registration. However, differences of waiting mortality by MELD system were more prominent and discriminate. In comparisons by MELD score in exclusive Status 2A waiting patients, there was a significant difference of waiting mortality by MELD score. This means that the MELD system is a good predictor of short-term survival after listing compared with status system with CTP score. Korean national-based retrospective study showed the superiority of the MELD system in prediction of short-term mortality and usefulness as a determinant for allocation priority.