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.

Early Clinical Outcomes of Tricuspid Valve Repair with a Tri-Ad Annuloplasty Ring in Comparison with the Outcomes Using an MC³ Ring

BACKGROUND: We evaluated the early clinical outcomes of tricuspid valve annuloplasty (TAP) with the Tri-Ad annuloplasty ring for functional tricuspid regurgitation (TR). METHODS: From January 2015 to March 2017, 36 patients underwent TAP with a Tri-Ad ring for functional TR. To evaluate the early clinical outcomes of TAP with the Tri-Ad ring, we conducted a propensity score-matched analysis comparing the Tri-Ad and MC3 tricuspid annuloplasty rings (n=34 in each group). The follow-up duration was 11.0±7.07 months. RESULTS: There was 1 case of operative mortality (2.8%) and no cases of late mortality. Postoperative complications occurred in 15 patients (41%), including acute kidney injury in 6 patients (16%), bleeding requiring reoperation in 4 patients (11%), and low cardiac output syndrome in 4 patients (11%). There were no ring-related complications, such as atrioventricular block or ring dehiscence. The TR grade decreased significantly (from 2.03±1.06 to 1.18±0.92, p < 0.01), as did the systolic pulmonary artery pressure (from 43.53±13.84 to 38.00±9.72 mm Hg, p=0.03). There were no cases of severe residual TR, but moderate TR was observed in 3 patients, all of whom had severe TR preoperatively. Severe preoperative TR was also associated with moderate in the univariate analysis (p < 0.01). In the propensity score-matched analysis comparing the Tri-Ad and MC3 rings, there was no significant difference in early clinical outcomes. CONCLUSION: TAP with the Tri-Ad ring corrected functional TR effectively and provided good early clinical and echocardiographic results without ring-related complications. However, severe preoperative TR was associated with moderate or severe residual TR in the immediate postoperative period. A follow-up study is necessary to confirm the stability of this procedure.

Primary Intrapulmonary Thymoma Presenting as a Solitary Pulmonary Nodule

Primary intrapulmonary thymoma (PIT) is a very rare lesion of uncertain pathogenesis. PIT should be considered when the histopathological appearance of a lung tumor shows features that are uncommon but similar to those of a thymoma. In this case report, we discuss the case of a 59-year-old female with a solitary pulmonary nodule that was confirmed to be PIT on the basis of pathological tests. Treatment with complete resection showed good results.

Initial Experiences using Robot-assisted Distal Pancreatectomy: A Single Institution Study of 28 Patients

PURPOSE: Surgical procedures using robot-assisted surgery, including pancreatic surgery, have recently become popular. This study aimed to report our initial experiences with distal pancreatectomy procedures using the robot-assisted surgery system. METHODS: The clinical records of 28 patients who underwent robot-assisted distal pancreatectomy (RDP) between July 2012 and January 2016 were reviewed. RESULTS: Of the 28 patients, 5 (17.9%) were male and 23 (82.1%) were female. Their ages ranged from 11 to 78 years, with a median age of 44.5 years. The mean diameter of the pancreatic tumors was 3.6 cm. The median operative time was 192.5 (range, 100~390) minutes, and the median blood loss was 200 (range, 50~1,900) ml. All of the 28 RDPs were successfully completed. Spleen preservation was achieved in 16 (57.1%) patients. Clinically significant postoperative pancreatic fistula was detected in 4 (14.3%) patients. Postoperative complications were evident in 5 (17.9%) of the 28 patients. CONCLUSION: Our experiences suggest that RDP is feasible for patients with benign or borderline tumors at the body or tail of the pancreas. It may be considered as an effective surgical procedure for benign or borderline tumors of the pancreas in the future; however, further studies to confirm this are warranted.

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.

Timing of Cholecystectomy after Percutaneous Cholecystostomy for Acute Cholecystitis / 대한소화기학회지

BACKGROUND/AIMS: Laparoscopic cholecystectomy is the standard treatment for acute cholecystitis. Percutaneous cholecystostomy is an alternative treatment to resolve acute inflammation in patients with severe comorbidities. The purpose of this study is to determine the optimal timing of laparoscopic cholecystectomy after percutaneous cholecystostomy for the patients with acute cholecystitis. METHODS: This retrospective study was conducted in patients who underwent cholecystectomy after percutaneous cholecystostomy from January 2010 through November 2014. Seventy-four patients were included in this study. The patients were divided into two groups by the operation timing. Group I patients underwent cholecystectomy within 10 days after percutaneous cholecystostomy (n=30) and group II patients underwent cholecystectomy at more than 10 days after percutaneous cholecystostomy (n=44). RESULTS: There was no significant difference between groups in conversion rate to open surgery, operation time, perioperative complications rate, and days of hospital stay after operation. However, complications related to cholecystostomy such as catheter dislodgement occurred significantly more often in group II than group I (group I:group II=0%:18.2%; p=0.013). CONCLUSIONS: Timing of laparoscopic cholecystectomy after percutaneous cholecystostomy did not influence postoperative outcomes. However, late surgery caused more complications related to cholecystostomy than early surgery. Therefore, early laparoscopic cholecystectomy should be considered over late surgery after percutaneous cholecystostomy insertion.

Clinical features and survival outcome of locally advanced extrahepatic cholangiocarcinoma

BACKGROUNDS/AIMS: Little is known about clinical features and survival outcome in locally advanced unresectable extrahepatic cholangiocarcinoma (EHC). The aim was to investigate the clinical features and the survival outcome in these patients, and to evaluate the role of palliative resections in locally advanced unresectable EHC. METHODS: Between 1995 and 2007, 280 patients with locally advanced unresectable EHC were identified. Clinical, pathologic, and survival data were investigated. A comparative analysis was done between those who received palliative resection (PR) and those who were not operated on (NR). RESULTS: The overall median survival of the study population was 10+/-1 months, and the 3- and 5-year survival rates (YSR) were 8.5% and 2.5%, respectively. The median survival, 3- and 5-YSR of PR were 23 months, 32.1% and 13.1%, respectively. For NR, they were 9 months, 3.9% and 0%, which were significantly worse than PR (p<0.001). In univariate analysis, T classification, N classification, tumor location, palliative resection, adjuvant treatment, chemotherapy, and radiation therapy were factors that showed survival difference between PR and NR. Regional lymph node metastasis (RR, 2.084; 95% CI, 1.491-2.914; p<0.001), non-resections (RR, 2.270; 95% CI, 1.497-3.443; p<0.001), and no chemotherapy (RR, 1.604; 95% CI, 1.095-2.349; p=0.015) were identified as risk factors for poor outcome on multivariate analysis. CONCLUSIONS: Without evidence of systemic disease, palliative resection may provide some survival benefit in selected locally advanced unresectable EHCs and adjuvant treatment may further improve survival outcome.

Factors Associated with Re-excision after Breast-Conserving Surgery for Early-Stage Breast Cancer / 한국유방암학회지

PURPOSE: Re-excisions after breast-conserving surgery (BCS) for breast cancer cause delays in the adjuvant treatment, increased morbidity, and leads to poor aesthetic results. Thus, efforts to reduce the re-excision rate are essential. This study aimed to conclusively determine the re-excision rate and the factors associated with re-excision after BCS. METHODS: We retrospectively reviewed the medical records and pathological reports of 711 cases that underwent BCS for early-stage breast cancer. Univariate and multivariate analyses were performed. RESULTS: Of the 711 cases of BCS, 71 (10.0%) required re-excision. Patients in the re-excision group were younger than those in the no re-excision group. Non-palpable lesions, the presence of non-mass-like enhancement at magnetic resonance imaging, multifocality, the presence of a ductal carcinoma in situ (DCIS) component, and an infiltrative tumor border were also significantly associated with re-excision. Multivariate analysis indicated that younger age, non-palpable lesions, multifocal lesions, and the presence of a DCIS component were factors which were independently associated with re-excision. Tumors located in the lower inner quadrant had a relatively high involved resection margin rate as well as a narrow resection margin width, especially at the superior and medial margins. Lateral margins showed a tendency toward a wider resection margin width. CONCLUSION: At our institution, the rate of re-excision was low despite the lack of an intraoperative frozen section. Patients with non-palpable or multifocal tumors, a DCIS component, or those who were younger than 50 years were more likely to require re-excision after BCS. These factors should be considered when planning surgical management of early-stage breast cancer. Positive resection margin rates and margin widths differed on a directional basis based on tumor location, and these differences were considerable.