Multiple intussusceptions after blunt abdominal trauma in a 9-year-old boy: A case report and literature review.

Traumatic intussusception is exceedingly rare. According to the existing literature, most cases are treated surgically. However, the treatment and prognosis of traumatic intussusception are not well understood, and more research is needed to determine the most beneficial treatment options. Multiple intussusceptions were found on a computed tomography scan of a 9-year-old boy with multiple severe traumatic injuries resulting from a car accident while riding an electric scooter. Conservative management was performed, and spontaneous reduction was successfully achieved without complications. This is the first reported case where multiple traumatic intussusceptions in a pediatric patient were managed without surgical intervention. Thus, traumatic intussusception of varied quantity and quality might be managed conservatively, yielding spontaneous resolution with the prerequisites of stable vital signs and no evidence of intestinal ischemia or perforation.

Inner Ear Symptoms Are Prevalent in Patients with High Head Abbreviated Injury Scale Scores after Blunt Head Trauma.

INTRODUCTION: The purpose of this article was to determine the prevalence of inner ear symptoms in patients with blunt head trauma and to explore whether the severity of head trauma was associated with the incidence of such symptoms. METHODS: We performed a retrospective review of 56 patients admitted with blunt head trauma who underwent audiovestibular evaluation within 1 month after injury. Two scales were used to measure the severity of trauma; these were the Glasgow Coma Scale (GCS) and the Head Abbreviated Injury Scale (H-AIS). Patients with sensorineural-type hearing loss, or dizziness with nystagmus, were considered to have inner ear symptoms. RESULTS: About half of all patients (45%) with blunt head trauma showed trauma-related inner ear symptoms. Patients with inner ear symptoms were significantly more likely to have H-AIS scores ≥4 than those without inner ear symptoms (p = 0.004), even without concomitant temporal bone fracture (p > 0.05). Also, patients with inner ear symptoms required a statistically significantly longer time (measured from admission) before undergoing their ontological evaluations than did those without such symptoms (p = 0.002), possibly due to prolonged bed rest and use of sedatives. CONCLUSION: Thus, detailed history-taking and early evaluation using trauma scales are essential for all patients suffering from severe head trauma. It may be necessary to initiate early treatment of traumatic inner ear diseases.

A course on endovascular training for resuscitative endovascular balloon occlusion of the aorta: a pilot study for residents and specialists.

PURPOSE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as a salvage technique changing the paradigm in the management of noncompressible torso hemorrhage. However, training for the REBOA procedure is rarely performed. The endovascular training for REBOA (ET-REBOA) course was conducted to develop the endovascular skills of participants. METHODS: Sixteen residents and 12 specialists participated in this educational course. All participants were provided with precourse learning materials. The ET-REBOA course consisted of 2 sections; an ultrasound-guided sheath insertion on the puncture model, and a balloon manipulation on the vascular circuit model. A 13-item procedure checklist and the time required to perform the procedure were examined. Pre/post self-reported confidence score and course satisfaction questionnaire were obtained. RESULTS: Twenty-eight participants performed the 56 REBOA procedures. On the first attempt, the median total time for REBOA from ultrasound-guided vascular access to balloon inflation was 1,139 ± 250 seconds in the resident group and 828 ± 280 seconds in the specialist group. The median shortened time for completion was 273 seconds and 290 seconds respectively. A significant decrease in procedure task time was observed between first and second attempts in the resident group (P = 0.016), specialist group (P = 0.004), and in total among all participants (P < 0.001). CONCLUSION: The ET-REBOA course significantly decreased the time taken to perform the REBOA procedure with high satisfaction of the participants. The course could be an effective curriculum for the development of endovascular skills for performing REBOA.

Effect of early enteral nutrition on the incidence of acute acalculous cholecystitis among trauma patients.

BACKGROUND AND OBJECTIVES: Acute acalculous cholecystitis (AAC) often occurs in critically ill patients, especially in those that have experienced trauma, surgery, shock, and prolonged fasting. Early enteral nutrition has been shown to significantly reduce morbidity and mortality compared to other nutritional support strategies. The purpose of this study was to evaluate the effect of early enteral nutrition on the incidence of AAC among trauma patients. METHODS AND STUDY DESIGN: Multi-strategy nutritional protocol was implemented in the intensive care unit (ICU) in 2016 for early enteral nutrition and proper nutritional support. The traumatized critically-ill patients without volitional intake who were admitted to ICU between 2015 and 2017 were included. Basic characteristics, duration of fasting, and the incidence of percutaneous cholecystostomy (PC) due to AAC were analyzed according to the year. RESULTS: Enteral nutrition was indicated in 552 trauma patients (28.2%). The mean duration of fasting was shortened from 6.5 days in 2015 to 5.4 days in 2017 (p=0.202). The incidence of PC was significantly decreased from 2015 to 2017 [6/171 (3.5%) vs. 6/204 (2.9%) vs. 0/177 (0%), p=0.023]. The provision of central parenteral nutrition (p=0.001) and fasting over 7 days (p=0.014) proved to be a risk factor of AAC. CONCLUSIONS: This study showed that the incidence of PC due to AAC was decreased significantly after the implementation of a nutritional protocol among traumatized critically ill patients. Early enteral nutrition may be effective in reducing the AAC among trauma patients who are at high risk of AAC.

Impacts of Social Distancing During the COVID-19 Outbreaks in Korea: Level 1 Trauma Center Data of Domestic Incidents and Intentional Injury.

OBJECTIVES: As a protective measure to slow down the transmission of coronavirus disease 2019 in Korea, social distancing was implemented from February 29th, 2020. This study aimed to evaluate the prevalence of domestic incidents and intentional injury during March 2020 when social distancing was in effect. METHODS: There were 12,638 patients who visited the Level 1 trauma center of Chungnam province with injuries from domestic incidents, familial discord, and intentional injury. The prevalence of injuries during March 2020 was compared with the average of the previous 5 years, and the average for every March between 2015 and 2019. RESULTS: The prevalence of domestic incidents in March 2020 was significantly higher than the 5-year average, and the average for every March from 2015 to 2019 (p < 0.001). Familial discord (p = 0.002) and intentional injury (p = 0.031) were more frequently observed in March 2020. Adolescents showed a markedly higher level of intentional injury in March 2020 than in both the 5-year average (p = 0.031), and average for every March over the previous 5 years (p = 0.037). CONCLUSION: The prevalence of domestic incidents and intentional injury were significantly higher during the period of social distancing in Korea. There is a need for social consensus, better policies, and psychological support services, especially if faced with a second or third wave of coronavirus disease.

Are management decisions in critical patients changed with use of hemodynamic parameters from transpulmonary thermodilution technique?

BACKGROUND: The assessment of hemodynamic variables is a mainstay in the management of critically ill patients. Hemodynamic variables may help physicians to choose among use of a vasopressor, an inotropic agent, or discontinuation of drugs. In this study, we aimed to investigate the usefulness of advanced hemodynamic variables in clinical decision-making. METHODS: Surveys regarding the case were administered to 25 surgeons working in nationally designated trauma centers or on trauma teams, using a voting system at a medical conference. The patient was a 67-year-old male with a crush injury of the left leg after a pedestrian traffic accident, who had aggravated pulmonary edema after leg amputation. Three clinical situations were given and the decision choices were: immediately after amputation, in 8 hours, and on the second day after amputation. Three kinds of variables from hemodynamic monitoring systems were provided for each clinical situation: conventional hemodynamic variables, including central venous pressure; variables from pulse contour analysis (PCA) [cardiac output (CO), stroke volume index, stroke volume variation (SVV), and systemic vascular resistance index); and variables from transpulmonary thermodilution (TPTD) technique (global ejection fraction and extravascular lung water index). The changes in decisions according to each provided hemodynamic variable were investigated and analyzed. RESULTS: The advanced hemodynamic parameters were considered to have a decisive effect on choosing vasopressors and inotropic agents. The decision was changed in 88% (22/25) of physicians using variables from the advanced monitoring systems. Among them, 82% (18/22) of physicians chose hemodynamic variables from the TPTD technique as their reason for change regarding management of a patient with severe pulmonary edema. CONCLUSIONS: Advanced monitoring systems might be helpful in decision-making for critically ill patients. Multiple parameters and trends in change could be more important than a single value. Clinicians should select the system most appropriate according to its advantages and limitations, and interpret the variables obtained correctly.

Comparison of long-term clinical outcomes of external and internal pancreatic stents in pancreaticoduodenectomy: randomized controlled study.

BACKGROUND: To determine the most appropriate pancreatic drainage method, by investigating differences in 12-month clinical outcomes in patients implanted with external and internal pancreatic stents as an extension to a previous study on short-term outcome. METHODS: This prospective randomized controlled trial enrolled 213 patients who underwent pancreaticoduodenectomy with duct to mucosa pancreaticojejunostomy between August 2010 and January 2014 (NCT01023594). Of the 185 patients followed-up for 12 months, 97 underwent external and 88 underwent internal stenting. Their long-term clinical outcomes were compared. RESULTS: Overall late complication rates were similar in the external and internal stent groups (P = 0.621). The percentage of patients with >50% atrophy of the remnant pancreatic volume after 12 months was similar in both groups (P = 0.580). Factors associated with pancreatic exocrine or endocrine function, including stool elastase level (P = 0.571) and rate of new-onset diabetes (P = 0.179), were also comparable. There were no significant between-group differences in quality of life, as evaluated by the EORTC QLQ-C30 and QLQ PAN26 questionnaires. CONCLUSION: External and internal stents showed comparable long-term, as well as short-term clinical outcomes, including late complication rates, preservation of pancreatic duct diameters, pancreatic volume changes with functional derangements, and quality of life after surgery.

Blunt trauma of unilateral intraperitoneal kidney: A case report.

The kidney is located and fixed with Gerota's fascia in the retroperitoneal space and is surrounded by a fat pad that acts as a shock absorber in the normal anatomy; however, the kidney becomes more vulnerable to external shock when it is located intraperitoneally. Bleeding from an injury may advance to hemoperitoneum and unstable hemodynamics may develop, requiring emergency surgery. Although various anatomical variations of the kidney have been reported, to our knowledge, an intraperitoneal kidney has never been reported previously except for one case in the world literature. This paper describes a successful nephrectomy of a unilateral intraperitoneal kidney in a 69-year-old woman who had grade IV laceration based on the renal injury scale of the American Association for the Surgery of Trauma with unstable hemodynamics after blunt trauma.

Prognostic significance of E-cadherin and ZEB1 expression in intraductal papillary mucinous neoplasm.

There is an urgent need to investigate the genetic changes that occur in intraductal papillary mucinous neoplasm (IPMN), which is a well-known precursor of pancreatic cancer. In this study, gene expression profiling was performed by removing unwanted variation to determine the differentially expressed genes (DEGs) associated with malignant progression of IPMN. Among the identified DEGs, zinc finger E-box binding homeobox 1 (ZEB1) and E-cadherin, a crucial regulator of epithelial-to-mesenchymal transition (EMT), was validated among identified DEGs. A total of 76 fresh-frozen tissues were used for gene expression profiling and formalin-fixed, paraffin-embedded blocks from 87 patients were obtained for immunohistochemical analysis. Loss of E-cadherin expression (p = 0.023, odd ratio [OR] = 4.923) and expression of ZEB1 in stromal cells (stromal ZEB1, p < 0.001, OR = 26.800) were significantly correlated with degree of dysplasia. The hazard of death was significantly increased in patients with loss of E-cadherin expression (hazard ratio [HR] = 13.718, p = 0.004), expression of epithelial ZEB1 (HR = 19.117, p = 0.001), and stromal ZEB1 (HR = 6.373, p = 0.043). Based on the results of this study, loss of E-cadherin and expression of stromal ZEB1 are associated with increased risk of malignant progression. Epithelial and stromal ZEB1, as well as E-cadherin may be strong predictors of survival in patients with IPMN. Our finding suggests that these EMT markers may be utilized as potential prognosticators and may be used to improve and personalize treatment of IPMN.

Prediction of Pancreatic Fistula After Distal Pancreatectomy Based on Cross-Sectional Images.

BACKGROUND: Postoperative pancreatic fistula (POPF) is one of the most common and clinically relevant complications after distal pancreatectomy (DP), occurring in 5-40% of patients. Determining risk factors for this complication may aid in its prevention. This study sought to predict the development of POPF after DP preoperatively and objectively based on radiologic findings. METHODS: This study included 60 patients who underwent DP using a stapler for pancreatic division between June 2011 and January 2013. Fatty infiltration, apparent diffusion coefficients (ADC) on preoperative MRI, pathologic fat, and fibrosis were measured. Pancreatic thickness and cross-sectional area of the pancreas stump on CT scan were also measured. RESULTS: Mean patient age was 60.5 years, 26 patients (46.3%) had pancreatic cancer and 20 (33.3%) underwent laparoscopic surgery. Clinically relevant POPF was observed in 12 patients (20.0%). Linear regression analysis showed a significant correlation between fat quantification on MRI and pathologic fat (pathologic fat = 1.978 × MR fat -6.393, p < 0.001, R 2 = 0.777). Univariate analysis showed that ≤8% fat on MRI (p = 0.040), ≤5% pathologic fat (p = 0.002), ADC ≤ 1.3 × 10-3 mm2/s (p = 0.020), thicker pancreas (p = 0.007), and wider cross-sectional area of the pancreas (p = 0.013) were significantly associated with clinically relevant POPF after DP. Multivariate analysis revealed that pancreas thickness >17.6 mm [odds ratio (OR) 6.532, p = 0.064] and cross-sectional area >377 mm2 (OR 12.676, p = 0.052) were marginally related to clinically relevant POPF. CONCLUSIONS: Pancreatic thickness and cross-sectional area of the transected surface of the pancreas are marginally significant risk factors for POPF development after DP. Measuring pancreatic thickness and cross-sectional area can be a promising tool for the preoperative prediction of POPF.

Effect of Polyglycolic Acid Mesh for Prevention of Pancreatic Fistula Following Distal Pancreatectomy: A Randomized Clinical Trial.

Importance: The rate of postoperative pancreatic fistula (POPF) after distal pancreatectomy ranges from 13% to 64%. To prevent POPF, polyglycolic acid (PGA) mesh was introduced, but its effect has been evaluated only in small numbers of patients and retrospective studies. Objective: To evaluate the efficacy of PGA mesh in preventing POPF after distal pancreatectomy. Design, Setting, and Participants: Prospective randomized clinical, single-blind (participant), parallel-group trial at 5 centers between November 2011 and April 2014. The pancreatic parenchyma was divided using a stapling device; no patient was given prophylactic octreotide. Perioperative and clinical outcomes were compared including POPF, which was graded according to the criteria of the International Study Group For Pancreatic Fistulas. A total of 97 patients aged 20 to 85 years with curable benign, premalignant, or malignant disease of the pancreatic body or tail were enrolled (44 in the PGA group and 53 in the control group). Interventions: Patients in the PGA group underwent transection of the pancreas and application of fibrin glue followed by wrapping the PGA mesh around the remnant pancreatic stump. Main Outcomes and Measures: The primary end point of this study was the development of a clinically relevant POPF (grade B or C by the International Study Group grading system). The secondary end point was the evaluation of risk factors for POPF. Results: The study therefore evaluated a total of 97 patients, 44 in the PGA group and 53 in the control group. Thirty-nine patients were women and 58 patients were men. There were no differences in mean (SD) age (59.9 [12.0] years vs 54.5 [14.1] years, P = .05), male to female ratio (1.0:1.3 vs 1.0:1.7, P = .59), malignancy (40.9% vs 32.1%, P = .37), mean (SD) pancreatic duct diameter (1.92 [0.75] mm vs 1.94 [0.95] mm, P = .47), soft pancreatic texture (90.9% vs 83.0%, P = .17), and mean (SD) thickness of the transection margin (16.9 [5.4] mm vs 16.4 [4.9] mm, P = .63) between the PGA and control groups. The rate of clinically relevant POPF (grade B or C) was significantly lower in the PGA group than in the control group (11.4% vs 28.3%, P = .04). Conclusions and Relevance: Wrapping of the cut surface of the pancreas with PGA mesh is associated with a significantly reduced rate of clinically relevant POPF. Trial Registration: clinicaltrials.gov Identifier: NCT01550406.

Incidental pancreatic cystic neoplasms in an asymptomatic healthy population of 21,745 individuals: Large-scale, single-center cohort study.

Although incidental pancreatic cystic neoplasms are being diagnosed with increasing frequency, little is known about the accurate prevalence of pancreatic cysts in the general population. The aims of this study were to evaluate the crude prevalence rate of pancreatic cystic neoplasms in asymptomatic healthy adults, and calculate the age- and sex-adjusted nationwide prevalence rate.A total of 21,745 asymptomatic individuals who underwent abdominal computed tomography (CT) as a health screening examination were enrolled between 2003 and 2013 at the Seoul National University Hospital Healthcare System Gangnam Center. Nationwide population data of 2010 were collected from the National Statistical Office, Korea.Incidental pancreatic cystic neoplasms were found in 457 individuals whose mean age was 58.7 years. The types of neoplasms were reviewed by 2 separate designated radiologists and the final diagnosis was made as follows: intraductal papillary mucinous neoplasm: 376 (82%), serous cystic neoplasm: 19 (4%), mucinous cystic neoplasm: 7 (2%), and indeterminate cysts: 55 (12%). Eight cases underwent operation. The crude prevalence rate was 2.1% and the age- and sex-adjusted expected nationwide prevalence was 2.2%. The prevalence increased with age.Here, we reported the first large-scale study among the healthy population to find out the prevalence rate of pancreatic cystic neoplasms; the age- and sex-adjusted prevalence was 2.2%, and increased with age. Further investigations regarding the clinical implications of incidental pancreatic neoplasms are necessary.

The natural course of pancreatic fistula and fluid collection after distal pancreatectomy: is drain insertion needed?

PURPOSE: Postoperative pancreatic fistula (POPF) is one of the most common and clinically relevant complications after distal pancreatectomy. Some aspects of POPF management remain controversial. Therefore, the aim of this study was to determine the natural course of POPF and fluid collection after distal pancreatectomy and to reappraise the necessity of intraoperative abdominal drainage insertion. METHODS: For recent 10 years, 264 distal pancreatectomies were performed at Seoul National University Hospital. Clinicopathologic data including POPF and postoperative fluid collection (POFC), and its treatment modality were reviewed retrospectively. During follow-up, the location, size, and clinical impact of the POFC were determined on the basis of CT images. RESULTS: Clinically relevant POPFs were identified in 72 patients (27.3%). Therapeutic interventions were performed in 40 patients (55.6%), and conservative management was successful in 32 patients (44.4%). POFC was detected in 191 cases (72.3%) on the first postoperative CT. During follow-up, spontaneous regressions were observed in 119 cases (93.0%). Only thick pancreatic stump increased the risk of clinically relevant POPF (≥17.3 mm, P = 0.002) and the occurrence of POFC (≥16.0 mm, P < 0.001) in multivariate analysis. CONCLUSION: Intraoperative abdominal drainage insertion could be selectively indwelled in patients with a thickness of pancreas ≥17.3 mm. Since radiologically-proven POFC after distal pancreatecomy showed a 93.0 rate of spontaneous regression, POFC without signs of infection can be safely monitored.

An Analysis of Complications, Quality of Life, and Nutritional Index After Laparoscopic Distal Pancreatectomy with Regard to Spleen Preservation.

BACKGROUND: Whether splenectomy is adverse or spleen preservation offers significant advantages in distal pancreatic resection is unclear. The aim was to compare the early/late clinical results and the functional outcomes in terms of quality of life (QoL) and nutrition between conventional laparoscopic distal pancreatectomy (LDP) and laparoscopic spleen-preserving distal pancreatectomy (LSPDP). STUDY DESIGN: Clinical data and computed tomography findings of 111 laparoscopic distal resections (79 LDPs and 32 LSPDPs) between 1999 and 2012 were retrospectively reviewed. QoL was assessed by the EORTC QLQ-C30. Body mass index and biochemical tests were examined as nutritional indices. Comparative analysis was done. RESULTS: The mean follow-up was 25 months. The operation time was shorter in LSPDP (127.9 minutes vs. 158.0 minutes, P < .001). The lesion size was larger in LDP (36.8 mm vs. 27.2 mm, P < .01). Mucinous cystic neoplasm (MCN) was the most common diagnosis in LDP and intraductal papillary mucinous neoplasm (IPMN) in LSPDP. Early results showed similar hospital days and infection episodes. Nonvascular complications were more frequent in LDP owing to more fluid collections (43.0% vs. 21.9%, P = .04). The ISGPF grade B/C pancreatic fistula rates were similar (27.8% in LDP vs. 25.0% in LSPDP, P = .760). Vascular complications were more frequent in LSPDP (64.5% vs. 26.0%, P < .01). Excluding some fluid collections, none required a specific treatment. Late results demonstrated no differences in nonvascular results. Vascular complications were more frequent in LSPDP (65.6% vs. 4.2%, P < .01). The vascular complications did not require any specific treatment or have any serious sequelae. There was no overwhelming postsplenectomy infection. QoL and nutritional indices showed no difference. QoL decreased at discharge and recovered from 3 months thereafter. Nutritional indices showed a similar pattern. CONCLUSION: LDP is associated with more fluid collections and LSPDP with more vascular complications, all with a minimal clinical impact. Both methods had similar functional outcomes. Either LDP or LSPDP could be performed depending on the indication and surgeon's experiences considering the comparable results.

The clinical usefulness of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) in follow-up of curatively resected pancreatic cancer patients.

BACKGROUND: Computed tomography and serum tumor markers have limited value in detecting recurrence after curative surgery of pancreatic cancer. This study evaluated the clinical utility of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) in diagnosing recurrence. METHODS: One hundred ten patients underwent curative resection of pancreatic cancer were enrolled. The diagnostic value of abdominal computed tomography (CT), PET-CT and serum carbohydrate antigen (CA) 19-9 concentration were compared. The prognostic value of SUVmax on PET-CT was evaluated. RESULTS: PET-CT showed relatively higher sensitivity (84.5% vs. 75.0%) and accuracy (84.5% vs. 74.5%) than CT, whereas PET-CT plus CT showed greater sensitivity (97.6%) and accuracy (90.0%) than either alone. In detecting distant recurrences, PET-CT showed higher sensitivity (83.1% vs. 67.7%) than CT. Nineteen patients showed recurrences only on PET-CT, with eleven having invisible or suspected benign lesions on CT, and eight had recurrences in areas not covered by CT. SUVmax over 3.3 was predictive of poor survival after recurrence. CONCLUSIONS: PET-CT in combination with CT improves the detection of recurrence. PET-CT was especially advantageous in detecting recurrences in areas not covered by CT. If active post-operative surveillance after curative resection of pancreatic cancer is deemed beneficial, then it should include PET-CT combined with CT.

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.

Use of TachoSil(®) patches to prevent pancreatic leaks after distal pancreatectomy: a prospective, multicenter, randomized controlled study.

BACKGROUND: We performed a prospective, multicenter, randomized controlled study to investigate the clinical outcomes, including postoperative pancreatic fistulas (POPF), after using the TachoSil® patch in distal pancreatectomy (NCT01550406). METHODS: Between June 2012 and September 2014, 101 patients at five centers were randomized into Control (n = 53) and TachoSil (n = 48) groups. In all patients, the pancreas was resected using a stapler with Endo-GIA™ staples. The TachoSil patch was wrapped around the pancreatic stump only in the TachoSil group, not in Control group. RESULTS: The patient characteristics, including age and diagnosis, were comparable in both groups. The mean operation time (159.4 vs. 172.3 min, P = 0.081) and postoperative hospital stay (10.0 vs. 9.7 days, P = 0.279) were similar in the Control and TachoSil groups, respectively. The overall incidence of POPF was 62.4% (n = 63). The distribution of grades A, B, and C POPF was similar in the Control (n = 14/14/1) and TachoSil (n = 23/11/0) groups, as were the overall incidence (54.7% vs. 70.8%, P = 0.095) and the incidence of grade B and C POPF (28.3% vs. 22.9%, P = 0.536). CONCLUSION: This study showed that the TachoSil® patch did not reduce the incidence of POPF after distal pancreatectomy.

Comparison of laparoscopic versus open left-sided hepatectomy for intrahepatic duct stones.

BACKGROUND: Laparoscopic hepatectomy for intrahepatic duct (IHD) stones is limited by technical difficulties caused by adhesion to adjacent tissue or distorted anatomy resulting from recurrent inflammation. This study compared perioperative and clinical outcomes in patients undergoing laparoscopic and open hepatectomy for left IHD stones. METHODS: From January 2002 to December 2013, 40 patients underwent laparoscopic left-sided hepatectomy [left hemihepatectomy (n = 7) or left lateral sectionectomy (n = 33)] and 54 patients without combined operations and previous operation histories underwent open left-sided hepatectomy [left hemihepatectomy (n = 24) or left lateral sectionectomy (n = 30)]. Their perioperative and clinical outcomes were compared, including stone clearance rates, stone recurrence rates, and median follow-up duration. RESULTS: There was no difference in age (56.8 ± 8.2 vs. 55.6 ± 9.6 years, p = 0.531), sex (1.0:4.0 vs. 1.0:1.8 male:female, p = 0.108), or BMI (22.8 ± 2.8 vs. 22.9 ± 3.0 kg/m(2), p = 0.802) between the laparoscopic and open hepatectomy groups. Lateral sectionectomy was more frequent in the laparoscopic group (33/40 vs. 30/54, p = 0.010). Operation time (174.2 ± 56.6 vs. 210.4 ± 51.6 min, p = 0.002) and postoperative hospital stay (7.9 ± 2.6 vs. 14.3 ± 5.5 days, p < 0.001) were shorter in the laparoscopic group, and complication rate (17.5 vs. 40.7%, p = 0.016), in particular surgical site infection rate (5.0 vs. 18.5%, p = 0.052), was lower in the laparoscopic group than in the open hepatectomy group. Similar results were observed in the hemihepatectomy and lateral sectionectomy subgroups. There was no operation-related mortality. There were no significant differences in follow-up periods (48 ± 33.6 vs. 59.2 ± 41.7 months, p = 0.235) and rates of initial stone clearance (87.5 vs. 75.9%, p = 0.159), final clearance (100 vs. 94.4%, p = 0.130), and stone recurrence (2.5 vs. 5.6%, p = 0.468). CONCLUSION: Laparoscopic hepatectomy is safe and effective for well-selected patients with left IHD stones, when performed by experienced surgeons. Laparoscopic hepatectomy resulted in shorter operation time and postoperative hospital stay, and a lower postoperative morbidity rate, than open hepatectomy.

Suggestions for improving perihilar cholangiocarcinoma staging based on an evaluation of the seventh edition AJCC system.

The first separate staging system for perihilar cholangiocarcinoma was introduced by the seventh edition American Joint Committee on Cancer (AJCC) manual. To determine whether it strengthens the prognostic value, a comparative analysis with the sixth edition was performed, through which some areas for improvements were identified. The tumor-nodes-metastasis (TNM) stage and R status of 378 operated perihilar cholangiocarcinoma patients between 1990 and 2011 were reviewed. Survival analyses were conducted. Although the stages were up-numbered from I to II and II to III, the sixth and seventh editions had intercorresponding stages providing similar classifications. Applying the seventh edition, 9.8% were downstaged and 1.3% upstaged. Several issues were identified. First, both editions did not discriminate node-free locally advanced resectable diseases and node-positive resectable diseases. Second, stages IVA and IVB in the seventh edition had different prognoses suggesting misclassification of stage IVA. Third, the prognosis of liver invasion (T2b) resembled that of T3 more than T2a in the seventh edition, warranting investigation into the downstaging of liver invasion. Lastly, curative resections were possible in some Bismuth type 4 tumors allowing for better survival, suggesting that classifying them as unresectable disease (T4) should be revised. A discrete staging for perihilar cholangiocarcinoma is necessary; however, some points need further clarifications.