Association between breast diseases and symptomatic uterine fibroids by using South Korean National Health Insurance database.

Both the uterus and breasts have sex hormone dependence, yet there are few studies on the association between breast disease and uterine fibroids (UFs). The purpose of this study was to investigate the incidence of benign breast disease (BBD), carcinoma in situ (CIS), and breast cancer (BC) in women treated for UFs compared to women who were not treated for UFs. This retrospective cohort study used national health insurance data from January 1st, 2011, to December 31st, 2020. We selected women between 20 and 50 years old who (1) were treated for UFs (UF group) or (2) visited medical institutions for personal health screening tests without UFs (control group). We analyzed independent variables such as age, socioeconomic status (SES), region, Charlson comorbidity index (CCI), delivery status, menopausal status, menopausal hormone therapy (MHT), endometriosis, hypertension (HTN), diabetes mellitus (DM), and dyslipidemia based on the first date of uterine myomectomy in the UF group and the first visiting date for health screening in the non-UF group. There were 190,583 and 439,940 participants in the UF and control groups, respectively. Compared with those of the control group, the RRs of BBD, CIS, and BC were increased in the UF group. The hazard ratios (HRs) of BBD, CIS, and BC in the UF group were 1.335 (95% confidence interval (CI) 1.299-1.372), 1.796 (95% CI 1.542-2.092), and 1.3 (95% CI 1.198-1.41), respectively. When we analyzed the risk of BC according to age at inclusion, UFs group had the increased risk of BCs in all age groups in comparison with control group. Women with low SES (HR 0.514, 95% CI 0.36-0.734) and living in rural areas (HR 0.889, 95% CI 0.822-0.962) had a lower risk of BC. Our study showed that women with UFs had a higher risk of BBD, CIS, and BC than those without UFs. This result suggests that women with UFs should be more conscious of BC than those without UFs. Therefore, doctors should consider recommending regular breast self-exams, mammography, or ultrasound for the early detection of BC in women with UFs.

Comparison between Two-Dimensional and Point Shear Wave Elastography Techniques in Evaluating Liver Fibrosis Using Histological Staging as the Reference Standard: A Prospective Pilot Study.

Evaluation of hepatic fibrosis is essential to prevent liver-related morbidity and mortality. Although various types of ultrasound shear wave elastography (SWE) have been used and validated, there are limited studies on the relatively newer technique, two-dimensional SWE (2D-SWE). Therefore, this study aimed to compare the diagnostic performances of 2D-SWE and point SWE (p-SWE) for evaluating liver fibrosis using histology as the reference standard. To measure liver stiffness (LS) values, 87 patients underwent 2D-SWE and p-SWE using the same machine. Technical failures and unreliable measurements were also evaluated. The diagnostic performances of 2D-SWE and p-SWE were compared using area under the receiver operating characteristic (AUROC) curve analysis. No technical failures were observed in either method; however, unreliable measurements were less frequent in 2D-SWE (1/87 [1.1%]) than in p-SWE (8/87 [9.2%]) (p < 0.001). The AUROC of the LS values of 2D-SWE were significantly higher than those of p-SWE for diagnosing significant fibrosis (0.965 vs. 0.872, p = 0.022) and cirrhosis (0.994 vs. 0.886, p = 0.042). In conclusion, 2D-SWE is more reliable and accurate than p-SWE for diagnosing hepatic fibrosis.

Laparoscopic Liver Resection Enhanced by an Intervention-Guided Fluorescence Imaging Technique Using Sodium Fluorescein.

BACKGROUND AND OBJECTIVES: In laparoscopic liver resections, tumor localization is a critical aspect of ensuring clear resection margins and preserving the hepatic parenchyma. In this study, we designed a fluorescence imaging technique using a new fluorophore for tumor localization. MATERIALS AND METHODS: Immediately before laparoscopic or transthoracic liver resection, microcatheter was inserted through the hepatic artery and used to engrave the segment containing the tumor in the intervention room. Under blue light, the fluorescence of the lesion was visually confirmed, and the location was determined through intraoperative sonography. After tumor localization, liver resection was performed. RESULTS: From February 2017 to March 2020, 24 patients underwent laparoscopic liver resection (LLR) or video-assisted transthoracic liver resection (VTLR) using intervention-guided fluorescence imaging technique (IFIT). CONCLUSIONS: IFIT can provide some advantages in the field of LLR. In addition, in cases of VTLR for hepatocellular carcinoma in the superior posterior segment in patients with marginal liver function, IFIT is considered useful.

Recovery from ischemic monomelic neuropathy after delayed ligation of dialysis access.

Ischemic monomelic neuropathy is characterized by acute painful muscle weakness shortly after access creation and neuronal axon loss without adjacent tissue necrosis, thus, differentiating ischemic monomelic neuropathy from the steal syndrome. Immediate ligation of vascular access is emphasized in current guidelines. We present two cases of recovery from ischemic monomelic neuropathy despite delayed ligation for over 20 days after ischemic monomelic neuropathy development. The gradual change in serial nerve conduction studies over the 15-month follow-up after surgical ligation was noted along with clinical recovery. Our report indicates that the clinical course and prognosis of ischemic monomelic neuropathy may be more diverse than previously known.

Video-assisted transthoracic liver resection in patients with marginal liver function: a retrospective cohort study.

Purpose: Laparoscopic hepatectomy has been widely performed by hepatobiliary surgeons for malignancy of liver and gained wide acceptance for various liver tumors, thanks to advances in surgical techniques and devices. But, there are some challenges for right side tumor in patients of cirrhotic liver. Especially, tumor located in right upper area is difficult for wedge resection in patients with marginal liver function, because trans-abdominal approach requires normal parenchymal dissection. Radiofrequency wave ablation is also difficult for such a lesion. So, we demonstrate unique technique of video-assisted transthoracic liver resection (VTLR) for overcome right upper side tumor abutting diaphragm. Methods: Four patients underwent VTLR. Four ports in right chest wall were created by a chest surgeon and diaphragm was open. Then traction of the diaphragm was done by suture. After exposure of liver surface, tumor localization was done by ultrasound. The mass excision was done by ultrasonic shear. Results: Four patients were discharged without complications within 11.3 days (range, 6-15 days). On average, patients started to consume a normal diet on an average of 2.4 days (range, 1-4 days). Conclusion: VTLR is could be performed by an experienced surgeon and chest surgeon for right upper liver malignancy abutting diaphragm in patient of marginal liver function.

Comparison of point and 2-dimensional shear wave elastography for the evaluation of liver fibrosis.

PURPOSE: This study aimed to assess the technical performance of ElastQ Imaging compared with ElastPQ and to investigate the correlation between liver stiffness (LS) values obtained using these two techniques. METHODS: This retrospective study included 249 patients who underwent LS measurements using both ElastPQ and ElastQ Imaging equipped on the same machine. The applicability, repeatability (coefficient of variation [CV]), acquisition time, and LS values were compared using the chi-square or Wilcoxon signed-rank tests. In the development group, the correlation between the LS values obtained by the two techniques was assessed with Spearman correlation coefficients and linear regression analysis. In the validation group, the agreement between the estimated and real LS values was evaluated using a Bland-Altman plot. RESULTS: ElastQ Imaging had higher applicability (94.0% vs. 78.3%, P<0.001) and higher repeatability, with a lower median CV (0.127 vs. 0.164, P<0.001) than did ElastPQ. The median acquisition time of ElastQ Imaging was significantly shorter than that of ElastPQ (45.5 seconds vs. 96.5 seconds, P<0.001). The median LS value obtained using ElastQ Imaging was significantly higher than that obtained using ElastPQ (5.60 kPa vs. 5.23 kPa, P<0.001). The LS values between the two techniques exhibited a strong positive correlation (r=0.851, P<0.001) in the development group. The mean difference and 95% limits of agreement were 0.0 kPa (-3.9 to 3.9 kPa) in the validation group. CONCLUSION: ElastQ Imaging may be more reliable and faster than ElastPQ, with strongly correlated LS measurements.

Role of peribrachial fat as a key determinant of brachial artery dilatation for successful arteriovenous fistula maturation in hemodialysis patients.

The functional quality of the inflow artery is one of the most important determinants of arteriovenous fistula (AVF) success. We evaluated the association of early optimal brachial arterial dilatation with a successful AVF maturation and assessed the role of peribrachial adipose tissue in determining brachial arterial distensibility. All patients underwent a preoperative vascular mapping with Doppler ultrasound (US), and only patients who had suitable vessels for AVF creation were enrolled (n = 162). Peribrachial fat thickness was measured using US. To evaluate the degree of brachial dilatation, follow-up US was performed at 1 month after surgery, and early brachial artery dilation was defined as the change in postoperative arterial diameter compared to the preoperative value. The primary outcome was failure to achieve a clinically functional AVF within 8 weeks. Nonfunctional AVF occurred in 21 (13.0%) patients, and they had a significantly lower brachial dilatation than patients with successful AVF during early period after surgery (0.85 vs. 0.43 mm, p = 0.003). Patients with a brachial dilatation greater than median level showed a 1.8-times higher rate of achieving a successful AVF than those without. Interestingly, the early brachial dilatation showed significant correlations with diabetes (r = -0.260, p = 0.001), peribrachial fat thickness (r = -0.301, p = 0.008), and the presence of brachial artery calcification (r = -0.178, p = 0.036). Even after adjustments for demographic factors, comorbidities, and baseline brachial flow volume, peribrachial fat thickness was an independent determinant for early brachial dilatation (ß = -0.286, p = 0.013). A close interplay between the peri-brachial fat and brachial dilatation can be translated into novel clinical tools to predict successful AVF maturation.

Retrograde installation of percutaneous transhepatic negative-pressure biliary drainage stabilizes pancreaticojejunostomy after pancreaticoduodenectomy: a retrospective cohort study.

BACKGROUND: Leakage from the pancreatoenteric anastomosis has been one of the major complications of pancreaticoduodenectomy (PD). The aim of this study was to investigate the feasibility of retrograde installation of percutaneous transhepatic negative-pressure biliary drainage (RPTNBD), as part of which the drainage tube is intraoperatively inserted into the bile duct and afferent loop by surgical guidance to reduce pancreaticoenteric leakage after PD. METHODS: We retrospectively reviewed the medical records of the patients who underwent pylorus-preserving PD or Whipple's operation for a malignant disease between June 2012 and August 2016. We performed intraoperative RPTNBD to decompress the biliopancreatic limb in all patients and compared their clinical outcomes with those of internal controls. RESULTS: Twenty-one patients were enrolled in this study. The operation time was 412.0 ± 92.8 min (range, 240-600 min). The duration of postoperative hospital stay was 39.4 ± 26.4 days (range, 13-105 days). Ten patients (47.6%) experienced morbidities of Clavien-Dindo grade > II, and 2 patients (9.5%) experienced pancreaticojejunostomy-related complications. The internal controls showed a higher incidence rate of pancreaticojejunostomy-related complications than the study participants (P = 0.020). Mortality occurred only in the internal controls. CONCLUSION: For stabilizing the pancreaticoenteric anastomosis after PD for a malignant disease, RPTNBD is a feasible and effective procedure. When PD is combined with technically demanding procedures, including hepatectomy or vascular reconstruction, RPTNBD could prevent fulminant anastomotic failure.

Laparoscopic Whipple's Operation for Locally Advanced Gastric Cancer Invading the Pancreas and Duodenum: a Case Report.

Few surgeons have adopted pancreaticoduodenectomy (PD) for the treatment of advanced gastric cancer (AGC) invading the pancreas or duodenum because it remains controversial whether its prognostic benefits outweigh the high morbidity rates in such advanced cases. However, recent technical advances have revived diverse surgical procedures in minimally invasive approaches. Inspired by this trend, laparoscopic PD procedures have been performed for AGC in our institute since 2014. We recently performed a laparoscopic Whipple's operation in a case of cT4b gastric cancer with invasion of the pancreatic head and duodenum.

A new fluorescence imaging technique for visualizing hepatobiliary structures using sodium fluorescein: result of a preclinical study in a rat model.

BACKGROUND: Near-infrared fluorescence imaging has been recently applied in the field of hepatobiliary surgery. Our objective was to apply blue light fluorescence imaging to cholangiography and liver mapping during laparoscopic surgery. Therefore, we designed a preclinical study to evaluate the feasibility of using blue light fluorescence for cholangiography and liver mapping in a rat model. METHODS: Sodium fluorescein solution (1 mL to each individual) were administered intravenously to 20 male Sprague-Dawley rats (6 weeks old, 200-250 g), after laparotomy. Whole abdominal organs were observed under blue light (at a wavelength of 440-490 nm) emitted from a commercialized LED curing light. RESULTS: Immediately after the tracer solution was administered into the circulatory system of the rat, it was possible to visualize the location of the kidneys and the bile duct under blue light emitted from the light source. The liver was vaguely stained green by the tracer, while the ureters were not. After establishing biliary retention via duct clamping in the left lateral segment of the liver, the green color of the segment became distinct by the tracer, which showed vague coloration following release of the clamp. CONCLUSION: We established the preclinical basis for using blue light fluorescence cholangiography and liver mapping in this study. The clinical feasibility of these techniques during laparoscopic cholecystectomy and hepatectomy remained to be demonstrated.

Erratum: Therapeutic induction of hepatic atrophy for isolated injury of the right anterior sectoral duct following laparoscopic cholecystectomy.

[This corrects the article on p. 189 in vol. 15, PMID: 26421038.].

A new glove port for single incision procedure.

Single-incision laparoscopic surgery has gained increasing attention due to its potential to improve the benefits of laparoscopic surgery. However, inconvenience remains for inexperienced surgeons during surgery when instruments conflict with each other, and a glove port is used hesitantly for such diagnosis related groups (DRG) because of its high cost. Authors made a new glove port by an odd surgical gloves and one wound protectors. This glove port is ease to make besides being convenient to us, and inexpensive. This new glove port has the benefit of easy utilization and cost effectiveness for surgeons performing single-incision laparoscopic surgery.

Protective effect of ischemic postconditioning against hepatic ischemic reperfusion injury in rat liver.

PURPOSE: The efficiency of ischemic postconditioning (IPC) was evaluated in a rat model of ischemic liver. Concentration of survivin of liver tissue correlated with the degree of antiapoptosis, so survivin was estimated to evaluate the efficiency of IPC on ischemic reperfusion (IR) injury. METHODS: Twenty-four healthy rats were divided to three groups (SHAM, IR, and IPC). Rats in the SHAM group displayed no change during 3 hours. Rats in the IR group were ischemic within 1 hour of clamping the left hepatic artery and left portal vein. Reperfusion for 2 hours was then done. IPC group, intermittent 2, 3, 5, and 7 minutes of reperfusion followed by 1 hour of warm ischemia. Two-minute reocclusion was done after each reperfusion. Rat sera were analyzed for AST and ALT, and Western blot analysis of rat liver tissue of rats evaluated malondialdehyde (MDA) and survivin. RESULTS: MDA in the liver tissue of rats in the IR and IPC group were significantly high than in the liver tissue of the SHAM group (P = 0.003 and P = 0.008, respectively). Survivin was higher in the IPC group than in the SHAM and IR groups (P = 0.021 and P = 0.024, respectively). CONCLUSION: IPC could not prevent lipid oxidation in liver cell mitochondria, but did aid in the regeneration of ischemic injured liver cells. The results indicate that IPC can suppress the apoptosis of liver cells and reduce reperfusion injury of liver tissue.

Synergistic effect of sorafenib and vitamin K on suppression of hepatocellular carcinoma cell migration and metastasis.

Vitamin K plays a role in controlling cell growth. Anti-angiogenic effects of sorafenib lead to impairment of vitamin K uptake and induction of des-γ-carboxyprothrombin release by hepatocellular carcinoma (HCC) cells. We examined sorafenib and vitamin K individually and in combination regarding their ability to suppress migration and metastatic potential of HCC cells. HepG2 cells (HCC cell line) were treated with hepatocyte growth factor (HGF). E-Cadherin expression, phospho-MET (p-MET), and phospho-extracellular signal-regulated kinase (p-ERK) levels and cell migration were evaluated. HGF-stimulated HepG2 cells, which were treated with a combination of sorafenib and vitamin K, showed significantly increased expression of E-cadherin and impairment of migration ability compared to when treated with either agent alone. This combination therapy also induced marked inhibition of epithelial-mesenchymal transition phenotype; inhibition of HGF-stimulated cell proliferation, invasion and migration; and inhibition of HGF/c-MET signaling pathway. Levels of p-MET and p-ERK were also significantly reduced by this combination. Our experimental study demonstrated that sorafenib and vitamin K can function synergistically to inhibit the migration and proliferation of HCC cells. Combination therapy with sorafenib and vitamin K appears to be worthy of clinical trial with expectation of synergistic therapeutic effects.

Oncological and surgical results of laparoscopic versus open liver resection for HCC less than 5 cm: case-matched analysis.

BACKGROUND: The purpose of this study is the evaluation of the surgical and oncological results of laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) by comparing laparoscopic and open liver resection (OLR) in the treatment of this disease. Retrospective analysis of laparoscopic and OLR for HCC (<5 cm) performed over a 4-year period was conducted. The LLR was done by a single surgeon. METHODS: The study was performed on patients who received liver resection for HCC between July 2007 and August 2011 in our institution. Propensity-based matched analyses were used to account for operative method selection biases. During the 4 years, 1,050 patients with HCC received an operation. Among them patients who never received TACE or RFA before surgery and had HCC (<5 cm) were selected for this study. RESULTS: 174 patients had OLR, and 58 patients underwent LLR. Patients who received LLR had lower operative time, transfusion rate, complication rate, and shorter hospital days. There were significant differences in hospital mortality and morbidity between the two groups. Dietary recovery was relatively fast in the group of LLR. Overall and disease-free survival rates during the 4 years were also not significantly different between the two groups. CONCLUSIONS: LLR is a developing and safe technique in a select group of patients including those with malignancies, and use of this procedure is associated with short hospital stays, a rapid return to a normal diet, full mobility, and minimal morbidity, with acceptable oncological parameters. It may be an optimal method of hepatectomy in HCC (<5 cm). Further, long-term follow-up should be acquired for adequate evaluation for survival.

Single-port laparoscopic distal pancreatectomy: initial experience.

INTRODUCTION: Laparoscopic distal pancreatectomy has become the standard treatment of choice for pancreatic tail cystic and solid tumors when technically feasible. Technological advances have led to the development of single-port laparoscopic surgery, a safe alternative procedure. We present our experiences with single-port laparoscopic distal pancreatectomy. MATERIALS AND METHODS: We retrospectively reviewed clinical records and compared clinical outcomes in 40 patients diagnosed with a pancreatic tail mass between 2007 and 2013 who received either conventional laparoscopic (n=28) or single-port laparoscopic distal pancreatectomy (n=12). RESULTS: The mean surgery time in the single-port group (279.8±53.0 minutes) was significantly longer than in the conventional group (186.9±86.6 minutes) (P=.001). The mean duration of postoperative hospital stay in the single-port group (12.2±5.4 days) was also significantly longer than in the conventional group (8.3±4.7 days) (P=.028). The spleen was preserved more in the conventional group (60.7%) than in the single-port group (33.3%), but the difference was not significant (P=.112). There were no significant differences in intraoperative blood loss, tumor size, conversion rate, or postoperative complications between the two groups. CONCLUSIONS: Blood loss and postoperative complications of single-port laparoscopic distal pancreatectomy are similar to those of conventional laparoscopic distal pancreatectomy. Single-port laparoscopic distal pancreatectomy can be performed safely and effectively in select patients with pancreas tail neoplasms, but is associated with a longer surgery time and postoperative hospital stay.

Robotic versus laparoscopic liver resection: a comparative study from a single center.

PURPOSE: The significant advantages of robotic surgery have expanded the scope of surgical procedures that can be performed through minimally invasive techniques. The aim of this study was to compare the perioperative outcomes between robotic and laparoscopic liver surgeries at a single center. METHODS: From July 2007 to October 2011, a total of 206 patients underwent laparoscopic or robotic liver surgery at the Asan Medical Center, Seoul, Korea. We compared the surgical outcomes between robotic liver surgery and laparoscopic liver surgery during the same period. Only patients who underwent left hemihepatectomy or left lateral sectionectomy were included in this study. RESULTS: The robotic group consisted of 13 patients who underwent robotic liver resection including 10 left lateral sectionectomies and three left hemihepatectomies. The laparoscopic group consisted of 17 patients who underwent laparoscopic liver resection during the same period including six left lateral sectionectomies and 11 left hemihepatectomies. The groups were similar with regard to age, gender, tumor type, and tumor size. There were no significant differences in perioperative outcome such as operative time, intraoperative blood loss, postoperative liver function tests, complication rate, and hospital stay between robotic liver resection and laparoscopic liver resection. However, the medical cost was higher in the robotic group. CONCLUSIONS: Robotic liver resection is a safe and feasible option for liver resection in experienced hands. The authors suggest that since the robotic surgical system provides sophisticated advantages, the retrenchment of medical cost for the robotic system in addition to refining its liver transection tool may substantially increase its application in clinical practice in the near future.

Laparoscopic liver resection for hepatocellular carcinoma: a three-year study of 57 Patients.

BACKGROUND/AIMS: Laparoscopic liver resection has become an increasingly popular operation but is still in relatively limited use. Here we evaluate the intermediate-term results of laparoscopic liver resection. METHODOLOGY: Fifty-seven patients with HCC underwent laparoscopic liver resection at the Asan Medical Center. Data for all resections were recorded and analyzed retrospectively. Patient gender, age, preoperative laboratory data, presence of cirrhosis, blood loss, hospital stay length, pathology report, tumor site and size, resection type, resection margin, morbidity and mortality were assessed. RESULTS: The mean patient age ranged from 35-74 years and the mean tumor size from 0.8-5.5 cm. Tumors were located in the left lateral lobe, left medial lobe and right lobe. Left lateral sectionectomy was performed in 32 cases, partial hepatectomy in 11, left hepatectomy in 6, right hepatectomy in 2, laparoscopy-assisted right hepatectomy in 2 and laparoscopy-assisted right posterior sectionectomy in 4. Median operation time ranged from 95-380 min while median blood loss ranged from 150-800 mL. The mean resection margin was 2.08±1.68 cm with no in-hospital mortalities. Return to normal diet was achieved on average at 1.83±0.8 days; mean hospital stay ranged from 3 to 17 days. The 3-year overall and disease-free survival rates were 81% and 71%, respectively. CONCLUSIONS: Laparoscopic liver resection for HCC is feasible, safe and promising for a select group of patients. Its benefits include short hospital stays, rapid return to normal diet, full mobility and minimal morbidity with acceptable oncological parameters.

Usability of ringed polytetrafluoroethylene grafts for middle hepatic vein reconstruction during living donor liver transplantation.

Large vein allografts are suitable for middle hepatic vein (MHV) reconstruction, but their supply is often limited. Although polytetrafluoroethylene (PTFE) grafts are unlimitedly available, their long-term patency is relatively poor. We intended to enhance the clinical usability of PTFE grafts for MHV reconstruction during living donor liver transplantation (LDLT). Two sequential studies were performed. First, PTFE grafts were implanted as inferior vena cava replacements into dogs. Second, in a 1-year prospective clinical trial of 262 adults undergoing LDLT with a modified right lobe, MHV reconstruction with PTFE grafts was compared with other types of reconstruction, and the outcomes were evaluated. In the animal study, PTFE grafts induced strong inflammatory reactions and luminal thrombus formation, but the endothelial lining was well developed. In the clinical study, the reconstruction techniques were revised to make a composite PTFE graft with an artery patch on the basis of the results of the animal study. MHVs were reconstructed with cryopreserved iliac veins (n = 122), iliac arteries (n = 43), aortas (n = 13), and PTFE (n = 84), and these reconstructions yielded 6-month patency rates of 75.3%, 35.2%, 92.3%, and 76.6%, respectively. The overall 6-month patency rates for the iliac vein and PTFE grafts were similar (P = 0.92), but the 6-month patency rates with vein segment 5 were 51.0% and 34.7%, respectively (P = 0.001). The overall graft and patient survival rates did not differ among these 4 groups. In conclusion, ringed PTFE grafts combined with small vessel patches showed high patency rates comparable to those of iliac vein grafts; thus, they can be used for MHV reconstruction when other sizable vessel allografts are not available.