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Backgrounds/aims Surgical resection is the only curative treatment for biliary tract cancers; however, most patients undergo palliative chemotherapy because they are contraindicated for surgery. Conversion surgery, a treatment strategy for downsizing chemotherapy and subsequent surgical resection, is feasible for initially unresectable biliary tract cancers following the introduction of effective chemotherapeutic agents. Methods Patients initially diagnosed with unresectable biliary tract cancers, and treated with conversion surgery after palliative chemotherapy between 2013 and 2019, were reviewed retrospectively. Results Twelve patients underwent conversion surgery after palliative chemotherapy for initially unresectable biliary tract cancers. The final pathological diagnosis included six perihilar cholangiocarcinomas, four distal common bile duct cancers, and two gallbladder cancers. Different chemotherapy regimens were used, but all the patients were treated with gemcitabine at some point during their treatment. The median overall survival was 28 months, which was longer than that of patients treated with isolated palliative chemotherapy in previous studies. Conclusions Conversion surgery represents a therapeutic alternative for specific cases of unresectable biliary tract cancers. Palliative chemotherapy for initially unresectable biliary tract cancers is recommended for downsizing the tumor and expanding the indications for surgery. Further studies and clinical trials are required to develop new and effective chemotherapeutic regimens.

Backgrounds/aims We performed a retrospective, single-center cohort study to evaluate the impact of various treatment modalities and recent changes in treatment modalities, including the increased application of chemotherapy, on survival in patients with pancreatic cancer. Methods All patients with pancreatic cancer who were diagnosed and treated at Seoul National University Hospital between January 2007 and December 2014 were registered in a prospective clinical database and included in this retrospective study. All patients' radiologic imaging diagnoses were re-reviewed according to the National Cancer Center Network guidelines. The patients were divided into four groups according to their clinical stage, and each clinical stage group was further divided into four groups according to treatment modality. Results Overall, 475 (28.9%) patients had resectable pancreatic cancer, 129 (7.8%) patients borderline resectable pancreatic cancer, 384 (23.3%) patients locally advanced pancreatic cancer, and 658 (40.0%) patients metastatic pancreatic cancer. Among the patients with borderline resectable pancreatic cancer, the median survival was significantly longer in the neoadjuvant therapy (NAT)+surgery groups (24 months) than the surgery without NAT (16 months) group (p=0.049). A multivariate survival analysis revealed that compared with the surgery group, the 5-year mortality risk was decreased by 35% in the NAT+surgery group (24 vs. 20 months, p=0.045). Conclusions This retrospective cohort study showed that the rates of resectable and surgically treatable pancreatic cancer were 29.1% and 32.2%, which are higher than those reported previously, and aggressive NAT for select advanced-stage patients could lead to better survival outcomes.

Introduction Pancreatic resection is technically difficult and has higher postoperative mortality and morbidity rates than those of other abdominal operations. As the incidence of postoperative morbidity and mortality has gradually decreased, some centers have reported remarkable achievements by attempting minimally invasive surgery. This study was performed to investigate the chronological trends of pancreatectomies by analyzing a large-scale database. Methods The medical records of 5,175 patients who underwent pancreatic resection between 1961 and 2019 at a single institution were collected and reviewed. The chronological trend of surgical outcome was investigated by dividing the period into 5-year intervals. To investigate the chronological change in survival outcomes of periampullary cancer, the survival data of 3,108 patients were analyzed. Results Patient age and the proportion of pancreatic cancer have increased over time. Pancreatic cancer was most common (35.9%) in 2015-2019, followed by pancreatic cyst (24.8%), common bile duct cancer (13.4%), and ampulla of Vater cancer (10.1%). The incidence of postoperative complications tended to decrease over time (26.0% in 2000-2004 and 20.8% in 2015-2019). A comparison of survival outcomes of periampullary malignancies by period revealed that pancreatic cancer significantly improved (5-year survival rate: 14.4% before 2000 vs. 15.2% in 2000-2009 vs. 29.0% after 2009, p < 0.001). Conclusions Postoperative complication rate and duration of recovery have improved in pancreatic resection over time. The proportion of minimally invasive pancreatectomies is gradually increasing. To improve outcomes in the future, active multidisciplinary approach and postoperative management are needed.

Introduction There are not many reports of postoperative long-term malignant risk or postoperative sequelae after surgery on choledochal cyst (CC). The purpose of this study was to report the long-term results of operated CC. Methods The patients who underwent surgical treatments for CC between 2003 and 2020 at the Seoul National University Hospital were enrolled. Clinicopathologic factors and pre/postoperative CT or MRI were reviewed. Results Of the 153 patients, the female was 85%, and the mean age was 41 years old. The most common symptom was abdominal pain. According to the Todani classification, the most common type was 1c (36.6%). APBDU was 85.6% and C-P type, P-C type APBDU were observed at 43.8%, 41.8% respectively. Fourteen patients (9.2%) had biliary tract cancer including 8 cholangiocarcinomas and 8 gallbladder cancer. Two patients had both cancers. A comparison of patients with and without malignancy showed that age, operative time, EBL were significantly higher in the malignant group, while the diameter of the cyst is significantly smaller in the malignant group. There was no significant difference in APBDU type and Todani classification type between the two groups. The incidence of long-term complication was 14.3% and the median time interval was 30 months. The two most common complication was cholangitis or stricture (5.9%). There were 2 cases (1.3%) of new cancer near the intrapancreatic remnant bile duct. Conclusions The 9.2% of resected CCs had combined malignancy on biliary tracts. Long-term complications such as cholangitis, anastomosis stricture, and new cancer may occur. Therefore continuous surveillance is required.

Introduction Because the clinical symptoms of gallbladder (GB) cancers are lacking or vague, objective tools for diagnosing GB cancer were necessary. Although serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 were widely utilized for the diagnosis of GB cancer, few studies existed about the diagnostic performance of these biomarkers. This study aimed to investigate the diagnostic performance of serum CEA and CA 19-9, and demonstrate the clinical usefulness of them in diagnosing GB cancer. Methods This was a retrospective cohort study. Between January 2000 and March 2020, total 751 GB cancer patients and 2,310 normal controls were included. Two biomarkers were measured before surgery. Receiver operating characteristics curves were obtained, and sensitivity and specificity of each biomarker were evaluated. Cancer stage was unified to American Joint Committee on Cancer 7th staging system. Results 666 (88.8%) patients had serum CEA ≤ 5 ng/mL, and 546 (72.7%) patients had serum CA 19-9 ≤ 37 IU/mL. In terms of differentiating the GB cancer from the control, the sensitivity and specificity of serum CEA at 5 ng/mL was 11.2% and 99.2%, and those of serum CA 19-9 at 37 IU/mL was 27.3% and 94.6%. When these cut-off values were applied to differentiate early GB cancer from advanced tumor, the sensitivity and specificity at these cut-off values were 14.2% and 96.1% in CEA and 33.6% and 90.1% in CA 19-9. Conclusions Serum CEA and CA 19-9 were not suitable for screening GB cancer patients from controls. Two biomarkers should be replaced to new biomarkers with higher.

Introduction The Bismuth-Corlette type IV Klatskin tumor has been considered as unresectable. This study was to demonstrate survival improvement of type IV Klatksin tumor when resected, and suggest possible radiological features for R0 resectability. Methods Data on type IV Klatskin tumor diagnosed from 2008 to 2019 were retrospectively reviewed. Patients with poor general condition/liver function, distant metastasis, concomitant other cancers at the initial state, and extensive vascular invasion were excluded. Survival outcomes and radiologic parameters of bile duct tumor were compared between curative-intended resection (R0, 1 resection) and non-resection groups. Results Demographic findings of patient with curative-intended resection (n = 48) and with non-resection (n = 111) were comparable. Both were potentially resectable at the initial state. The most common surgical procedure was the right-sided hepatectomy (60.4%). The postoperative morbidity was 22.9% and the 90-days mortality 4.2%. There was a significant difference in median survival month among the curative-intended resection, palliative treatment, and supportive care (35, 16, and 12 months respectively; p < 0.001). In right-sided hepatectomy, shorter length of the left bile duct tumor (17.89 ± 6.42, 23.74 ± 7.48; p < 0.001) and longer length of left tumor end to the umbilical point (25.59 ± 7.69, 14.52 ± 9.40; p < 0.001) and in left-sided hepatectomy, shorter length of the right anterior bile duct tumor (17.22 ± 6.07, 21.50 ± 7.46; p = 0.001) were observed in the curative-intended resection compared to the non-resection group. Conclusions In patients without extensive tumor extension into adjacent tissues including major vessels, aggressive surgical resection should be considered because it warrants markedly better survival than any other treatment.

Introduction Littles is known about the role of serum carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 on the detection of extrahepatic bile duct cancer (EBDC). This study evaluated the diagnostic accuracy of these biomarkers. Methods A total of 710 patients who underwent surgery for EBDC at a tertiary center between 1995 and 2018 were included, with 23 patients excluded owing to concurrent pancreatobiliary diseases, which could affect serum CEA or CA19-9. For a control group, 2,310 patients who underwent cholecystectomy for benign gallbladder diseases during the same period were used. Diagnostic accuracy was evaluated using sensitivity, specificity, and area under the receiver operating characteristics curve (AUC). Results After excluding patients, 687 qualifying patients consisted of 488 men and 199 women with a mean age of 65.8 years. Median serum levels of CEA and CA19-9 were 1.8 ng/mL and 47.0 U/mL, respectively. CEA (cut-off: 5.0 ng/mL) showed AUC of 0.541, sensitivity of 9.0%, and specificity of 99.2%, and CA19-9 (cut-off: 37 U/mL) had AUC of 0.753, sensitivity of 56.2%, and specificity of 94.5%. According to AJCC stage, early T stage (stage 0-2) had lower sensitivity in CA19-9 (47.0% vs. 64.9%) than advanced T stage (stage 3 and 4). In addition, N0 stage showed lower sensitivity (50.1% vs. 68.8%) than lymph node metastasis. Conclusions Serum CEA and CA19-9 have limited usefulness for the diagnosis of EBDC, particularly in early detection, because of their quite low sensitivity. A novel biomarker for the diagnosis of cancer will also be needed in the future.

Introduction Pancreatic exocrine insufficiency after pancreatectomy affects clinical outcomes of patients in postoperative course. This study aimed to analyze risk factors influencing severe pancreatic exocrine insufficiency (PEI) after pancreaticoduodenectomy measured by patient's stool elastase (SE) level. Methods Among patients who received pancreaticoduodenectomy in Seoul National University Hospital from October 2007 through February 2013, patients who measured both preoperative and postoperative SE level were included. Deteriorated (exocrine function) group was defined as patients who decreased from 100 µg/g or more preoperatively to less than 100 µg/g postoperatively. Results Of 202 included patients, 135 patients were deteriorated group and 67 patients were maintained group. Patients in deteriorated group had higher preoperative stool elastase level (309.6 vs. 143.0, p < 0.001), benign diseases (26.7% vs. 13.4, p = 0.033), presence of clinically relevant postoperative pancreatic fistula (19.3% vs. 7.5%, p = 0.029) compared to maintained group. Postoperative weight showed the lowest at postop 3 months and recovery at 12 months. Weight change in postop 3 months was significantly different between two groups (-4.6 vs. -3.5, p = 0.045). Patients who did not recover their weight of postop 3 months at postop 12 months had higher portion of adjuvant radiotherapy, presence of postoperative pancreatic fistula and high grade of complication compared to recovery group. Conclusions Those with benign diseases and clinically relevant postoperative pancreatic fistula have a tendency of marked deterioration of pancreatic exocrine function after pancreatoduodenectomy. Therefore physicians should pay attention to support PEI in those with risk factors such as monitoring of exocrine function and optimal enzyme supplements.

Introduction Single-incision-robotic cholecystectomy (SIRC) using the da Vinci Xi system (Xi) (Intuitive, Sunnyvale, CA, USA) is a safe and effective operation. Recently, the da Vinci SP system (SP) (Intuitive) which is a new platform specialized for single-port surgery has been released. The study aimed to compare perioperative outcomes of Xi and SP in regards to SIRC. Methods In this multicenter retrospective cohort study, patients who underwent SIRC with benign gallbladder disease between 2019 and 2020 were enrolled. In Seoul National University Hospital, Xi was used with 3 separate arms of instruments inserted through the single incision made in umbilical area. In Ewha Womans University Seoul Hospital, SP was used with single multi-channel port through the umbilical incision. Patient's demographics, intraoperative factors, postoperative complications, and postoperative pain were investigated. Results 258 patients underwent SIRC with Xi, and 72 patients with SP. There were significant differences between Xi and SP groups in operation time at console (23.1 vs. 20.3 min, p = 0.018), numbers of postoperative analgesic injection (4.0 vs. 3.2, p 0.999). SP group showed more estimated blood loss (14.3 vs. 19.2 mL, p = 0.031). Conclusions Although operation time at console was shorter and pain was less in SP group statistically, clinical benefit appears to be minimal. Both Xi and SP can be a safe and feasible platform to perform SIRC, but further investigation is needed as prospective study.

Introduction Surgical indications of main-duct intraductal papillary mucinous neoplasm (MD-IPMN) except for main pancreatic duct (MPD) diameter ≥ 10 mm remain controversial. Diameter of MPD alone could result in overestimation of malignancy. We aimed to predict malignancy risk of MD-IPMN based on morphologic features presented in CT scan or MRI. Methods We retrospectively reviewed 258 patients with main-duct or mixed-type IPMN between 2000 and 2017 in our institute. MD-IPMN is defined as segmental or diffuse dilatation of MPD > 5 mm without other causes of obstruction. We divided MD-IPMN into focal ectatic and diffuse type by pattern of dilated MPD. Results Of 258 patients with main-duct involved IPMN, 47 (18.2%) and 211 (81.8%) had main-duct and mixed-type IPMN. Risk of malignant (high-grade dysplasia + invasive lesion) (66.0% vs. 46.9%; p = 0.018) and invasive IPMN (53.2% vs. 26.1%; p 37 IU/mL (p = 0.014), MPD ≥ 10 mm (p = 0.017), thickened cyst wall (p = 0.005), and distal atrophy (p = 0.015) were independent predictive factors for malignant IPMN. Conclusions Malignancy risk increased proportionally to the diameter of MPD in MD-IPMN. Those with above mentioned risk factors should be the candidate of surgery.

Introduction Although the lack of high-level evidence, laparoscopic distal pancreatectomy (LDP) in pancreatic ductal adenocarcinoma (PDAC) is being performed by many surgeons due to the development of surgical techniques. The purpose of this study was to investigate the long-term oncologic outcomes of LDP in PDAC through propensity score matching (PSM) analysis with large-scale national database. Methods Patients who received DP for PDAC registered in the official database of KAHBPS (KOTUS-BP) were enrolled. For long-term oncologic outcome analysis, 5-year overall survival rate (5YOSR) and 5-year disease-free survival rate (5YDFSR) were compared to open DP (ODP). Results From May 2001 to December 2016, 1,202 patients with detailed operative information and sufficient pathological data in 16 hospitals were selected. There were 846 ODP cases (70.4%) and 356 LDP cases (29.6%). In the ODP group, more aggressive surgery was performed, the pathologic stage was higher, R0 rate was higher (81.2% vs. 77.0%, p < 0.001) and there was a greater number of retrieved lymph nodes (15.3 vs. 13.5, p = 0.002) than the LDP group. PSM was performed with 8 variables including age, sex, operation period, combined organ resection, major vessel resection, R status, T stage, and N stage. After matching, the 5YOSR of ODP and LDP were 37.3% and 41.4% (p = 0.150), and 5YDFSR was 23.4% and 27.2% (p = 0.332), respectively. Prognostic factors for 5YOSR were R status, T stage, N stage, differentiation, and lymphovascular invasion. Conclusions LDP was performed in a selected group, and within this group, it had comparable long-term oncologic outcome to ODP in patients with PDAC.

Introduction Extended cholecystectomy (EC) has been considered as the standard surgery of T2 gallbladder (GB) cancer. However, little is known an appropriate surgical strategy for intracholecystic papillary neoplasm (ICPN) of the GB, especially for the invasive ICPN. This study conducted to investigate clinicopathologic characteristics of T2 ICPN and compare the survival outcomes according to the surgical extent. Methods This was a retrospective cohort study. Between 2003 and 2018, patients who underwent curative-intent simple cholecystectomy (SC) or EC were included. EC was defined as liver wedge resection with at least 2-cm margin from the GB and lymphadenectomy around hepatoduodenal ligament. Preoperative patients' demographics and pathologic data were investigated. Results Of total 96 patients with T2 ICPN, 29 (30.2%) and 67 (69.8%) patients underwent SC and EC, respectively. Age at surgery was older in SC than EC group (73.0 vs. 65.4 years, p = 0.002). Overall, EC group showed better survival outcome than SC group (5-year overall survival [5YSR], 83.3% vs. 49.8%, p = 0.001). However, statistical significance was not shown in patients with age ≥ 75 years (5YSR, EC 67.7% vs. SC 35.6%, p = 0.606). In a multivariate analysis, older age (≥ 75 years, HR 3.03; p = 0.009), higher preoperative CA 19-9 level (≥ 37 IU/mL; p = 0.001), histologic differentiation (moderate, HR 2.47; p = 0037), and surgical extent (SC, HR 2.58; p = 0.022) were independent risk factors for worse survival outcome in T2 ICPN. Systemic recurrence was more frequently in SC group (31.0% vs. 7.5%; p = 0.003). Conclusions Similar to the T2 GB cancer, EC should be the standard surgical extent of T2 ICPN.

Introduction Sequential extended cholecystectomy (SEC) is currently recommended for gallbladder cancer (GBC) stage T2 and higher incidentally found after simple cholecystectomy (SC), but the value, timing and extent of re-resection has not been fully studied. This study evaluated long-term oncologic outcomes according to the type of surgery and time interval from initial cholecystectomy to SEC. Methods Patients diagnosed with T2 GBC who underwent extended cholecystectomy (EC), SEC or SC between 2002 and 2017 were retrospectively reviewed. Results In 226 patients diagnosed with T2 GBC, 173, 44, and 53 patients underwent EC, SEC, and SC, respectively. Age, ASA performance score was higher in the SC group than EC and SEC groups combined. Five-year overall survival (OS) was 73.2%, 78.7%, and 50.1%, and disease-free survival (DFS) was 66.3%, 65.2%, and 46.8% for EC, SEC, and SC patients, respectively. OS and DFS were higher in EC than SC (p = 0.007 and p = 0.001), higher in SEC than SC (p = 0.001 and p = 0.065), but similar between EC and SEC (p = 0.909 and p = 0.722). SEC patients who underwent SEC ≤ 30 days after initial cholecystectomy had longer DFS than the > 30 days group (114 months vs. 71 months; p = 0.023). Recurrence pattern (local or distant) of SC vs. EC and SEC combined showed significant difference, but not between EC and SEC. Seventeen of 18 SC recur patients had distant metastasis at the time of recurrence. Conclusions SEC is recommended for incidental T2 GBC because SEC provides better survival outcomes than SC alone. A time interval of ≤ 30 days between initial cholecystectomy and SEC is recommended.

Introduction Intrahepatic cholangiocarcinoma (ICC) exhibits a variety of morphologic and histologic growth pattern, and its treatment and prognosis are known to vary depending on the location and extent of tumor. This study aims to compare the clinical data according to the tumor location in ICC and to verify the current staging system used in ICC. Methods 302 patients who underwent curative resection were reviewed. Central type ICC (C-ICC) was defined when the tumor had an invasion of intrahepatic secondary confluence or segmental branches of the bile duct and peripheral type ICC (P-ICC) when the tumor was located more peripherally. Clinicopathologic characteristics, oncological outcomes, and prognostic stratification of the AJCC 8th staging system were assessed. Results Among 302 patients, 123 were classified as C-ICC and 179 as P-ICC. Bigger tumor size, higher rate of elevated CA19-9 level, vascular invasion, periductal invasion type, R1 rate, and advanced T stage was found in C-ICC. Five-year overall survival rates were 34.0% for C-ICC and 47.5% for P-ICC (p = 0.005). A significant difference in disease-free survival was seen as well (p = 0.036). The prognostic utility of ICC T stage was assessed in N0 C-ICC but failed to stratify T2, T3, and T4 tumors (median survival; T2: 37 m. T3: 34 m. T4: 33 m. p = 0.591). When applying the perihilar cholangiocarcinoma staging system (p < 0.001), stratification was improved and similar results were also seen in the overall staging. Conclusions C-ICC has a worse aggressive clinical course compared to P-ICC. The perihilar cholangiocarcinoma cancer staging system is better than ICC staging to stratify the prognosis of C-ICC.

Introduction Pancreatoduodenectomy (PD) is the most challenging abdominal surgery. In spite of the popularization of laparoscopic procedures for most GI surgery, laparoscopic PD is not so widely spread. Recently, robotic PD has gained popularity due to many merits. So we investigated current trends of types of PD and the clinical role of robotic surgery. Methods Between 2015 and 2020, a total of 1,263 PD was performed. 929 patients underwent open PD, and 334 underwent robotic PD. Demographics and surgical outcomes were analyzed according to the time period, and propensity score-matched (PSM) analysis was performed to evaluate complications and oncologic outcomes. Results Patients undergoing robotic PD were younger (63.7 vs. 65.2 years, p = 0.035); however, no significant difference was observed in sex (p = 0.152) and BMI (p = 0.742). Robotic PD patients were more likely to have the benign disease (30.2%) than those who received open surgery (13.7%). Robot PD has gradually increased from 6.3% to 71.6%. Operation time was longer in the robot group (338.8 vs. 296.5 minutes, p < 0.001); however, estimated blood loss did not significantly differ (473.5 vs. 429.2 mL, p = 0.335). Overall complication (18.6% vs. 17.9%, p = 0.843) and CR-POPF rates (9.9% vs. 8.4%, p = 0.478) were similar. The hospital stay was shorter in robot PD (10.9 days) than open PD (15.3 days). After PSM analysis, no significant difference of morbidity and survival outcome in cancer patients was observed. Conclusions The number of robot PD has markedly increased in a relatively short time showing comparable morbidity/mortality and oncologic outcome. Considering better recovery and cosmetic outcomes, robot PD has become one of standard surgical methods in pancreatic surgery.

Introduction Postoperative pancreatic fistula (POPF) is the most common and troublesome complication after pancreaticoduodenectomy (PD). To reduce POPF, various types of pancreaticojejunostomy (PJ) anastomosis have been introduced. The study aimed to compare the short-term outcomes of two different anastomotic methods of duct-to-mucosa PJ, out-layer continuous suture anastomosis (OCA) and modified Blumgart method (mBM). Methods In this retrospective cohort study, patients who underwent curative-intent open PD between 2015 and 2020 were enrolled. In in-layer anastomosis, duct-to-mucosa anastomosis using 5-6 interrupted sutures were performed. In mBM, two transpancreatic U-sutures was done in both dorsal and ventral side of jejunal loop with reinforced suture in the central part. Patient's demographics, diagnosis and intraoperative factors, postoperative complications, and POPF defined by the International Study Group on Pancreatic Fistula were investigated. Clinically-relevant POPF (CR-POPF) included grade B, C POPF. Results OCA was performed in 184 patients (65.7%) and mBM was performed in 96 patients (34.3%). There were no significant differences between the OCA and mBM group in CR-POPF rates (7.1% vs. 7.3%; p = 0.944), and overall surgical complication rates (21.7% vs. 30.2%; p = 0.097). Total operation time (242 vs. 233 minutes; p = 0.103) were comparable, but operation time for PJ is shorter in mBM (20.0 vs. 18.1 minutes; p < 0.001). Conclusions No significant differences were shown in postoperative outcome between OCA and mBM groups, but operation time for PJ in mBM was shorter. Since mBM is safe, relatively simple, and time-saving technique, it can be a good choice when duct-to-mucosa PJ is performed.