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In severe acute pancreatitis, accompanied by local complications such as acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection and walled-off necrosis, the mortality rate is as high as 12-25%. In many cases, interventional procedure or surgical treatment are required at an appropriate time. Conservative treatment is considered for acute peripancreatic fluid collection. Endoscopic drainage could be considered preferentially for the treatment of pancreatic pseudocysts with clinical symptoms or complications. In the case of necrotizing pancreatitis, conservative treatment is preferred, but therapeutic intervention should be considered if infectious pancreatic necrosis with clinical deterioration is suspected. For therapeutic intervention, it is recommended to proceed with a step-up approach in which drainage is first performed and, if necessary, necrosectomy is performed. The optimal timing of intervention is considered 4 weeks after the onset of pancreatitis when necrosis become walled-off, but early drainage within 4 weeks can be considered depending on the patient's condition. This guideline provides an overview of current treatment strategies for local complications of acute pancreatitis.

Hepatic hemangiomas infrequently exhibit atypical imaging features, which may cause diagnostic confusion with hepatic malignancies and lead to unnecessary surgery. We report a rare case of multilocular cystic hemangioma of the liver mimicking a mucinous cystic neoplasm of the liver in a 48-year-old female, focusing on computed tomography and magnetic resonance imaging features and their differential diagnosis.

Bladder cancer is the 9th most frequent cancer worldwide. Its incidence is increasing. The pancreas is an infrequent site of metastasis in relation to any type of malignancy. In this study, we report our experience with a patient who has undergone a pancreaticoduodenectomy for metastatic bladder cancer. A 61-year-old male was admitted with jaundice and pancreas head mass. He underwent robot assisted-cystectomy and ileal conduit for bladder cancer 7 months ago. Initial diagnosis under the imaging study was a resectable pancreas head cancer. However, we did not rule-out a metastatic bladder cancer. He underwent a classic pancreaticoduodenectomy. Based on histologic findings and immunohistochemistry results, a pancreas tumor with 4.9-cm sized metastatic urothelial carcinoma was diagnosed. He experienced no complication. He was discharged 11 days after the surgery. Four cycles of gemcitabine and cisplatin were administered. He remained recurrence-free of tumors for 16 months. Although the benefit of pancreatectomy for patient survival has been reported for metastases from renal cell carcinoma, it is unknown for bladder cancer because of no report. We believe that curative resection for metastasis to pancreas of urothelial carcinoma might be helpful for its management.

Despite its limited benefits, operative site drainage after elective hepatectomy is routinely used. This study aimed to investigate the safety and effectiveness of left lateral sectionectomy without operative site drainage.This study retrospectively collected data from 31 patients who underwent elective left lateral sectionectomy between January 2017 and June 2020. Based on whether operative site drainage was used, the patients were divided into two groups: drainage and non-drainage of the operative site and a comparative analysis was conducted.A total of 31 patients underwent left lateral sectionectomy during the study period. Of these, 22 patients were diagnosed with hepatocellular carcinoma; three, with intrahepatic cholangiocarcinoma; three, with liver metastasis; and three, with benign liver disease. Ten patients underwent laparoscopy. No significant differences were observed between the open and laparoscopic surgery groups. In the univariate analysis, there were no significant differences in the pre-, intra-, and postoperative clinicopathological factors between the non-drainage and drainage groups. The hospitalization period in the non-drainage group was significantly shorter than in the drainage group (8.44 days vs. 5.87 days,Routine use of surgical drainage for left lateral sectionectomy of the liver to prevent intraperitoneal fluid collection is unnecessary.

BACKGROUND Gemcitabine plus nab-paclitaxel (GA) and modified FOLFIRINOX (FFX) have been widely used as standard first-line treatment in pancreatic cancer. However, it is unclear which regimen is more efficacious. AIM To evaluate a retrospective analysis comparing the efficacy and safety of FFX and GA as first-line chemotherapeutic regimens in patients with metastatic pancreatic cancer. METHODS We retrospectively analyzed and compared outcomes in 101 patients who presented with pancreatic cancer and were treated with either GA (n = 54) or FFX (n = 47). Moreover, we performed subgroup analysis based on the neutrophil/lymphocyte ratio (NLR) and Eastern Cooperative Oncology Group (ECOG) performance status. RESULTS There were no significant differences between two groups in baseline characteristics, except for the ECOG performance status. The median progression-free survival (PFS) (6.43 mo vs 4.90 mo, P = 0.058) was comparable between two groups; however, median overall survival (OS) (10.17 mo vs 6.93 mo, P = 0.008) was longer in patients who received GA regimen. In patients with ECOG 0 (PFS: 8.93 mo vs 5.43 mo, P = 0.002; OS: 16.10 mo vs 6.97 mo, P = 0.000) and those with NLR < 3 (PFS: 8.10 mo vs 6.57 mo, P = 0.008; OS: 12.87 mo vs 9.93 mo, P = 0.002), GA regimen showed higher efficacy. CONCLUSION GA regimen may be recommended to the patients with NLR < 3 or ECOG 0 status although GA and FFX showed comparable efficacy outcomes in patients with metastatic pancreatic cancer.

BACKGROUND Combination chemotherapy (gemcitabine plus nab-paclitaxel and FOLFIRINOX) is widely used as the standard first-line treatment for pancreatic cancer. Considering the severe toxicities of combination chemotherapy, gemcitabine monotherapy (G mono) could be used as a first-line treatment in very elderly patients or those with a low Eastern Cooperative Oncology Group status. However, reports on the efficacy of G mono in patients older than 75 years are limited. AIM To evaluate the efficacy of G mono and combination chemotherapy by comparing their clinical outcomes in very elderly patients with pancreatic cancer. METHODS We retrospectively analyzed 104 older patients with pancreatic cancer who underwent chemotherapy with G mono (n = 45) or combination therapy (n = 59) as a first-line treatment between 2011 and 2019. All patients were histologically diagnosed with ductal adenocarcinoma. Primary outcomes were progression-free survival and overall survival. We also analyzed subgroups according to age [65-74 years (elderly) and ≥ 75 years (very elderly)]. Propensity score matching was performed to compare the outcomes between the two chemotherapy groups. RESULTS The baseline characteristics were significantly different between the two chemotherapy groups, especially regarding age, ratio of multiple metastases, tumor burden, and Eastern Cooperative Oncology Group performance status. After propensity score matching, the baseline characteristics were not significantly different between the chemotherapy groups in elderly and very elderly patients. In the elderly patients, the median progression-free survival (62 d vs 206 d, P = 0.000) and overall survival (102 d vs 302 d, P = 0.000) were longer in the combination chemotherapy group. However, in the very elderly patients, the median progression-free survival (147 d and 174 d, respectively, P = 0.796) and overall survival (227 d and 211 d, respectively, P = 0.739) were comparable between the G mono and combination chemotherapy groups. Adverse events occurred more frequently in the combination chemotherapy group than in the G mono group, especially thromboembolism (G mono vs nab-paclitaxel vs FOLFIRINOX; 8.9% vs 5.9% vs 28%, P = 0.041), neutropenia (40.0% vs 76.5% vs 84.0%, P = 0.000), and neuropathy (0% vs 61.8% vs 28.0%, P = 0.006). CONCLUSION In elderly patients, combination therapy is more effective than G mono. However, G mono is superior for the management of metastatic pancreatic cancer in very elderly patients.

Background IPNB is very rare disease and most previous studies on IPNB were case series with a small number due to low incidence. The aim of this study is to validate previously known clinicopathologic features of intraductal papillary neoplasm of bile duct (IPNB) based on the first largest multicenter cohort. Methods Among 587 patients previously diagnosed with IPNB and similar diseases from each center in Korea, 387 were included in this study after central pathologic review. We also reviewed all preoperative image data. Results Of 387 patients, 176 (45.5%) had invasive carcinoma and 21 (6.0%) lymph node metastasis. The 5-year overall survival was 80.9% for all patients, 88.8% for IPNB with mucosal dysplasia, and 70.5% for IPNB with invasive carcinoma. According to the “Jang & Kim's modified anatomical classification,” 265 (68.5%) were intrahepatic, 103 (26.6%) extrahepatic, and 16 (4.1%) diffuse type. Multivariate analysis revealed that tumor invasiveness was a unique predictor for survival analysis. (p = 0.047 [hazard ratio = 2.116, 95% confidence interval 1.010–4.433]). Conclusions This is the first Korean multicenter study on IPNB through central pathologic and radiologic review process. Although IPNB showed good long-term prognosis, relatively aggressive features were also found in invasive carcinoma and extrahepatic/diffuse type.

Acute pancreatitis can range from a mild, self-limiting disease requiring no more than supportive care, to severe disease with life-threatening complications. With the goal of providing a recommendation framework for clinicians to manage acute pancreatitis, and to contribute to improvements in national health care, the Korean Pancreatobiliary Association (KPBA) established the Korean guidelines for acute pancreatitis management in 2013. However, many challenging issues exist which often lead to differences in clinical practices. In addition, with newly obtained evidence regarding acute pancreatitis, there have been great changes in recent knowledge and information regarding this disorder. Therefore, the KPBA committee underwent an extensive revision of the guidelines. The revised guidelines were developed using the Delphi method, and the main topics of the guidelines include the following: diagnosis, severity assessment, initial treatment, nutritional support, convalescent treatment, and the treatment of local complications and necrotizing pancreatitis. Specific recommendations are presented, along with the evidence levels and recommendation grades.

BackgroundSignificant changes were made in the grading and staging systems for neuroendocrine neoplasms (NENs) in 2017. Therefore, a clinical report to comprehensively update the clinicopathological characteristics, therapeutic approaches, and prognosis of these patients should be drafted.MethodsWe retrospectively reviewed a database of 16 patients who developed NENs or mixed endocrine non-endocrine neoplasms (MiNENs) after curative resection. Among them, eight had ampulla of Vater (AoV) tumors, and eight had non-AoV tumors. One patient had NEN Grade 1, five had NEN Grade 2, and five had NEN Grade 3 (G3); all had poorly differentiated neuroendocrine carcinoma. Five patients had MiNEN or combined carcinoma.ResultsThe mean age was 57.88 years. The overall survival rates after curative surgery at 1, 3, and 5 years were 87.1, 80.4, and 71.4%, respectively. The 1-, 3-, and 5-year disease-free survival rates were 87.1%, 79.8%, and 71.8%, respectively. In univariate analysis, age >65 years, mitotic count (>20/10 high-power fields), Ki-67 index >20%, and presence of stones were significant prognosticators, whereas only the mitotic count was statistically significant in the multivariate analysis. Age >65 years (p=0.039), a Ki-67 index >20% (p=0.03), presence of stones (p=0.021), G3 stage disease, MiNEN (p=0.002), or perineural invasion (pConclusionHigh mitosis count had a greater effect on extrahepatic biliary NEN than the tumor-node-metastasis staging system. Patients with AoV tumors had better prognostic predictor factors compared to those with non-AoV tumors.

Gene therapy is a suitable alternative to chemotherapy due to the complications of drug resistance and toxicity of drugs, and is also known to reduce the occurrence of cellular mutation through the use of gene carriers. In this study, gene carrier nanoparticles with minimal toxicity and high transfection efficiency were fabricated from a biocompatible and biodegradable polymer, l-tyrosine polyurethane (LTU), which was polymerized from presynthesized desaminotyrosyl tyrosine hexyl ester (DTH) and polyethylene glycol (PEG), by using double emulsion and solvent evaporation techniques, resulting in the formation of porous nanoparticles, and then used to evaluate their potential biological activities through molecular controlled release and transfection studies. To assess cellular uptake and transfection efficiency, two model drugs, fluorescently labeled bovine serum albumin (FITC-BSA) and plasmid DNA-linear polyethylenimine (LPEI) complex, were successfully encapsulated in nanoparticles, and their transfection properties and cytotoxicities were evaluated in LX2 as a normal cell and in HepG2 and MCF7 as cancer cells. The morphology and average diameter of the LTU nanoparticles were confirmed using light microscopy, transmission electron microscopy, and dynamic light scattering, while confocal microscopy was used to validate the cellular uptake of FITC-BSA-encapsulated LTU nanoparticles. Moreover, the successful cellular uptake of LTU nanoparticles encapsulated with pDNA-LPEI and the high transfection efficiency, confirmed by gel electrophoresis and X-gal assay transfection, indicated that LTU nanoparticles had excellent cell adsorption ability, facilitated gene encapsulation, and showed the sustained release tendency of genes through transfection experiments, with an optimal concentration ratio of pDNA and LPEI of 1:10. All the above characteristics are ideal for gene carriers designed to transport and release drugs into the cytoplasm, thus facilitating effective gene therapy.

Pancreatic enzyme reflux into the biliary tract is associated with chronic inflammation and increased cellular proliferation in the biliary epithelium, leading to biliary carcinoma. We evaluated the relationship between high bile juice amylase levels and biliary microflora in patients with malignant gallbladder lesions.In this retrospective study, 25 gallbladder specimens were obtained from patients with gallbladder cancer to evaluate amylase levels and perform bacterial culture. The samples were divided into high and low amylase groups and culture-positive and negative groups for analysis. Bile juice amylase 3 times higher than the normal serum amylase level (36-128 IU/L) was considered high.The number of positive cultures was higher in the high amylase group than in the low amylase group, but the difference was insignificant. There were no differences in other clinicopathological factors. Sixteen patients showed positive culture results;Bacteria in gallbladder were identified more frequently when the amylase level was high. High amylase levels in the gallbladder can be associated with caused chronic bacterial infections with occult pancreaticobiliary reflux, potentially triggering gallbladder cancer.

Percutaneous balloon dilation with or without placement of an external biliary drain is a nonoperative alternative method for treating benign bilioenteric anastomotic strictures. Although this procedure has a high technical success rate, outcomes are less optimal when attempting to dilate refractory tight strictures. For the stricture, cutting balloon can be an option. We present four patients with benign bilioenteric anastomotic strictures refractory to conventional balloon dilation. To the patients, a peripheral cutting balloon over-the-wire system was inflated, following subsequent conventional non-compliant balloon dilation. After the balloon dilation treatment, an external drainage catheter was placed through the stricture site and maintained for up to 30 days. Technical and end-treatment success was achieved in all four patients. In conclusion, the use of cutting balloon dilation may appear to be a safe and effective alternative method of treatment in patients with benign bilioenteric anastomotic strictures refractory to conventional balloon dilation.

Biliary tract cancer (BTC) has poor prognosis, thus, early diagnosis is important to decrease mortality. Although vimentin-positive circulating tumor cells (V-CTCs) are a good candidate for diagnostic and prognostic biomarkers, studies on the topic are limited. We aimed to evaluate the diagnostic efficacy of V-CTCs between BTC and benign biliary disease (BBD) and determine the prognostic value of V-CTCs in BTC patients. We recruited 69 participants who had BTCs and BBDs from a single tertiary referral center. We analyzed CTCs and V-CTCs in peripheral blood using the CD-PRIMETM system. Seven patients were excluded due to a technical failure of CTC detection. CTCs were detected in all 62 patients. CTC count &gt, 40/mL blood (55.8% vs. 20%, p = 0.039), V-CTC count &gt, 15/mL blood (57.7% vs. 10%, p = 0.005), and V-CTC/CTC ratio &gt, 40% (48.1% vs. 10%, p = 0.025) were significantly different between BTCs and BBDs. Two or more of these three parameters (61.5% vs. 10%, p = 0.002) increased the accuracy. A combination of CTC markers with CA19-9 and biopsy increased the accuracy (90.4% vs. 10%, p = 0.000). V-CTC &gt, 50/mL blood was a significant factor affecting survival (140 (66.6–213.3) vs. 253 (163.9–342.1) days, p = 0.008). V-CTC could be a potential biomarker for early diagnosis and predicting prognosis in patients with BTC.

Although the current nodal staging system for gallbladder cancer (GBC) was changed based on the number of positive lymph nodes (PLN), it needs to be evaluated in various situations. We reviewed the clinical data for 398 patients with resected GBC and compared nodal staging systems based on the number of PLNs, the positive/retrieved LN ratio (LNR), and the log odds of positive LN (LODDS). Prognostic performance was evaluated using the C-index. Subgroups were formed on the basis of an restricted cubic spline plot as follows: PLN 3 (PLN = 0, 1–2, ≥ 3); PLN 4 (PLN = 0, 1–3, ≥ 4); LNR (LNR = 0, 0–0.269, ≥ 0.27); and LODDS (LODDS

Backgrounds/Aims This study aimed to evaluate clinical application of InnoSEAL Plus (a mussel-inspired catecholamine hemostat) as a new hemostatic material for humans. Methods Patients treated with topical hemostatic patches after liver resection were enrolled. They were divided into an experimental group (InnoSEAL Plus group) and two control groups (TachoSil® group and Surgicel Fibrillar® group) for efficacy evaluation. Results A total of 15 patients were enrolled. Each group had five patients. The 3-minute hemostasis success rate was 80.0% (4/5 patients) in the InnoSEAL Plus group, 80.0% (4/5 patients) in the TachoSil® group, and 40.0% (2/5 patients) in the Surgicel Fibrillar® group, showing no significant difference in the success rate among these groups (p > 0.05). All three groups exhibited 100% success rate for 10-minute hemostasis. Both InnoSEAL Plus and TachoSil® groups had one patient developing adverse events, which were treated easily with drug administrations. Conclusions InnoSEAL Plus is expected to be functionally not inferior to other conventional hemostatic agents. However, it is necessary to confirm this through multicenter prospective studies in the future.

Background: This study was performed to investigate the oncologic role of lymph node (LN) management and to propose a surgical strategy for treating intrahepatic cholangiocarcinoma (IHCC). Methods: The medical records of patients with resected IHCC were retrospectively reviewed from multiple institutions in Korea and Japan. Short-term and long-term oncologic outcomes were analyzed according to lymph node metastasis (LNM). A nomogram to predict LNM in treating IHCC was established to propose a surgical strategy for managing IHCC. Results: A total of 1138 patients were enrolled. Of these, 413 patients underwent LN management and 725 did not. A total of 293 patients were found to have LNM. The No. 12 lymph node (36%) was the most frequent metastatic node, and the No. 8 lymph node (21%) was the second most common. LNM showed adverse long-term oncologic impact in patients with resected IHCC (14 months, 95% CI (11.4&ndash, 16.6) vs. 74 months, 95% CI (57.2&ndash, 90.8), p &lt, 0.001), and the number of LNM (0, 1&ndash, 3, 4&le, ) was also significantly related to negative oncologic impacts in patients with resected IHCC (74 months, 95% CI (57.2&ndash, 90.8) vs. 19 months, 95% CI (14.4&ndash, 23.6) vs. 11 months, 95% CI (8.1&ndash, 13.8)), p &lt, 0.001). Surgical retrieval of more than four (&ge, 4) LNs could improve the survival outcome in resected IHCC with LNM (13 months, 95% CI (10.4&ndash, 15.6)) vs. 30 months, 95% CI (13.1&ndash, 46.9), p = 0.045). Based on preoperatively detectable parameters, a nomogram was established to predict LNM according to the tumor location. The AUC was 0.748 (95% CI: 0.706&ndash, 0.788), and the Hosmer and Lemeshow goodness of fit test showed p = 0.4904. Conclusion: Case-specific surgical retrieval of more than four LNs is required in patients highly suspected to have LNM, based on a preoperative detectable parameter-based nomogram. Further prospective research is needed to validate the present surgical strategy in resected IHCC.

To evaluate the long-term radiologic and clinical outcomes of stent-graft placement for the treatment of post-pancreaticoduodenectomy arterial hemorrhage (PPAH) based on the imaging findings of stent-graft patency and results of liver function tests.We retrospectively reviewed the medical records of nine consecutive patients who underwent stent-graft placement for PPAH between June 2012 and May 2017. We analyzed the immediate technical and clinical outcomes and liver function test results. Stent-graft patency was evaluated using serial CT angiography images.All stent-grafts were deployed in the intended position for the immediate cessation of arterial hemorrhage and preservation of hepatic arterial blood flow. Technical success was achieved in all nine patients. Eight patients survived after discharge, and one patient died on postoperative day 28. The median follow-up duration was 781 days (range: 28-1766 days). Follow-up CT angiography revealed stent-graft occlusion in all patients. However, serum aspartate aminotransferase or alanine aminotransferase levels in all patients were well below those observed in hepatic infarction cases.Stent-graft placement is a safe and effective treatment method for acute life-threatening PPAH. Liver function and distal hepatic arterial blood flow were maintained postoperatively despite the high incidence of stent-graft occlusion observed on follow-up CT.간 기능 검사와 영상 소견을 기반으로 하여 췌십이지장절제술 후 발생한 후기 출혈에서 스텐트-그라프트를 이용한 치료의 장기적 영상의학적, 임상적 경과를 보고자 한다.2012년 6월부터 2017년 5월까지 췌십이지장절제술 후 발생한 후기 출혈로 스텐트-그라프트 삽입술을 받은 9명의 환자를 후향적으로 분석하였다. 저자들은 시술 직후 술기적, 임상적 결과와 간 기능 검사를 검토하였다. 스텐트-그라프트의 개통성은 CT angiography를 이용하여 평가하였다.모든 스텐트-그라프트는 즉각적인 동맥 출혈을 멈추면서 간동맥 혈류를 유지할 수 있도록 의도했던 위치에 배치되었다. 기술적 성공은 모든 9명의 환자에게서 이루어졌다. 8명의 환자는 시술 후 생존하여 퇴원하였으며 한 명의 환자는 시술 28일 후 사망하였다. 평균 추적 관찰 기간은 781일이었다(범위: 28~1766일). 추적관찰 CT angiography에서 모든 환자의 스텐트-그라프트는 폐쇄되었다. 그러나 모든 환자들에서 간 경색을 시사할 만한 혈중 아스파르테이트아미노전달효소나 알라닌아미노전달효소 수치의 증가를 보이지 않았다.스텐트-그라프트 삽입술은 췌십이지장절제술 후 발생한 생명을 위협하는 후기 출혈의 안전하고 효과적인 치료이다. 간 기능과 간 말단부 동맥혈 공급은 추적관찰 CT상 스텐트-그라프트가 높은 확률로 막힘에도 불구하고 유지된다.

Mussel-inspired adhesion chemistry provides a useful alternative to the use of fibrin glues., Since the first report of underwater adhesive proteins of marine mussels in 1981, numerous studies have reported mussel-inspired synthetic adhesive polymers. However, none of them have developed up to human-level translational studies. Here, we report a sticky polysaccharide that effectively promotes hemostasis from animal bleeding models to first-in-human hepatectomy. We found that the hemostatic material instantly generates a barrier layer that seals hemorrhaging sites. The barrier is created within a few seconds by in situ interactions with abundant plasma proteins. Therefore, as long as patient blood contains proper levels of plasma proteins, hemostasis should always occur even in coagulopathic conditions. To date, insufficient tools have been developed to arrest coagulopathic bleedings originated from genetic disorders, chronic diseases, or surgical settings such as organ transplantations. Mussel-inspired adhesion chemistry described here provides a useful alternative to the use of fibrin glues up to a human-level biomedical application.

Most models for predicting malignant pancreatic intraductal papillary mucinous neoplasms were developed based on logistic regression (LR) analysis. Our study aimed to develop risk prediction models using machine learning (ML) and LR techniques and compare their performances. This was a multinational, multi-institutional, retrospective study. Clinical variables including age, sex, main duct diameter, cyst size, mural nodule, and tumour location were factors considered for model development (MD). After the division into a MD set and a test set (2:1), the best ML and LR models were developed by training with the MD set using a tenfold cross validation. The test area under the receiver operating curves (AUCs) of the two models were calculated using an independent test set. A total of 3,708 patients were included. The stacked ensemble algorithm in the ML model and variable combinations containing all variables in the LR model were the most chosen during 200 repetitions. After 200 repetitions, the mean AUCs of the ML and LR models were comparable (0.725 vs. 0.725). The performances of the ML and LR models were comparable. The LR model was more practical than ML counterpart, because of its convenience in clinical use and simple interpretability.

Leiomyosarcoma of an artery is very rare, and cases with hepatic metastasis are even rarer. We describe a case of a 70-year-old man who after follow up due to rectal cancer, presented with an intra-abdominal hypervascular mass and a hepatic mass. After surgical resection, it was diagnosed as a leiomyosarcoma of the right gastroepiploic artery with hepatic metastasis. Multiple metastases had recurred at the liver. He has survived more than 53 mo through multimodal treatments (three surgical resections, radiofrequency ablation, transarterial chemoembolization, chemotherapies, and targeted therapy). Multimodal treatments, including active surgical resection, may be helpful in the treatment of aggressive diseases such as arterial leiomyosarcoma with metastasis.

In ampullary adenocarcinoma cases, the clinical effects of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) have not yet been well-studied, unlike other prognostic factors that have been reported till date. This study aimed to investigate the clinical impact of maximum standardized uptake value (SUVmax) in predicting the prognosis of ampullary adenocarcinoma. Thirty-eight patients who underwent pre-operative 18F-FDG PET/CT and curative-intent resection of ampullary adenocarcinoma at Pusan National University Hospital (Pusan, South Korea) between 2008 and 2017 were retrospectively analyzed in this study. We evaluated the clinicopathologic outcomes according to the SUVmax using univariate and multivariate Cox proportional hazard regression analyses and receiver operating characteristic analysis to arrive at a cutoff value. Lymph node metastasis was detected in 9 patients, and 15 patients experienced a recurrence during the follow-up period. Among 38 patients, 33 showed an increased FDG uptake by the main tumor. SUVmax of 4.55 was selected as a significant independent predictive factor for patient survival along with poor tumor differentiation and high neutrophil-to-lymphocyte ratio in multivariate analysis (P = .016, hazard ratio = 5.040). Patients with SUVmax under 4.55 exhibited significantly longer overall survival than the rest (

Background The clinical implication of lymph node (LN) dissection of intrahepatic cholangiocarcinoma (ICCA) is still controversial, and LN metastasis (LNM) based on tumor site has not been confirmed yet. Methods Patients who underwent curative-intent surgery at 10 tertiary referral centers were identified and divided into peripheral (PP) and near second confluence level tumor (NC) groups on the basis of the distance from the second confluence and oncological outcomes were compared. Results Of 179 patients, 121 patients with LND were divided into the NC (n = 89) and PP groups (n = 32) on the basis of 4.5 cm from the second confluence. NC group showed higher LNM rate than PP group (46.1 vs 21.9%, p = 0.016) and NC was a risk factor for LNM (odds ratio: 4.367; 95% confidence interval: 1.234–15.453, p = 0.022). The 5-year overall survival (OS) rate (38.0% vs. 27.8%, p = 0.777) and recurrence-free survival (RFS) rates (22.8% vs. 25.8%, p = 0.742) showed no differences between the PP and NC groups. In the NC group, N1 patients showed worse 5-year OS (12.7% vs 39.0%, p = 0.004) and RFS (8.8% vs 28.6%, p = 0.004) than the N0 patients. In the PP group, discordant results in 5-year OS (48.9% vs. 50.0%, p = 0.462) and RFS (41.3% vs. 0%, p = 0.056) were found between the N0 and N1 patients. Conclusion The NC group was an independent risk factor for LNM and LNM worsened prognosis in NC group for ICCA. In the PP group, LND should not be omitted because of high LNM rate and insufficient oncologic evidence.

Introduction Despite limited availability, prophylactic operative site drainage after elective hepatectomy has been used routinely. The objective of this study was to investigate the safety and effectiveness of nonuse of operative site drainage after left lateral sectionectomy. Methods Elective left lateral sectionectomy was performed 31 patients between Jan 2017 and June 2020. We retrospectively evaluate d data that were prospectively collected on left lateral sectionectomy. Patients were divided into drainage group (n = 16) and non-use group (n = 15). Results The patients included 22cases of hepatocellular carcinoma, 3cases of intrahepatic cholangiocarcinoma, 3cases of liver metastasis and 3cases of benign liver disease. Ten cases were performed by laparoscopic surgery. There was no difference between the two groups in clinicopathological factors and surgical outcomes such as incidence of surgical related complications. There was no case of intraperitoneal fluid collection requiring additional procedure after heaptectomy and early re-admission. But, in the period from surgery to discharge, the non-use group was significantly shorter than that of the drainage group (5.87 days vs. 8.44 days, p = 0.005). Conclusions We concluded operative site drainage is unnecessary after elective left lateral sectionectomy.

Introduction In ampullary adenocarcinoma cases, the clinical effects of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) have not yet been well-studied, unlike other prognostic factors that have been reported till date. This study aimed to investigate the clinical impact of maximum standardized uptake value (SUVmax) in predicting the prognosis of ampullary adenocarcinoma. Methods Thirty-eight patients who underwent preoperative 18F-FDG PET/CT and curative-intent resection of ampullary adenocarcinoma at Pusan National University Hospital (Busan, Korea) between 2008 and 2017 were retrospectively analyzed in this study. We evaluated the clinicopathologic outcomes according to the SUVmax using univariate and multivariate Cox proportional hazard regression analyses and receiver operating characteristic analysis to arrive at a cutoff value. Results Lymph node metastasis was detected in nine patients, and 15 patients experienced a recurrence during the follow-up period. Among 38 patients, 33 showed an increased FDG uptake by the main tumor. SUVmax of 4.55 (sensitivity 61.5% and specificity 60.0%) was selected as a significant predictive factor for advanced lesions (larger size, p = 0.02; advanced T stage, p = 0.02; node metastasis, p = 0.01; and lymphovascular invasion, p = 0.04). Patients with SUVmax under 4.55 exhibited significantly longer overall survival than the rest (< 4.55 vs. ≥ 4.55), and the 5-year overall survival was 82.8% vs. 57.4% (p = 0.05). Conclusions SUVmax of 4.55 on 18F-FDG-PET/CT could be a predictive factor for tumor biology and long-term survival in patients with ampullary adenocarcinoma. Nevertheless, considering the cost aspect and its limited prognostic effect, this study seems to require more patients.

Introduction Laparoscopic central bisectionectomy is still an area of great challenge and technically requiring surgery due to high incidence of surgical complication and poor intraoperative outcomes. We report our experience totally laparoscopic central bisectionectomy for colorectal cancer liver metastasis (CRLM) using indocyanine green (ICG) fluorescence imaging. Methods The patient was 77-years-old man and was performed laparoscopic low anterior resection with ileostomy, cholecystectomy for rectal cancer 3 years before admission. He diagnosed metachronous CRLM and on magnetic resonance imaging, 5 cm sized hepatic mass was shown between segment 4 and 8 with middle hepatic vein (MHV) involvement. During operation, the Cavitron Ultra Sonic Aspirator® and Sonicision™ (Medtronic) was applied for hepatic parenchyma dissection. For resection of major glissonian pedicle and MHV, Signia™ staple (Medtronic) was used. After right anterior glissonian pedicle was isolated and temporary clamping, 2.5 mg ICG was injected intravenously. The ICG stained area could be recognized, and subsequent parenchyma dissection was completed successfully under Pringled maneuver. Specimen was retieved via extended umbilical port site. Results The operation time was 205 minutes and the estimated blood loss was 300 mL. No transfusion was done intraoperatively and postoperatively. There was no significant complication after surgery. Computed tomography was checked on postoperative day 5, showed no abnormal pathologic findings. On pathologic findings, metastatic adenocarcinoma sized 5.4 cm with clear resection margin was diagnosed. The patient discharged on postoperative day 7. Conclusions Laparoscopic central bisectionectomy is safe and feasible compared with conventional open surgery. ICG imaging system is effective and helpful for safe hepatic resection.

Introduction Neuroendocrine neoplasm of extrahepatic bile ducts are very rare. The aim of this study to elucidate the clinicopathological characteristics, therapeutic approach and prognosis of these patients. Methods The subjects were 16 patients who were diagnosed with neuroendocrine neoplasm or mixed adenoneuroendocrine carcinoma (MANEC) after curative resection. There were 8 ampulla of Vater and 8 non ampulla of Vater (6 gallbladder and 2 distal bile duct). Results The female to male ratio was 1.3/1 with mean age of 57.9 years (ranging from 36 to 74 years). There were 8 cases of incidental diagnosis in health screenings and 2 cases during evaluation for other disease. The most common symptoms were abdominal discomfort (3 pain and 1 dyspepsia) and jaundice (2 cases). According to the 2010 WHO classification, 1 patient had NET G1, 5 NET G2, 6 NET G3 and 5 MANEC. G3 and MANEC were small cell type. Pancreatoduodenectomy was performed in 9 patients (1 combined minor hepatectomy), extended cholecystectomy in 6 cases (1 combined pancreaticoduodenectomy and right hemicolectomy) and radical bile duct resection in 1 case. There were no association between OS and DFS with various clinicopathological factors including TNM stage. Ki-67 (cut-off 20%) was only prognostic factor in OS (5-year survival: 100% vs. 42.3%; p = 0.044) and DFS (5-year survival: 100% vs. 47.6%; p = 0.059). Conclusions In NET of extrahepatic bile duct, the titer of Ki-67 is more important than TNM according to AJCC, and attention of Ki-67 titer may be needed in treatment of recurrence.

Purpose InnoSEAL Plus is an adhesive, coagulant-free hemostatic material that mimics the adhesion mechanism of marine mussels. This study reports on the safety and efficacy of InnoSEAL Plus for patients with hemorrhage after hepatectomy despite first-line hemostasis treatments. Methods This is a multicenter, prospective, single-blinded, randomized clinical trial involving 96 hepatectomy patients. TachoSil was used as a comparator group. Three-minute and 10-minute hemostatic success rates were monitored. Rebleeding rates were also observed. Safety was assessed by recording all novel undesirable symptoms. Results InnoSEAL Plus showed a 3-minute hemostasis rate of 100%, while TachoSil had a rate of 98.0% (48 of 49 patients), demonstrating that the 2 had similar hemostatic efficacies. The difference in efficacy between the test and comparator group was 2.04%, and the lower limit of the one-sided 97.5% confidence interval was −1.92%; as this is greater than the noninferiority limit of −23.9%, the 2 treatments were equivalent. Meanwhile, the 10-minute hemostatic success rate was the same in both groups (100%). No rebleeding occurred in either group. In the safety evaluation, 89 patients experienced adverse events (45 in the test group and 44 in the comparator group). The difference between the 2 groups was not significant. No death occurred after application of the test or comparator group product. Conclusion Given that InnoSEAL Plus is a coagulation factor-free product, the hemostasis results are encouraging, especially considering that TachoSil contains a coagulation factor. InnoSEAL Plus was found to be a safe and effective hemostatic material for control of bleeding in hepatectomy patients.

Purpose: Necrotizing soft tissue infection is the infection of the soft tissue with necrotic changes. It is rare, but results in high mortality. We analyzed the characteristics of patients, prognosis, and mortality factors after reviewing 30 cases of a single hospital for 5 years. Methods: From January 2009 to December 2013, 30 patients diagnosed with necrotizing fasciitis or Fournier’s gangrene in Pusan National University Hospital were enrolled for this study. The following parameters were analyzed retrospectively: demographics, infection site, initial laboratory finding, initial antibiotics, isolated microorganisms, number of surgeries, time to first operation, length of intensive care unit, and total hospital stays. Results: The overall mortality rate was 23.3%. Mean body mass index (BMI) of the survival group (24.7 ± 5.0 kg/㎡) was significantly higher than the nonsurvival group (22.0 ± 1.4 kg/㎡, P = 0.029). When BMI was less than 23 kg/㎡, the mortality rate was significantly higher (P = 0.025). Two patients (6.7%) with chronic kidney disease requiring hemodialysis died (P = 0.048). Initial WBC count (>13×10 3 /μL), CRP (>26.5 mg/dL), and platelet (PLT) count ( 3 /μL) were found to have negative impact on the prognosis of necrotizing soft tissue infection. Factors such as potassium level, blood urea nitrogen (>27.6 mg/dL), serum creatinine (>1.2 mg/dL) that reflected kidney function were significant mortality factors. Conclusion: Patients with low BMI or abnormal values of WBC count, CRP, and PLT count reflecting the degree of infection or abnormal renal function will need more intensive care.