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Resuscitative endovascular balloon occlusion of the aorta (REBOA) is widely performed as an adjunct to resuscitation or bridge to definitive control of non-compressible torso hemorrhage in patients with hemorrhagic shock. It is a crucial adjunct for the maintenance of cerebral and coronary perfusion during resuscitation. However, in polytrauma patients with concomitant neurotrauma, such as traumatic brain injury (TBI) or spinal cord injury, the physiological effects of REBOA are unclear. In this report on REBOA performed in a clinical setting for polytrauma patients with spinal cord injury or TBI, the physiological effects of REBOA in neurotrauma are reviewed.

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

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

Abdominal wall hernias are common in patients with ascites. Elective surgical repair is recommended for the treatment of abdominal wall hernias. However, surgical hernia repair in cirrhotic patients with refractory ascites is controversial. In this study, we aimed to evaluate the outcomes of elective surgical hernia repair in patients with liver cirrhosis with and without refractory ascites. From January 2005 to June 2018, we retrospectively reviewed the records of consecutive patients with liver cirrhosis who underwent a surgical hernia repair. This study included 107 patients; 31 patients (29.0%) had refractory ascites. Preoperatively, cirrhotic patients with refractory ascites had a higher median model for end-stage liver disease (MELD) score (13.0 vs 11.0, P = 0.001) than those without refractory ascites. The 30-day mortality rate (3.2% vs 0%, P = 0.64) and the risk of recurrence (hazard ratio 0.410; 95% CI 0.050–3.220; P = 0.39) did not differ significantly between cirrhotic patients with refractory ascites and cirrhotic patients without refractory ascites. Among cirrhotic patients with refractory ascites, albumin (P = 0.23), bilirubin (P = 0.37), creatinine (P = 0.97), and sodium levels (P = 0.35) did not change significantly after surgery. In advanced liver cirrhosis patients with refractory ascites, hernias can be safely treated with elective surgical repair. Mortality rate within 30 days did not differ by the presence or absence of refractory ascites. Elective hernia repair might be beneficial for treatment of abdominal wall hernia in cirrhotic patients with refractory ascites.

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

Background In high-risk and unfit-for-surgery patients with acute cholecystitis (AC), treatment options are controversial. Few studies have reported the results of long-term follow-up. This study aimed to evaluate the clinical course of patients after removal of the percutaneous cholecystostomy (PC) catheter in high-risk patients with AC, time interval to relapse, and factors influencing relapse. Methods From 2000 to 2011, 183 patients with AC underwent PC and catheter removal in Seoul National University Hospital and Boramae Hospital, Korea. Sixty cases were reviewed retrospectively after excluding cases with intended interval cholecystectomy, malignant biliary obstruction, loss to follow-up, and insufficient follow-up information. Results The mean age was 68.6 ± 13.8 years, and the mean Karnofsky performance score was 24.8 ± 9.7. After insertion of a PC catheter, symptom resolution and improvement on imaging were achieved in 95% and 97.9% of patients, respectively. Laboratory values were also improved (P

Background Classifications of intraductal papillary mucinous neoplasm (IPMN) remain ambiguous, especially for the mixed type. Factors predicting malignancy remain unclear. The aim of this study was to evaluate the usefulness of factors predicting malignancy in the new international consensus guidelines for resection of branch duct-type (BD)-IPMN and to compare them with those in the previous version. Methods A prospectively collected database of patients with biopsy-proven BD-IPMN was analysed to compare factors between the first and second consensus guidelines, particularly as predictors of malignancy. Results Of 350 patients with BD-IPMN, sensitivity (0·724) and balanced accuracy (0·751) of the second guidelines were superior to those (0·639 and 0·730) in the first version at the expense of slightly reduced specificity (0·779 versus 0·822 for the first version) by random forest models. Multiple logistic regression analysis showed that main pancreatic duct dilatation greater than 5 mm (hazard ratio (HR) 4·54, 95 per cent confidence interval 2·45 to 8·41; P < 0·001), mural nodules (HR 6·27, 3·27 to 12·01; P < 0·001) and carbohydrate antigen 19–9 level above 37 units/ml (HR 4·03, 1·83 to 8·90; P = 0·001) were independent predictors of BD-IPMN malignancy. Conclusion The new consensus guidelines provide better sensitivity, performance of factors predicting malignancy, and balanced accuracy in the diagnosis of BD-IPMN malignancy. Size alone was limited in predicting malignancy. Variability in clinical significance of the individual factors associated with a risk of malignancy indicates the need for a tailored approach in the management of patients with BD-IPMN.

Surgical removal of mucinous cystic neoplasms (MCNs) is usually recommended because of the risk of malignancy. However, increased experience of MCNs suggests that the incidence of invasion is lower than had been thought. This study was designed to establish more reasonable surgical indications for MCN through re-assessment using strict pathologic diagnostic criteria.Ninety-four patients who underwent surgical removal of MCNs at Seoul National University Hospital from 1991 to 2012 were retrospectively analyzed. Pathologic results were re-evaluated by an experienced pathologist. Medical records and radiologic images were reviewed to determine factors predicting malignancy.Of the 94 patients, 4 were found to have intraductal papillary mucinous neoplasms (IPMNs). Of the 90 MCNs, 60 (66.7%) were low-grade, 21 (23.3%) were intermediate-grade, and 5 (5.5%) were high-grade dysplasias; and 4 (4.4%) were invasive carcinoma. Mural nodules on CT scan (p = 0.005) and abnormal serum CA19-9 concentration (p = 0.029) were significant predictors of malignancy. All MCNs less than 3 cm in size with normal serum tumor markers were benign and all malignant MCNs had cyst fluid CA19-9 over 10,000 units/ml. The five year disease specific survival rates were 98.8% for all patients and 75.0% for those with invasive MCNs.MCNs had a low prevalence of malignancy. Regardless of the histological grade, long-term outcome was excellent. Therefore, in the absence of specific symptoms, surgery may not be indicated for MCNs3 cm without mural nodules or elevated serum tumor markers. Validation by a prospective study with very careful design is needed.

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

Background/Aims The aim of this study was to investigate changes in the clinical and demographical characteristics of gallstone disease in Korea, based on 30 years of surgically treated patients at a single institute. Methods In total, 7,949 gallstone patients who underwent surgery between 1981 and 2010 were analyzed. Patients were divided into six time periods: period I (1981 to 1985, n=831), period II (1986 to 1990, n=888), period III (1991 to 1995, n=1,040), period IV (1996 to 2000, n=1,261), period V (2001 to 2005, n=1,651) and period VI (2006 to 2010, n=2,278). Results The total number and mean age of the patients gradually increased, and the male/female ratio decreased. The proportion of gallbladder (GB)-stone cases increased, whereas the proportions of common bile duct (CBD)- and intrahepatic duct (IHD)-stone cases decreased. Differences in patient geographical origins also decreased. Based on the relationship between changes in the prevalence of gallstone disease and socioeconomic status, the prevalence of CBD stones showed a strong correlation with Engel's coefficient (p

Background There are concerns about the extent of impaired endocrine and exocrine pancreatic function and poor quality of life (QoL) after pancreatectomy, but there is little information from large prospective follow-up studies. Methods Consecutive patients undergoing pancreaticoduodenectomy or distal pancreatectomy between 2007 and 2011 were included. Relative bodyweight (RBW), triceps skinfold thickness (TSFT), serum protein, albumin, transferrin, fasting blood glucose, postprandial 2-h glucose (PP2), glycosylated haemoglobin A1c and stool elastase measurements, and European Organization for Research and Treatment of Cancer QLQ-C30 questionnaires were collected serially for 1 year. Results Some 136 patients undergoing pancreatic resection completed the study. RBW and TSFT recovered to over 90 per cent of the preoperative value by 12 months, whereas transferrin, albumin and protein had returned to preoperative levels by 3 months. Diabetes mellitus, impaired fasting glucose or raised PP2 was present in 42 of 76 patients at 6 months and 36 of 76 at 12 months. Although steatorrhoea and diarrhoea had mainly resolved by 3 months, stool elastase level decreased after operation and showed no recovery. Nutritional status, pancreatic endocrine function and QoL returned to preoperative levels in 63 (46·3 per cent), 72 (52·9 per cent) and 77 (56·6 per cent) of 136 patients within 6 months of pancreatectomy. Multivariable analysis revealed that age 60 years or more, operation type, chronic pancreatitis and malignant disease had a significant impact on nutritional index, pancreatic function and QoL. Conclusion About half of all patients can expect recovery from pancreatectomy after 6 months, but those with risk factors need more careful follow-up and supportive management.

Using a right liver (RL) graft improves the outcomes in adult living donor liver transplantation (ALDLT). Here we report the recent excellent outcomes of 238 consecutive RL transplantations in ALDLT. Between January 2005 and June 2009, 238 consecutive adult recipients underwent RL transplantation; The middle hepatic vein (MHV) was reconstructed using artificial vascular grafts in 209 cases. Among these study subjects, UNOS status 1 and 2A were 12 (5.0 %) and 20 (8.4 %) patients, and the mean medical MELD score, was 19.9. Hepatitis B virus was the most common original liver disease in 184 patients (77.3 %). Hepatocellular carcinoma was diagnosed in 133 patients (56.3 %), and 102 patients (76.1 %) met the radiologic Milan criteria. The mean graft-versus-recipient weight ratio was 1.14 %. The primary endpoint of this study was the patient and graft survival rate. The mean follow-up period was 32 (0–69) months. The most common major complication was biliary complication (n = 62; 26 %). The 1-, 2-, and 5-year patient survival rates were 96, 95, and 94 %, and the graft survival rates were 99, 99, and 98 %. There were 4 hospital deaths (1.6 %). Eighteen late mortalities were observed after recurrence of hepatocellular carcinoma (HCC, n = 17) and one case of lymphoma recurrence. One case of graft failure 33 months after ALDLT was attributed to cholestatic fibrosing hepatitis B saved by re-ALDLT. On multivariate analysis, no drainage of MHV branches and accompanying HCC beyond Milan criteria were the risk factors for poor patients’ survival rate (p

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

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

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

Laparoscopic hepatectomy for intrahepatic duct (IHD) stones is limited by technical difficulties caused by adhesion to adjacent tissue or distorted anatomy resulting from recurrent inflammation. This study compared perioperative and clinical outcomes in patients undergoing laparoscopic and open hepatectomy for left IHD stones.From January 2002 to December 2013, 40 patients underwent laparoscopic left-sided hepatectomy [left hemihepatectomy (n = 7) or left lateral sectionectomy (n = 33)] and 54 patients without combined operations and previous operation histories underwent open left-sided hepatectomy [left hemihepatectomy (n = 24) or left lateral sectionectomy (n = 30)]. Their perioperative and clinical outcomes were compared, including stone clearance rates, stone recurrence rates, and median follow-up duration.There was no difference in age (56.8 ± 8.2 vs. 55.6 ± 9.6 years, p = 0.531), sex (1.0:4.0 vs. 1.0:1.8 male:female, p = 0.108), or BMI (22.8 ± 2.8 vs. 22.9 ± 3.0 kg/m(2), p = 0.802) between the laparoscopic and open hepatectomy groups. Lateral sectionectomy was more frequent in the laparoscopic group (33/40 vs. 30/54, p = 0.010). Operation time (174.2 ± 56.6 vs. 210.4 ± 51.6 min, p = 0.002) and postoperative hospital stay (7.9 ± 2.6 vs. 14.3 ± 5.5 days, p0.001) were shorter in the laparoscopic group, and complication rate (17.5 vs. 40.7%, p = 0.016), in particular surgical site infection rate (5.0 vs. 18.5%, p = 0.052), was lower in the laparoscopic group than in the open hepatectomy group. Similar results were observed in the hemihepatectomy and lateral sectionectomy subgroups. There was no operation-related mortality. There were no significant differences in follow-up periods (48 ± 33.6 vs. 59.2 ± 41.7 months, p = 0.235) and rates of initial stone clearance (87.5 vs. 75.9%, p = 0.159), final clearance (100 vs. 94.4%, p = 0.130), and stone recurrence (2.5 vs. 5.6%, p = 0.468).Laparoscopic hepatectomy is safe and effective for well-selected patients with left IHD stones, when performed by experienced surgeons. Laparoscopic hepatectomy resulted in shorter operation time and postoperative hospital stay, and a lower postoperative morbidity rate, than open hepatectomy.

To evaluate long-term follow-up results after surgical treatment of intraductal papillary mucinous neoplasm (IPMN) to optimize postoperative surveillance strategies.Little is known about the postoperative natural history of IPMN, especially about long-term follow-up results in patients with benign or noninvasive IPMN.Long-term follow-up was undertaken in a prospective cohort of 403 consecutive patients who underwent surgical treatment of IPMN at Seoul National University Hospital. Of these, 37 patients with ductal adenocarcinoma arising in IPMN were excluded from the analysis.Of the 366 patients, 82 had low-grade dysplasia, 171 had intermediate-grade dysplasia, 45 had high-grade dysplasia, and 68 had IPMN with associated invasive carcinoma. During a median follow-up of 44.4 months, the overall recurrence rate was 10.7%. Pathologic grade of dysplasia was associated with recurrence rate (P0.001). IPMNs involving main duct had higher rate of recurrence (P = 0.021). Of the 298 patients with benign or noninvasive IPMN, 16 (5.4%) had recurrences including distant metastasis. Multivariate analysis revealed that the degree of dysplasia was the most important predictor of recurrence (P0.001). The overall 5-year disease-free survival rate was 78.9% and was significantly lower in patients with high-grade dysplasia than in those with low- or intermediate-grade dysplasia (P = 0.045).Pancreatic IPMNs recur in 10.7% of patients. Recurrence is correlated with the degree of dysplasia, and 5.4% of patients with benign or noninvasive IPMN have recurrences including distant metastasis. Thorough postoperative surveillance is needed not only for patients with invasive IPMN but also for those with benign or noninvasive IPMN, especially for patients with high-grade dysplasia.

Objectives Current version of World Health Organization classification introduced the concept of ‘‘intraductal papillary mucinous neoplasm(IPMN) with an associated invasive carcinoma.’’ The authors investigated the clinicopathologic characteristics and prognosis of this disease category according to tumor morphology and percentage of invasive component. Methods Fifty-nine patients who underwent surgical resection of IPMN with an associated invasive carcinoma at Seoul National University Hospital were subgrouped according to the invasive component of less than 5% (minimally invasive [MI] intraductal papillary mucinous carcinoma [IPMC] [MI-IPMC]), 5%- 50% (invasive IPMC [IPMC-I]),and 50% or greater (pancreatic ductal adenocarcinoma [PDAC]-associated IPMN [PDAC-IPMN]). Prognosis was compared with 219 curatively resected conventional PDAC. Results Eleven MI-IPMCs (18.6%), 24 IPMC-Is (40.7%), and 24PDAC-IPMNs (40.7%) were identified. With the transition from MIIPMC to IPMC-I and PDAC-IPMN, percentage of advanced T (P G0.001) or N stage (P = 0.001), expression of S100A4 (P = 0.004), p53(P = 0.028), and CD24 (P = 0.009) increased; and SMAD4 expression decreased (P G 0.001). The overall 5-year survival rates for MIIPMC,IPMC-I, and PDAC-IPMN were 80.8%, 59.0%, and 29.3%,respectively (P G 0.001). Pancreatic ductal adenocarcinoma-associated IPMN had poor prognosis compared with MI-IPMC (P = 0.011) or IPMC-I (P = 0.026) but had comparable prognosis with conventional PDAC (P = 0.138). Conclusions Pancreatic ductal adenocarcinoma-associated IPMN has different clinicopathological characteristics compared with the IPMC-I.Intraductal papillary mucinous neoplasm with an associated invasive carcinoma is composed of a wide spectrum of disease.

Some suggest that metastatic lymph node ratio (LNR) may be prognostic of survival in patients with pancreatic cancer. However, this phenomenon was confused by inclusion of node-negative patients in the analysis. The present study was designed to evaluate the prognostic impact of metastatic LNR and the absolute number of metastatic LNs in patients resected for pancreatic cancer.Data were collected from 398 patients who underwent curative surgery for pancreatic head cancer at Seoul National University Hospital. Long-term survival was analyzed according to LNR and absolute number of metastatic LNs.Of the patients, 227 (57.0 %) had LN metastasis. The mean numbers of total retrieved and metastatic LNs were 19.5 and 1.9, respectively, and the mean LNR was 0.11. Median overall survival (OS) of patients was significantly higher in N0 than in N1 patients after curative resection (25.4 vs. 14.8 months, p0.001). Median OS was significantly lower in patients with 1 than in those with 0 positive LNs (17.3 vs. 25.4 months, p = 0.001). Among N1 patients, those with 0LNR ≤ 0.2 had comparable prognosis than those with0.2 LNR (median OS 17.2 vs. 12.8 months, p = 0.096), and the number of metastatic LNs did not correlate with median OS (p = 0.365).The presence of a single positive metastatic LN was associated with significantly poorer OS in patients with pancreatic cancer. When LN metastasis was present, the number of metastatic LNs and LNR had limited prognostic relevance.

BackgroundThe fate of a microscopic positive ductal margin (MPDM) of extrahepatic bile duct (EHBD) cancer is unclear. The purpose of this study was to analyse the clinicopathological features of EHBD cancer with MPDM and to identify the prognostic factors associated with survival.MethodsBetween 1995 and 2007, a retrospective analysis of 464 patients who had undergone surgical resection for EHBD cancer was conducted. Clinicopathological factors likely to influence survival were assessed using univariate and multivariate analysis.ResultsOne hundred twenty-four patients had MPDM which included invasive carcinoma (IC) (n=85) and carcinoma in situ (CIS)/ high-grade dysplasia (HGD) (n = 39). The median survival (MS) of R0, R1 as CIS/ HGD, and R1 as IC were 41 months, 29 months, and 18 months, respectively. Adverse prognostic factors were ‘IC’ on the resection margin [HR = 1.66, 95% confidence intervals (CIs) 1.06–2.59, P = 0.026], and no use of adjuvant chemoradiotherapy (HR = 1.57, 95% CIs 1.04–2.39, P = 0.033). Adjuvant chemoradiotherapy was beneficial in patients with MPDM as IC (5-year survival rate 19.7 compared with 2.8%, P = 0.011).ConclusionsThe presence of MPDM is an important prognostic factor in EHBD cancer. When a ductal resection margin is positive, discrimination between ‘IC’ and ‘CIS/ HGD’ is important.

The clinical usefulness of portal vein embolization (PVE) for Klatskin tumor is not well established. The authors explored the change in liver volume and function before and after major hepatectomy and evaluated the effect of PVE.Thirty-three consecutive patients who underwent right hepatectomy with an initial future liver remnant (FLR) ≤ 30% for Klatskin tumors at Seoul National University Hospital were included.Eleven patients underwent PVE, and eight patients received right trisectionectomy. PVE induced a mean FLR increase of 19.3% after a mean of 15.8 days. At postoperative month 1, liver volume and liver hypertrophy ratio was comparable between PVE and no-PVE group. For patients with an initial FLR ≤ 20%, postoperative liver hypertrophy rate of PVE group was comparable to no-PVE group. Liver function tests were not affected by PVE or the initial FLR. Postoperative liver hypertrophy ratio was negatively correlated with the initial FLR (hypertrophy ratio (%) = 326.7-0.4×initial FLR (ml), P = 0.001). There was no severe PVE-related morbidity, and postoperative morbidity rate was comparable in PVE and no-PVE group.The postoperative liver hypertrophy ratio, final liver volume, or liver function tests were not affected by PVE. Postoperative liver hypertrophy was related to the initial FLR.

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

Background/Aims: Extended cholecystectomy is generally recommended for patients with T2 gallbladder cancer. However, few studies have assessed the extent of resection relative to T2 gallbladder tumor location. This study analyzed the effects of surgical methods and tumor location on survival outcomes and tumor recurrence in patients with T2 gallbladder cancer. Methods: Clinicopathological characteristics, extent of resection, survival rates, and recurrence patterns were retrospectively analyzed in 88 patients with pathologically confirmed T2 gallbladder cancer. Results: The 5-year disease-free survival rate was 65.0%. Multivariate analysis showed that lymph node metastasis was the only independent risk factor for poor 5-year disease-free survival rate. Survival outcomes were not associated with tumor location. Survival tended to be better in patients who underwent extended cholecystectomy than in those who underwent simple cholecystectomy. Recurrence rate was not affected by surgical method or tumor location. Systemic recurrence was more frequent than local recurrence without distant recurrence. Gallbladder bed recurrence and liver recurrence were relatively rare, occurring only in patients with liver side tumors. Conclusions: Extended cholecystectomy is the most appropriate treatment for T2 gallbladder cancer. However, simple cholecystectomy with regional lymph node dissection may be appropriate for patients with serosal side tumors. (Gut Liver 2016;10:140-146)

Purpose: Free tumor cells in peritoneal fluid in patients with pancreatic cancer may have prognostic significance but there are few reports on methods for the effective detection of free tumor cells. The aims of this study were to identify free cancer cells in peritoneal fluid with fluorescent in situ hybridization (FISH) technique and to investigate its prognostic significance. Methods: Twenty-eight patients with resectable pancreatic cancer who underwent surgical resection were included. Peritoneal washing and peritoneal drainage fluid were examined by FISH for p53 deletion. Results: Among the study subjects, the R0 resection rate was 75%. None of the patients had positive cytology with Papanicolaou’s method. p53 deletion was detected in 9 peritoneal washings (32.1%) and in 5 peritoneal drainage fluids (17.9%). After a median of 18 months of follow-up, 25 patients (89.3%) experienced recurrence and 14 patients (50.0%) had peritoneal seeding. Patients with p53 deletion detected in the peritoneal drainage fluid had positive radial margin (60.0% vs. 17.4%, P = 0.046) more frequently and a lower peritoneal metastasis free survival (median, 11.1 months vs. 30.3 months; P = 0.030). Curative resection (P ＜ 0.001) and p53 deletion in peritoneal drainage fluid (P = 0.030) were independent risk factors of peritoneal metastasis free survival after multivariate analysis. Conclusion: FISH technique detects free cancer cells with higher sensitivity compared to Papanicolaou’s method. p53 deletion detected in peritoneal drainage fluid is correlated with positive radial resection margin and results in early peritoneal seeding. Patients with p53 deletion in peritoneal drainage fluid need more aggressive adjuvant treatment.

Despite it being a benign disease, a choledochal cyst must be removed with the gallbladder (GB) due to the risk of cancer in the biliary tract. Most patients are young females or children, all of whom express strong interest in the cosmetic results in addition to the complete resolution of their medical problems. Here, we introduce a laparoscopic management technique for a choledochal cyst.Between 2003 and 2011, we performed a laparoscopic choledochal cyst excision procedure on 82 patients using a four-hole method. There were three open-conversion cases, one case involving robotic surgery, and one case involving combined laparoscopic liver resection because the cyst had affected the liver. Excision of the cyst and anastomosis were performed laparoscopically. We will present our method with a video.The mean operation time was 230 min. The estimated blood loss was 197 ml. The average hospital stay was 8.6 days. The most common complications were minor bile leakage (7 %) and fluid collection (2.5 %), both of which were managed conservatively.Laparoscopic management can be a treatment of choice for the most instances of choledochal cyst considering its good cosmetic results and its feasible level of operative safety.

The purpose of this study was to examine the value of surgical resection and to find prognostic factors for metastatic gastric cancer.Clinicopathological data of 257 cM1 gastric cancer patients who underwent an operation at Seoul National University Hospital from January 1999 to December 2004 were reviewed. Patients were grouped into the resection (RS, n=165) and nonresection groups (NR, n=92). To evaluate whether there was any selection bias, patients were stratified according to chemotherapy and preoperative CT findings were compared.There were no significant differences in clinicopathologic features and preoperative CT findings between the RS and NR groups. For chemotherapy, the RS group had a survival benefit (median survival; 12.7 vs. 11.2 months, p=0.0107). In the subanalysis, there was a survival benefit to the RS group when metastasis was confined to one site (14 vs. 9.7 months, p=0.04). In patients with no chemotherapy, the RS group had no benefit (p=0.151). In univariate and multivariate analyses, resection (p=0.001), chemotherapy (p0.001), the number of organs with metastatic lesions (p=0.003), and elective operation (p0.001) were significant prognostic factors.This retrospective study suggests that surgical resection in metastatic gastric cancer may improve survival when combined with chemotherapy, especially when metastasis is confined to one site.

s / Pancreatology 13 (2013) S1–S80 S63 ml). There was no conversion to open. 2 patients had developed pancreatic fistula (Grade A), which resolved spontaneously. In five of 7 patient (71.4%), R0 resection could be achieved, but the remaining two patients showed R1 resection. The mean numbers of retrieved lymph nodes were 17 (range, 9w40). The average postoperative hospital stay was 17.4 days (range, 7w47 days). Median follow up was 12 months (range, 6w33months). Peritoneal recurrence occurred in 2 patients. One of them died by primary disease. The remaining 5 patients are alive without recurrence. Conclusions: LDP for PDAC can be feasible, safe, and effective in highly selected patients. Clearly, a prospective, randomized study is needed to elucidate appropriate indications and effects of the present procedure.