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There are three main competing treatment modalities for carotid artery stenosis (CS), i.e., carotid endarterectomy (CEA), carotid artery angioplasty/stenting (CAS), and medical treatment. In this study, we analyzed the performance and trends of CS research through bibliometric analysis.We searched the Thomson Reuters Web of Science citation indexing database. The key words used in the search were "carotid artery" and "carotid stenosis". The top 100 most cited manuscripts (T100) were analyzed based on title, author, institution, country of origin, year of publication, and topic.The T100 were published between 1990 and 2016. The Stroke published the most manuscripts (n=22) and the New England Journal of Medicine was the most cited (n=15,113). The United States had the greatest number of publications (n=43), and the University of Oxford was the institution with the most publications (n=7). Peter M. Rothwell was the corresponding author with the most publications (n=10). The main topics were in the following categories: CEA (n=22), medication (n=11), CAS (n=9), diagnosis (n=44), and CEA vs. CAS (n=14).This bibliometric analysis of CS research provides insight into publication trends and perspective on the treatment of CS.

Background: Kidney transplantation (KT) has become common in the treatment of end-stage renal disease. However, to date, there have been no bibliometric analyses of KT research to identify the most influential articles. The purpose of this research is to identify and characterize the 100 most cited articles that focus on KT and to clarify the trends in the accomplishments in this field. Methods: We searched the Thomson Reuters Web of Science citation indexing database and used keyword mapping of VOSviewer. The top 100 most cited manuscripts were analyzed based on their titles, authors, institutions, countries of origin, years of publication, and topics. Results: The New England Journal of Medicine has published the most manuscripts on kidney transplantation (n = 26) and is the most cited journal (n = 15,642). The United States has the highest number of publications (n = 61). Kashika is the corresponding author with the most published papers (n = 5; 2892 citations). The most common topics of publication are immunosuppressant (n = 34), clinical outcome (n = 26), and pathology (n = 22). Keywords related to immunosuppressant are the most common in keyword mapping with VOSviewer. Conclusions: This bibliometric analysis of KT research provides the research characteristics and publication trends of this topic. In KT research, immunosuppressants and post-transplant clinical outcomes have been important topics.

Background: To investigate the long-term effects of splenectomy on sepsis occurrence in patients undergoing distal pancreatectomy. Splenectomy is associated with sepsis and other severe infections. Splenic preservation has been advocated during distal pancreatectomy for benign or borderline pancreatic diseases. To date, no population-based study has investigated the risk of sepsis occurrence with regard to splenectomy in patients undergoing distal pancreatectomy. Methods: In this population-based study, the Health Insurance Review & Assessment Service (HIRA) database was used to identify patients who underwent distal pancreatectomy between 2010 and 2014. After propensity score matching, the variables that affect sepsis occurrence were analysed between the spleen-preserving distal pancreatectomy (SPDP) and the conventional distal pancreatectomy (CDP) groups. Findings: A total of 5,613 patients undergoing distal pancreatectomy were included in the HIRA database (2,560 splenectomised patients and 3,053 spleen-preserved patients). We matched 2,262 splenectomised patients to 2,262 spleen-preserved patients. No significant difference was observed in the rate of sepsis occurrence between the SPDP and CDP groups. Interpretation: Compared to spleen-preservation, splenectomy during distal pancreatectomy is not related to an increased likelihood of long-term sepsis. Thus, preservation of the spleen during distal pancreatectomy may not be mandatory in patients with benign pancreatic disease. However, further population-based studies are warranted to analyse the role of spleen-preserving distal pancreatectomy in other outcomes. Funding Information: This study received no financial support. Declaration of Interests: All authors declare no competing interests. Ethics Approval Statement: This study was approved by institutional review board of Kangnam Sacred Heart Hospital (HKS 2018-11-013), and the need for informed consent from each patient was waived because the authors did not have access to identifiable information.

Objective This study was performed to compare the outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography (ERCP) versus primary LCBDE for managing cholecystocholedocholithiasis. Methods We retrospectively analyzed data from 59 patients who underwent LCBDE during laparoscopic cholecystectomy (LC) for managing cholecystocholedocholithiasis from January 2013 to August 2019. The patients underwent either primary LCBDE plus LC (Group I) or LCBDE plus LC after failed ERCP (Group II). The demographics, reason for ERCP failure, perioperative details, and postoperative outcomes were evaluated. Results CBD stone removal using preoperative ERCP failed in 31 patients (Group II) because of remaining stones after ERCP (n = 9), failed cannulation (n = 6), failed sedation (n = 6), a periampullary diverticulum (n = 5), previous Billroth II gastrectomy (n = 3), a huge stone (n = 1), and an impacted stone (n = 1). The CBD stone clearance rate was >96% in both groups. The mean operative time, hospital stay, overall complication rate, and open conversion rate were not significantly different between the two groups. Conclusions When extraction of CBD stones by ERCP is likely to be difficult or fail, primary LCBDE is an acceptable alternative treatment for managing cholecystocholedocholithiasis.

Purpose Since endovascular aneurysm repair (EVAR) was first introduced in 1991, it has undergone rapid technical and quantitative developments. We analyzed the characteristics and trends of EVAR research through bibliometric analysis. Methods Comprehensive online searches focused on EVAR were performed from January 1994 to August 2017. The following information was collected: title, year of publication, countries' contribution, authorship, subspecialty, institution, subject category, and top 10 cited articles. Results A significant increase was demonstrated globally in the number of annual publications on EVAR. The highest number of publications was from the United States (n = 849, 35.08%), followed by England (n = 343, 14.17%), and the institutions with highest number of publications were Stanford University (n = 61, 2.52%) and Skane University Hospital Malmo (n = 45, 1.86%). The Journal of Vascular Surgery published approximately one quarter of the total publications. Vascular surgeons produced the most publications (n = 1871, 78.14%), followed by radiologists (n = 377, 15.58%) and cardiologists (n = 73, 3.02%). The most studied topics on EVAR were complications and procedures. The number of publications on complex EVAR and EVAR in juxtarenal aneurysm has increased more from 2013 to 2017 (5.1%, 9.5%) compared with from 1998 to 2002 (2.1%, 1.8%). Conclusion Our bibliometric analysis showed the characteristics and trends of publications on EVAR over a period of 25 years. The results of the bibliometric analysis revealed the quantitative improvements of publications and the qualitative improvements in challenging EVAR.

In recent years, many studies have focused on the host immune system and its relationship with tumor progression in a variety of solid tumors, including breast cancer. This study investigates recent trends of immunotherapy research in breast cancer and compares the contributions of research from different regions, institutions, and authors. A search of breast cancer and immunotherapy studies that were published between 2010 and 2019—with different keyword combinations—was performed in the Web of Science database. Bibliometric data were collected for analysis. VOSviewer software was used to generate a figure for the keyword’s co-occurrence network, so as to implement network visualization analysis. A total of 1,041 publications were identified. The United States and China contributed to approximately 50% of the publications, 336 and 208, respectively. Both countries drove the increase in publications after 2015. A paper entitled “Pembrolizumab in patients with advanced triple-negative breast cancer: Phase IB KEYNOTE-012 Study” that was published in the Journal of Clinical Oncology by Nanda et al. was the most cited (715 citations). The keywords found in this research were grouped into four clusters: “mechanism,” “vaccination,” “PD-L1,” and “chemotherapy.” The terms “tumor-infiltrating lymphocytes” and “PD-1/PD-L1” are among the latest hotspots, which mostly appeared in 2017. Author keyword analysis revealed that recent trends in breast cancer immunotherapy focus on the triple-negative breast cancer subtype and PD-1/PD-L1 immune checkpoint pathway and inhibitors. This study analyzed global trends in immunotherapy research on breast cancer over the past 10 years and provided insight into the features and research hotspots of the articles in this issue.

Objective Citation analysis represents one of the best available methods to identify the most influential articles. This study aimed to identify and characterize the top 100 highly cited articles (T100) that focus on hepatocellular carcinoma and to reveal the trends in accomplishments within this field. Methods A search of the Thomson Reuters Web of Science citation indexing database was conducted using terms related to hepatocellular carcinoma. The T100 were selected and analyzed further based on the number of citations, authorship, year of publication, journal, country of origin, institution, and article type. Results Hepatology published the highest number of papers (n = 15), and the United States produced the highest number of contributions (n = 31). Barcelona University was the institution with the highest number of articles in the T100 (n = 9). The T100 articles included 35 observational studies, 13 randomized control studies, 25 basic research articles, 18 reviews, seven clinical guidelines, and two meta-analyses. Conclusions This is the first bibliometric study to identify the most influential papers in hepatocellular carcinoma research. This report presents major advances and changes in research regarding hepatocellular carcinoma and can serve as a guide for writing a citable article.

Pancreatic cancer has a very high mortality with a 5-year survival of

자연재난과 사회재난 발생 빈도의 증가는 재난을 직⋅간접적으로 경험하는 재난 피해자에게 악영향을 주기 때문에, 국가차원의 재난복구체계를 지속적으로 보완하고 제시해야 할 필요가 있다. 하지만, 재난 피해자에 대한 심리적 지원보다는 물질적⋅경제적인 지원이 선행으로 이루어지고 있어 재난발생 이후에 발생하는 외상 후 스트레스 장애(PTSD)를 사전에 예방하지 못하는 문제점이 빈번하게발생하고 있다. 본 연구에서는 자연재난과 사회재난이 빈번하게 발생하고 있는 미국과 일본의 대규모 재난에 대한 심리지원 사례를 중심으로 국내의 심리지원체계에 적용 가능한 방향을 마련하고자한다. 또한 각 국가의 심리지원기관의 운영사례를 통해 국내 심리지원에 따른 시사점과 우선지원을위한 방향을 제시하고자 한다.

Korea repeatedly experiences floods and droughts that cause traumatic environmental conditions with huge economic impact. With an approach and solution such as Smart Water Grid these problems can be alleviated. Tapping into the retention ponds behind dams, rainfall harvest facilities in urban areas and any other structures installed to store rainfall water during flood events will mitigate the damage of flooding and provide a new source of national water resources. Similarly, purified waste water, ground water and desalinated sea water can also be feasible to use as alternative water resources. In this study, the water balance assessment model is being developed as a Smart Water Grid research. In fact, large proportions of water resources in Korea rely on a river fresh water. Also in the Youngjongdo island, tap water from water purification plant which use original source from the Han river. However the water supply system in the island is quite dangerous since the water purification plant is located in Incheon city and the water comes to island through the sea and no other source is used in the island. Therefore, once the accident at main water pipe in the sea, no water is available in this island. Information on water availability and water needs are crucial to identify hot spots of quantitative pressures on water resources. In this study, all available alternative water sources are calculated by the model developed through this study. Several physical and stochastic models on hydraulic and hydrological approaches are nominated to investigate physical characteristics of catchments

Purpose: Single-port laparoscopic cholecystectomy may result in postoperative complication in patients with cholecystitis. An additional right subcostal port could make laparoscopic surgery safe in these patients. We suggest the transumbilical laparoscopic cholecystectomy with additional port, which can be performed safely regardless of cholecystitis. Methods: Consecutive 291 patients underwent transumbilical laparoscopic cholecystectomy in the Department of Surgery by a single surgeon. We have usually used the globe port in the transumbilical area and an additional right subcostal port. Results: The mean operation time was 44.0±15.2 min (range: 20-140). The mean hospital stay after operation was 4.0±2.3 days (range: 1-9). Postoperative complications were umbilical hernia (n=7) and bile leakage (n=3). There was no in-hospital mortality. Conclusion: Transumbilical laparoscopic cholecystectomy can be performed in patients with most of benign gallbladder disease. And, an additional right subcostal port could be helpful in ensuring safe transumbilical laparoscopic cholecystectomy, even in patients with cholecystitis.

Objectives The aim of this study was to determine the prognosis of pancreatic adenocarcinoma patients with portal venous involvement according to its location and extent on radiologic findings. Methods From January 2003 to December 2011, the medical records of 543 patients who had undergone pancreaticoduodenectomy (PD) for pancreas head cancer in Asan Medical Center were retrospectively reviewed. The portal vein (PV) resection (PVR) patients (n = 147) were classified according to the location (NPVC group, without PV confluence invasion; PVC group, with PV confluence invasion) and extent (group A, the tumor surrounded less than two thirds of the vessel perimeter; group B, the tumor extended over two thirds) of venous involvement on radiologic findings. Results The survival rate of the patients who underwent PD with PVR was significantly lower than that of the patients who underwent PD without PVR (P = 0.009). The NPVC group and group A had significantly better prognoses than the PVC group and group B (P = 0.033 and P = 0.005, respectively). Conclusions Pancreatic cancer with venous involvement had different prognoses according to the location and extent of venous involvement. The patients with PV confluence or extensive vein invasion are recommended the neoadjuvant treatments.

Background: In hepatocellular carcinoma, anatomical resection is important because of portal spread. In right anterior sectionectomy (RAS) and right posterior sectionectomy (RPS), the right hepatic vein (RHV) may not correspond with the intersectional plane if an inferior RHV (IRHV) is present. The aim of this study was to evaluate the influence of the IRHV on the exposure of the RHV retrospectively. Methods: One hundred ninety-one patients underwent RAS or RPS by the Glissonean pedicle transection method. The calibres of the RHV and IRHV were measured and assessed the extent of exposure of RHV. Results: One hundred seventeen patients underwent RAS and 74 underwent RPS. The calibre of the RHV averaged 8.0 mm and that of the IRHV, 6.2 mm. Exposure of the RHV was divided into three groups: no exposure 31 (16.2%) (with IRHV, 20 patients; without IRHV, 11 patients), upper half exposure 49 (25.7%; with IRHV, 24; without IRHV, 25) and full exposure 111 (58.1%) (with IRHV, 16; without IRHV, 95). The effect of the IRHV on exposure of the RHV was substantial (P < 0.001). Conclusions: The IRHV can affect the course of the RHV and its exposure. Therefore, in RAS and RPS, it is important to evaluate the existence of the IRHV.

Background: Treatment options for patients with portal vein (PV) stenosis or occlusion after surgery are limited. The purpose of this study was to investigate the efficacy and safety of PV stent placement in patients with portal vein occlusion or stenosis after radical operation for hepatobiliary pancreatic malignant tumour. Methods: We retrospectively reviewed the records of 59 patients who underwent portal venous stent placement at the Asan Medical Center, Seoul, Korea, for PV stenosis or occlusion between February 2008 and February 2012. Results: Stents were placed in the portal venous system across stenotic (n = 47) and occlusive (n = 12) lesions after percutaneous transhepatic portography. Reasons for stent placement were tumour recurrence (n = 30), portal vein resection and anastomosis (n = 18) and post-operative inflammatory changes (n = 11). Pressure gradients (superior mesenteric vein, main PV) decreased immediately after stent placement, from 10.5 mm Hg 4.4 (standard deviation) to 2.5 mm Hg 2.6 (P < 0.0001). Liver function was improved post-stenting (P < 0.05). The median time between the original surgery and stent placement was 16 (1‐137) days in the vascularorientated group and 306 (13‐3703) days in the tumour recurrence group (P < 0.0001). Transient fever developed in 11 patients, but resolved in 2‐5 days. Stents were occluded in 15 of the 59 patients (25.4%). Conclusion: PV stent placement is a safe choice, has an acceptable success rate and provides marked relief from portal hypertension due to portal vein occlusion or stenosis after hepatobiliary pancreatic surgery. Liver function data are also improved after portal venous stent placement.

PURPOSE Inhibitory effect of paclitaxel on neointimal hyperplasia after open cutdown has not been elucidated. METHODS For the control group (n = 16), silicone 2.7-Fr catheters were placed via the right external jugular vein with the cutdown method. For the treatment group (n = 16), a mixture of 0.65 mg of paclitaxel and 1 mL of fibrin glue was infiltrated around the exposed vein after cutdown. After scheduled intervals (1, 2, 4, and 8 weeks), the vein segment was harvested and morphometric analysis was performed on cross-sections. RESULTS Proliferation of smooth muscle cell (SMC) was strongly suppressed in the treatment group, and the ratio of neointima to vein wall was significantly reduced in the treatment group (8 weeks; 0.63 ± 0.08 vs. 0.2 ± 0.08, P < 0.05). Luminal patency was significantly more preserved in the treatment group, and the luminal area was significantly wider in the paclitaxel-treated group compared to the control group (8 weeks; 1.91 ± 0.43 mm2 vs. 5.1 ± 0.43 mm2, P < 0.05). Mean SMC counts measured at 1 and 2 weeks after cutdown were significantly lower in the treatment group (2 weeks; 115 ± 22 vs. 62 ± 22). Paclitaxel was undetectable in systemic circulation (

For choledochal cyst, the treatment of choice is total excision of the cyst because there is a risk of biliary cancer including the gallbladder. The current report describes the authors’ early experiences using their technique of laparoscopic en bloc excision of choledochal cysts with Roux-en-Y biliary reconstruction. Between September 2009 and July 2011, laparoscopic excision for choledochal cyst was attempted for 20 patients at the Division of Hepatobiliary and Pancreatic Surgery, Asan Medical Center. Clinical, radiologic, and surgical data were analyzed retrospectively. The mean age of the patients was 37.8 ± 11.1 years (range, 18–65 years), and the male-to-female ratio was 1:4.0 (4:16). According to Todani’s classification, there were four type 1a cases, seven type 1c cases, and nine type 4a cases. The mean operation time was 395.8 ± 58.7 min. No perioperative transfusions were required. The average body mass index was 23.5 ± 4.04 kg/m2. Conversion to laparotomy was required for seven patients (35 %) due to bleeding (n = 1), Roux loop venous congestion (n = 1), abdominal obesity (n = 2), and severe fibrosis and inflammation around the cyst (n = 3). No malignancies were identified. Of the 13 patients who underwent laparoscopy, the jejunojejunostomy was created extracorporeally for the first 2 patients and intracorporeally for the subsequent 11 patients. All hepaticojejunostomies were performed intracorporeally. Oral feeding was resumed on postoperative day 3. The mean postoperative hospital stay was 9.3 days (range, 8–36 days). No major complications or mortalities occurred. The morbidity and mortality rates for the authors’ method are comparable with previously reported results. Although the conversion rate, mean operation time, and hospital stay were greater than reported in some studies, this probably reflected the authors’ learning curve for this technically challenging procedure. They believe laparoscopic approaches will eventually become an advantageous treatment option for laparotomy offered to selected choledochal cyst patients.

Transumbilical single-port laparoscopic appendectomy (SPLA) is a promising procedure that features less pain, faster recovery of postoperative bowel function and superior cosmetic results. We performed a retrospective comparative analysis of SPLA versus conventional laparoscopic surgery (CLA) to evaluate the safety and efficacy in acute appendicitis. From December 2008 to November 2013, laparoscopic surgery was performed on 636 patients with acute appendicitis at the Department of Surgery, Chuncheon Sacred Heart Hospital. Under approval of Institutional Review Board, data concerning baseline characteristics, operative outcomes, postoperative complications and postoperative functional recovery were compared between both procedures. After exclusion of 18 patients, 618 patients treated for acute appendicitis were included. SPLA was performed in 375 patients and CLA in 243 patients. Complicated appendicitis was more prevalent in the CLA group (26.3 %) than in the SPLA group (17.1 %) (p = 0.005). There was no difference between groups in operation time (p = 0.235), postoperative duration of hospital stay (p = 0.672) and readmission rate (p = 0.688). The rate of postoperative complications was similar in both groups (10.7 % in SPLA vs. 11.1 % in CLA, p = 0.862). In subgroup analysis of complicated appendicitis, more patients needed conversion to open surgery in the SPLA group (15.6 vs. 1.6 %, p = 0.005). In uncomplicated appendicitis, SPLA can be performed safely and efficiently. However, more selective indication for SPLA should be applied in cases of complicated appendicitis because of the greater risk of open conversion.

There is debate over whether T1b gallbladder cancer (GBC) should be treated by simple cholecystectomy (SC) or by extended cholecystectomy (EC). The aim of this study is to compare and analyze the results of these two procedures. The archived medical records of 805 patients with GBC who had undergone surgical resection in Asan Medical Center, or were referred from other hospitals after undergoing surgery, between 1997 and 2010 were retrospectively reviewed. Of these, 85 patients were diagnosed with pathologic stage T1b (muscular layer) GBC. By using propensity scoring, the EC group and the SC group were matched in the proportion of 1:2; so, 54 patients were enrolled in this study. Among the 54 pathologic stage T1b cancer patients, SC was performed in 36 (66.7 %) and EC in 18 (33.4 %). The mean operation time and hospital stay after surgery of the SC group was significantly shorter than in the EC group (83.2 vs. 356.4 min, 7.8 vs. 15.2 days; both p = 0.000). Disease recurrence was noted in four cases (11.1 %), all in the SC group; 50 % of recurred patients experienced recurrence at the lymph node. There was no significant intergroup difference in the 5-year survival rate (5-YSR) (88.8 % for SC vs. 93.3 % for EC, p = 0.521). In this study, for stage T1b GBC, both EC and SC offered similar cure rates. However, recurrence is associated with SC and inadequate lymph node dissection (LND). Therefore, EC including regional LND may be justified and preferred because of the possibility of lymph node metastasis and the accurate assessment of stage (LN status), except that the patients have a high risk of operation.

In hepatocellular carcinoma, anatomical resection is important because of portal spread. In right anterior sectionectomy (RAS) and right posterior sectionectomy (RPS), the right hepatic vein (RHV) may not correspond with the intersectional plane if an inferior RHV (IRHV) is present. The aim of this study was to evaluate the influence of the IRHV on the exposure of the RHV retrospectively.One hundred ninety-one patients underwent RAS or RPS by the Glissonean pedicle transection method. The calibres of the RHV and IRHV were measured and assessed the extent of exposure of RHV.One hundred seventeen patients underwent RAS and 74 underwent RPS. The calibre of the RHV averaged 8.0 mm and that of the IRHV, 6.2 mm. Exposure of the RHV was divided into three groups: no exposure 31 (16.2%) (with IRHV, 20 patients; without IRHV, 11 patients), upper half exposure 49 (25.7%; with IRHV, 24; without IRHV, 25) and full exposure 111 (58.1%) (with IRHV, 16; without IRHV, 95). The effect of the IRHV on exposure of the RHV was substantial (P0.001).The IRHV can affect the course of the RHV and its exposure. Therefore, in RAS and RPS, it is important to evaluate the existence of the IRHV.

Treatment options for patients with portal vein (PV) stenosis or occlusion after surgery are limited. The purpose of this study was to investigate the efficacy and safety of PV stent placement in patients with portal vein occlusion or stenosis after radical operation for hepatobiliary pancreatic malignant tumour.We retrospectively reviewed the records of 59 patients who underwent portal venous stent placement at the Asan Medical Center, Seoul, Korea, for PV stenosis or occlusion between February 2008 and February 2012.Stents were placed in the portal venous system across stenotic (n = 47) and occlusive (n = 12) lesions after percutaneous transhepatic portography. Reasons for stent placement were tumour recurrence (n = 30), portal vein resection and anastomosis (n = 18) and post-operative inflammatory changes (n = 11). Pressure gradients (superior mesenteric vein, main PV) decreased immediately after stent placement, from 10.5 mm Hg ± 4.4 (standard deviation) to 2.5 mm Hg ± 2.6 (P0.0001). Liver function was improved post-stenting (P0.05). The median time between the original surgery and stent placement was 16 (1-137) days in the vascular-orientated group and 306 (13-3703) days in the tumour recurrence group (P0.0001). Transient fever developed in 11 patients, but resolved in 2-5 days. Stents were occluded in 15 of the 59 patients (25.4%).PV stent placement is a safe choice, has an acceptable success rate and provides marked relief from portal hypertension due to portal vein occlusion or stenosis after hepatobiliary pancreatic surgery. Liver function data are also improved after portal venous stent placement.

A ruptured pseudoaneurysm is the most serious and life-threatening cause of post-pancreatoduodenectomy (PD) hemorrhages. We have evaluated the clinical course and management of pseudoaneurysms after PD. Of 586 patients who underwent PD for periampullary tumors in Asan Medical Center between March 2003 and March 2011, 27 experienced pseudoaneurysmal bleeding. Bleeding developed at a median of 21 days (range, 8 to 45 days) after surgery, including 9 patients who developed bleeding more than 4 weeks after surgery. Before development of bleeding, 26 patients showed pancreatic fistula. Bleeding was developed from the gastroduodenal artery stump in 12 patients, the common hepatic artery in eight, the proper hepatic artery in five, and the left hepatic artery in two. Of the angiographic group, 21 patients underwent with microcoil embolization, four underwent stent insertion, and one experienced technical failure. Only one patient required emergent laparotomy without angiography. Of 25 patients with angiographic procedures, all patients achieved hemostasis. The mortality rate was 22.2 per cent (6 patients). Delayed hemorrhage after PD is closely associated with pancreatic fistula and carried a significantly higher mortality rate. The patients with pancreatic fistula should be carefully monitored, even more than 4 weeks after surgery. Selective microcoil embolization or stent graft is effective for pseudoaneurysmal bleeding.

Backgrounds/Aims: By reviewing difficult resections for advanced hepatic malignancies, we discuss the effectiveness and extended indications for hepatectomy in such patients. Methods: We reviewed 7 patients who underwent extensive surgery between July 2008 and March 2011 for advanced hepatic malignancies. They had stage IV disease, except for in one case that was a stage IIIC (T4N0M0) hepatocellular carcinoma (HCC). Results: Patient 1 with intrahepatic cholangiocarcinoma (IHCC) underwent right hemihepatectomy and resection of the bile duct and left portal vein. At 39 months after surgery, she had no recurrence or metastasis. Patient 2 with HCC underwent palliative right trisectionectomy. At 38 months after surgery, he is alive despite residual pulmonary metastases. Patient 3 with HCC invading the hepatic vein and diaphragm underwent right trisectionectomy and caval venoplasty. At 12 months after surgery, he had no recurrence or metastasis. Patient 4, who had 2 large HCCs and pulmonary thromboembolism, underwent a right trisectionectomy. At 7 months after surgery, he had no evidence of recurred HCC. Patient 5, who had IHCC invading her inferior vena cava and main portal vein, underwent preoperative radiotherapy, left hemihepatectomy, and caval resection. At 20 months after surgery, she is well despite a caval thrombus. Patient 6 and 7 underwent repeated surgery due to a recurred IHCC and metastatic colon cancer, respectively. In addition, they are alive during each 20 and 17 months after surgery. Conclusions: Despite macroscopic extrahepatic metastases or major vessel involvement, extensive surgery for advanced hepatic malignancy may result in relatively favorable outcomes and be important modality for improving of survival in such patients. (Korean J Hepatobiliary Pancreat Surg 2011;15:218-224)

Internal jugular vein thrombosis is usually associated with intravenous drug abuse, long-term venous catheterization, local infection, or spontaneous occlusion. The antiphospholipid syndrome is now recognized as one of the commonest causes of acquired arterial or venous thrombosis. Lemierre's syndrome is an uncommon but potentially lethal complication of internal jugular vein thrombosis after an oropharyngeal infection. A 34-year-old man presented with fever and progressive, painful right neck swelling 6 days after an episode of pharyngitis. Clinical studies including radiological and laboratory tests confirmed the diagnosis of Lemierre's syndrome associated with antiphospholipid syndrome. Although Lemierre's syndrome is a well-known cause of internal jugular vein thrombosis, association with antiphospholipid syndrome is very rare.

s / Pancreatology Results: Fifty-nine patients (19%) had clinically-relevant POPF. CRP, PPA and DPA levels for postoperative day (POD) 1–3 differed significantly between the study groups. The POPF-predictive value of DPA (POD11322U/L; OR25; POD2 314U/L, OR35) was superior to that of PPA (OR14/16), especially when combined with CRP (POD3 202 mg/L; OR17). A model of DPA and CRP predicted 90% of the cases correctly (OR44). Patients with intraoperatively classified low-risk glands had negligible POPF-risks (specificity 99%, OR65). Conclusions: The intraoperative classification of pancreatic characteristics forms the basis for POPF risk assessment. In patients with intermediateor high-risk glands, a diagnostic model based on cut-off levels of serum C-reactive protein and drain pancreatic amylase could serve as predictive marker for the subsequent development of clinically-relevant pancreatic fistula following pancreaticoduodenectomy.