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Seoung Yoon Rho,1,2 Hyun Woong Lee,2,3 Do Young Kim,2,4 Kyung Sik Kim2,5 1Department of Surgery, Yongin Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; 2The Korean Liver Cancer Association, Seoul, Korea; 3Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; 4Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea; 5Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, KoreaCorrespondence: Kyung Sik KimDepartment of Surgery, Severance Hospital, Yonsei University College of Medicine, Ludlow Faculty Research Building, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, KoreaTel +82-2-2228-2100Email kskim88@yuhs.acHyun Woong LeeDepartment of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, KoreaTel +82-2-2019-3315Email LHWDOC@yuhs.acBackground: The opportunities for examining elderly patients with hepatocellular carcinoma (HCC) have increased. We investigated the treatment of HCC for elderly patients and the overall survival associated with each treatment modality.Methods: From January 2003 to December 2005 (n=578, period I) and January 2008 to December 2014 (n=2428, period II), the National Cancer Center and Korean Liver Cancer Association collected clinical data of 3006 patients with HCC aged ≥ 70 years old at 54 medical centers in Korea. We analyzed the treatment modalities and overall survival for patients with HCC aged ≥ 70 years.Results: The mean age, Child-Pugh score, and model for end-stage liver disease score and proportion of male patients were not different between period I and period II (74 years, 6.6, 10.4 and 70.1% vs 76 years, 6.2, 9.9 and 67.3%). TNM stage II and BCLC stage A were most commonly noted in periods I and II (44.3% and 49.1% vs 40.4% and 40.2%). Transarterial therapy was the most commonly used treatment modality according to age in both periods. Surgical resection was associated with significant superior overall survival compared to local ablation and transarterial therapy (p< 0.001). After propensity score matching between surgical resection and transarterial therapy in period II, surgical resection was associated with more favorable overall survival outcomes (median: 39 months vs 86 months, p< 0.001).Conclusion: Transarterial therapy was the most commonly used treatment modality for patients with HCC aged ≥ 70 years. However, surgical resection led to significantly higher overall survival rates compared to other treatment modalities.Keywords: hepatocellular carcinoma, elderly, surgical resection, transarterial therapy, local ablation therapy

Backgrounds/aims: In recent years, many minimally invasive techniques have been introduced to reduce the number of ports in laparoscopic cholecystectomy (LC), offering benefits such as reduced postoperative pain and improved cosmetic outcomes. ArtiSential ® is a new multi-degree-of-freedom articulating laparoscopic instrument that incorporates the ergonomic features of robotic surgery, potentially overcoming the spatial limitations of laparoscopic surgery. ArtiSential ® LC can be performed using only two ports. This study aims to compare the surgical outcomes of ArtiSential ® LC with those of single-fulcrum LC., Methods: This retrospective study compared ArtiSential ® LC and single-fulcrum LC among LCs performed for gallbladder (GB) stones at the same center, analyzing the basic characteristics of patients; intraoperative outcomes, such as operative time, estimated blood loss, and intraoperative GB rupture; and postoperative outcomes, such as length of hospital stay, incidence of postoperative complications, and postoperative pain., Results: A total of 88 and 63 patients underwent ArtiSential ® LC and single-fulcrum LC for GB stones, respectively. Analysis showed that ArtiSential ® LC resulted in significantly fewer cases of surgeries longer than 60 minutes (30 vs. 35 min, p = 0.009) and intraoperative GB ruptures (2 vs. 10, p = 0.007). In terms of postoperative outcomes, ArtiSential ® LC showed better results in the respective visual analog scale (VAS) scores immediately after surgery (2.59 vs. 3.73, p < 0.001), and before discharge (1.44 vs. 2.02, p = 0.01)., Conclusions: ArtiSential ® LC showed better results in terms of surgical outcomes, especially postoperative pain. Thus, ArtiSential ® LC is considered the better option for patients, compared to single-fulcrum LC.

Backgrounds/aims: This study aimed to compare the minimally invasive pancreatoduodenectomy with venous vascular resection (MI-PDVR) and open pancreatoduodenectomy with venous vascular resection (O-PDVR) for periampullary cancer., Methods: Data of 124 patients who underwent PDVR (45 MI-PDVR, 79 O-PDVR) between January 1, 2016, and December 31, 2023, was retrospectively reviewed., Results: MI-PDVR is significantly better than O-PDVR in terms of perioperative outcomes (median operation time [452.69 minutes vs. 543.91 minutes; p = 0.004], estimated blood loss [410.44 mL vs. 747.59 mL; p < 0.01], intraoperative transfusion rate [2 cases vs. 18 cases; p = 0.01], and hospital stay [18.16 days vs. 23.91 days; p = 0.008]). The complications until the discharge day showed no significant difference between the two groups (Clavien-Dindo < 3, 84.4% vs. 82.3%; Clavien-Dindo ≥ 3, 15.6% vs. 17.7%; p = 0.809). In terms of long-term oncological outcomes, there was no statistical difference in overall survival (OS, 51.55 months [95% CI: 35.95-67.14] vs. median 49.92 months [95% CI: 40.97-58.87]; p = 0.340) and disease-free survival (DFS, median 35.06 months [95% CI: 21.47-48.65] vs. median 38.77 months [95% CI: 29.80-47.75]; p = 0.585), between the two groups. Long-term oncological outcomes for subgroup analysis focusing on pancreatic ductal adenocarcinoma also showed no statistical differences in OS (40.86 months [95% CI: 34.45-47.27] vs. 48.48 months [95% CI: 38.16-58.59]; p = 0.270) and DFS (24.42 months [95% CI: 17.03-31.85] vs. 34.35 months, [95% CI: 25.44-43.27]; p = 0.740)., Conclusions: MI-PDVR can provide better perioperative outcomes than O-PDVR, and has similar oncological impact.

Background: Robot-assisted pancreaticoduodenectomy (R-PD) helps further improve the safety and efficacy of minimally invasive pancreaticoduodenectomy. However, it faces challenges such as high costs and limitations in availability at different centers, making it difficult for patients to access. In this study, we evaluate the initial experience of Artisential®-assisted PD (A-PD) and compare its perioperative outcomes with R-PD, discussing the clinical applicability of A-PD., Methods: This study reviewed cases of R-PD and A-PD conducted between 2022 and 2023. A total of 34 patients underwent R-PD, while 26 patients underwent A-PD. Statistical analysis was conducted based on factors related to the patient's surgical procedure and postoperative prognostic indicators., Results: There were no significant differences observed between the two groups in terms of surgical factors. There were also no differences in the occurrence of postoperative complications. However, there was a significant difference in the length of hospital stay, with the Artisential® group having an average of 11.50 ± 5.54 days and the Robot group having 15.06 ± 5.34 days (p = 0.001)., Conclusions: R-PD and A-PD showed no differences in procedures or outcomes. Using a multi-articulated device is beneficial where robot use is challenging., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background and Aims: Concerns about the safety of coronavirus disease 2019 (COVID-19) vaccines in patients with atrial fibrillation/flutter (AF/AFL) have arisen due to reports of thrombo-embolic events following COVID-19 vaccination in the general population. This study aimed to evaluate the risk of thrombo-embolic events after COVID-19 vaccination in patients with AF/AFL., Methods: This was a modified self-controlled case-series study using a comprehensive nationwide-linked database provided by the National Health Insurance Service in South Korea to calculate incidence rate ratios (IRRs) of thrombo-embolic events. The study population included individuals aged ≥12 years who were either vaccinated (e.g. one or two doses) or unvaccinated during the period from February to December 2021. The primary outcome was a composite of thrombo-embolic events, including ischaemic stroke, transient ischaemic attack, and systemic thromboembolism. The risk period was defined as 0-21 days following COVID-19 vaccination., Results: The final analysis included 124 127 individuals with AF/AFL. The IRR of thrombo-embolic events within 21 days after COVID-19 vaccination, compared with that during the unexposed control period, was 0.93 [95% confidence interval (CI) 0.77-1.12]. No significant risk variations were noted by sex, age, or vaccine type. However, patients without anticoagulant therapy had an IRR of 1.88 (95% CI 1.39-2.54) following vaccination., Conclusions: In patients with AF/AFL, COVID-19 vaccination was generally not associated with an increased risk of thrombo-embolic events. However, careful individual risk assessment is required when advising vaccination for those not on oral anticoagulant, as these patients exhibited an increased risk of thrombo-embolic events post-vaccination., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background/aim: Gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging (EOBMRI) further enhances the identification of additional hepatic nodules compared with computed tomography (CT) alone; however, the optimal treatment for such additional nodules remains unclear. We investigated the long-term oncological effect of aggressive treatment strategies for additional lesions identified using EOB-MRI in patients with hepatocellular carcinoma (HCC)., Methods: Data from 522 patients diagnosed with solitary HCC using CT between January 2008 and December 2012 were retrospectively reviewed. Propensity score-matched (PSM) analysis was used to compare the oncologic outcomes between patients with solitary HCC and those with additional nodules on EOB-MRI after aggressive treatment (resection or radiofrequency ablation [RFA])., Results: Among the 383 patients included, 59 had additional nodules identified using EOB-MRI. Compared with patients with solitary HCC, those with additional nodules on EOB-MRI had elevated total bilirubin, aspartate transaminase, and alanine transaminase; had a lower platelet count, higher MELD score, and highly associated with liver cirrhosis (P<0.05). Regarding long-term outcomes, 59 patients with solitary HCC and those with additional nodules after PSM were compared. Disease-free survival (DFS) and overall survival (OS) were comparable between the two groups (DFS, 60.4 vs. 44.3 months, P=0.071; OS, 82.8 vs. 84.8 months, P=0.986)., Conclusion: The aggressive treatment approach, either resection or RFA, for patients with additional nodules identified on EOBMRI was associated with long-term survival comparable with that for solitary HCC. However, further studies are required to confirm these findings.

Background: SurgiGuard ® is an absorbent hemostatic agent based on oxidized regenerated cellulose. The efficacy, effects and safety of SurgiGuard ® are equivalent to existing hemostatic agents in animal experiments. This study was designed to confirm that the use of SurgiGuard ® alone is effective, safe and feasible compared to combination with other hemostatic methods., Methods: We retrospectively reviewed clinical data from 12 surgery departments in seven tertiary centers in South Korea nationwide. All surgeries were performed between January and December 2018., Results: A total of 807 patients were enrolled; 447 patients (55.4%) had comorbidities. The rate of major surgery (operative time ≥4 hours) was 44% (n=355 patients). Regarding the type of SurgiGuard ® used in surgery, more than 70% of minor surgeries used non-woven types. In major surgery, more than five SurgiGuards ® were used in 7.3% (26 patients), and the proportion of co-usage (with four other hemostatic products) was 19.7% (70 patients). The effectiveness score was higher when SurgiGuard ® was used alone in both major (5.3±0.5 vs . 5.1±0.6, P=0.048) and minor surgery (5.4±0.6 vs . 5.2±0.4, P<0.001). Seven patients had immediate re-bleeding, and all of them used SurgiGuard ® and other products together. Nine patients reported adverse effects, such as abscess, bleeding, or leg swelling, but we found no direct correlation with SurgiGuard ® ., Conclusions: SurgiGuard ® exhibited greater effectiveness when used alone. No direct adverse effects associated with SurgiGuard ® use were reported, and SurgiGuard ® had stable feasibility. Prospective comparative studies are needed in the future., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-22-675/coif). MJ is current employee of Samyang Biopharmaceuticals Corp. The other authors have no conflicts of interest to declare., (2023 Gland Surgery. All rights reserved.)

Preferential dissolution behaviour of the austenite (γ) phase in Fe-27Cr- x C high chromium cast irons (HCCIs) immersed in 0.1 mol dm -3 H 2 SO 4 + 0.05 mol dm -3 HCl was investigated. Potentiodynamic and potentiostatic polarisation revealed that the primary and eutectic γ phases dissolved preferentially at -0.35 and 0.00 V Silver Silverchloride Electrode potential in sat. KCl (SSE) , respectively. The immersion of the HCCIs in the solution showed that the dissolution of the primary γ phase dominated for ca. 1 h, while the primary and eutectic γ phases dissolved after ca. 1 h. However, the carbide phases remained undissolved during the dissolution of the γ phases. Furthermore, the corrosion rate of the HCCIs increased with the increasing C content owing to the increase in the contact potential difference values of the γ and carbide phases. The change in electromotive force due to C addition was related to the accelerated corrosion rate of the γ phases., Competing Interests: There are no conflicts to declare., (This journal is © The Royal Society of Chemistry.)

Background: Minimally invasive pancreaticoduodenectomy (MIPD) is a challenging procedure. Laparoscopic pancreaticoduodenectomy (LPD) is feasible and safe. Since the development of robotic platforms, the number of reports on robot-assisted pancreatic surgery has increased. We compared the technical feasibility and safety between LPD and robot-assisted LPD (RALPD)., Methods: From September 2012 to August 2020, 257 patients who underwent MIPD for periampullary tumors were enrolled. Of these, 207 underwent LPD and 50 underwent RALPD. We performed a 1:1 propensity score-matched (PSM) analysis and retrospectively analyzed the demographics and surgical outcomes., Results: After PSM analysis, no difference was noted in demographics. Operation times and estimated blood loss were similar, as was the incidence of complications (p > 0.05). In subgroup analysis in patients with soft pancreas with pancreatic duct ≤ 2 mm, no significant between-group difference was noted regarding short-term surgical outcomes, including clinically relevant POPF (CR-POPF) (p > 0.05). In multivariable analysis, the only soft pancreatic texture was a predictive factor (HR 3.887, 95% confidence interval 1.121-13.480, p = 0.032)., Conclusion: RALPD and LPD are safe and effective for MIPD and can compensate each other to achieve the goal of minimally invasive surgery., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To investigate the feasibility and safety of RLDRH., Summary of Background Data: Data for minimally invasive living-donor right hepatectomy, especially RLDRH, from a relatively large donor cohort that have not been reported yet., Methods: From March 2016 to March 2019, 52 liver donors underwent RLDRH. The clinical and perioperative outcomes of RLDRH were compared with those of CODRH (n = 62) and LADRH (n = 118). Donor satisfaction with cosmetic results was compared between RLDRH and LADRH using a body image questionnaire., Results: Although RLDRH was associated with longer operative time (minutes) (RLDRH, 493.6; CODRH, 404.4; LADRH, 355.9; P < 0.001), mean estimated blood loss (mL) was significantly lower (RLDRH, 109.8; CODRH, 287.1; LADRH, 265.5; P = 0.001). Postoperative complication rates were similar among the 3 groups (RLDRH, 23.1%; CODRH, 35.5%; LADRH, 28.0%; P = 0.420). Regarding donor satisfaction, body image and cosmetic appearance scores were significantly higher in RLDRH than in LADRH. After propensity score matching, RLDRH showed less estimated blood loss compared to those of CODRH (RLDRH, 114.7 mL; CODRH, 318.4 mL; P < 0.001), but complication rates were similar among the three groups (P = 0.748)., Conclusions: RLDRH resulted in less blood loss compared with that of CODRH and similar postoperative complication rates to CODRH and LADRH. RLDRH provided better body image and cosmetic results compared with those of LADRH. RLDRH is feasible and safe when performed by surgeons experienced with both robotic and open hepatectomy., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Postoperative pancreatic fistula (POPF) and postoperative fluid collection (POFC) are common complications after distal pancreatectomy (DP). The previous method of reducing the risk of POPF was the application of a polyglycolic acid (PGA) sheet to the pancreatic stump after cutting the pancreas with a stapler (After-stapling); the new method involves wrapping the pancreatic resection line with a PGA sheet before stapling (Before-stapling). The study aimed to compare the incidence of POPF and POFC between two methods., Methods: Data of patients who underwent open or laparoscopic DPs by a single surgeon from October 2010 to February 2020 in a tertiary referral hospital were retrospectively analyzed. POPF was defined according to the updated International Study Group of Pancreatic Fistula criteria. POFC was measured by postoperative computed tomography (CT)., Results: Altogether, 182 patients were enrolled (After-stapling group, n = 138; Before-stapling group, n = 44). Clinicopathologic and intraoperative findings between the two groups were similar. Clinically relevant POPF rates were similar between both groups (4.3% vs. 4.5%, p = 0.989). POFC was significantly lesser in the Before-stapling group on postoperative day 7 (p < 0.001)., Conclusions: Wrapping the pancreas with PGA sheet before stapling was a simple and effective way to reduce POFC., (© 2021. The Author(s).)

Introduction: Activation mapping guided catheter ablation (CA) of ventricular arrhythmias (VAs) is limited in some cases when it is only relied on bipolar electrogram (EGM). We hypothesized that activation mapping with use of combined bipolar and unipolar EGM facilitates to identify the focal origin of VAs and results in reduction of recurrence rate of CA of VAs., Methods: We analyzed the data of patients undergoing repeat ablations for idiopathic out-flow tract VAs. The EGM of the 1 st and 2 nd ablations were compared for earliest local activation time (LAT), presence of discrete potentials, and polarity reversal, unipolar potential morphology (QS or non-QS), potential amplitude and activation slope., Results: Thirty-seven patients were included. The Local activation time was significantly earlier in the 2nd ablation as compared to the 1st procedure (36.90 msec vs 31.85 msec, P < 0.01). The incidence of discrete potentials and polarity reversal were similar in both procedures (51% vs 57%, P = 0.8 and 62% in both the occasions, respectively). The unipolar voltage was similar in both occasions (6.94 mV vs 7.22 mV in repeat ablations, P = 0.7). The recurrence rate (5.7%) was significantly lower with routine use of combined unipolar and bipolar EGMs, as compared to the use of bipolar EGM alone (16.7%) CONCLUSIONS: Use of both bipolar and unipolar electrograms helps in better delineation of the sites of earliest activation for effective ablation of VAs. Use of unipolar electrograms in addition to bipolar electrograms is associated with lower long term recurrence rate., Competing Interests: Declaration of competing interest None., (Copyright © 2021 Indian Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.)

Laparoscopic pancreatoduodenectomy (LPD) in pancreatic cancer is primarily criticized for its technical and oncological safety. Although solid evidence has not yet been established, many institutions are performing LPD for pancreatic cancer patients, with continuous efforts to ensure oncologic safety. In this video, we demonstrated a case of standard LPD combined with vascular resection in pancreatic cancer., Competing Interests: All authors have no conflicts of interest to declare., (Copyright © 2021 The Journal of Minimally Invasive Surgery. All rights reserved.)

Purpose: The aim of the current study was to evaluate the adverse clinical impact of intraoperative conversion during laparoscopic pancreaticoduodenectomy (LPD)., Materials and Methods: The medical records of patients who underwent pancreaticoduodenectomy (PD) were retrospectively reviewed. Perioperative clinical variables were compared between patients who underwent converted PD (cPD) and initially planned open PD (OPD) to investigate the clinical impact and predictive factors of intraoperative conversion during LPD., Results: A total of 171 patients were included. Among them, 31 patients (19.3%) were found to have intraoperative conversion during LPD. Failure of progression due to severe adhesion (12 patients, 7%) and major vessel invasion (7 patients, 4%) were the two most frequent reasons for conversion. On multivariate analysis, age [Exp(β)=1.044, p =0.044] and pancreatic texture [Expa(β)=2.431, p =0.039) were found to be independent factors for predicting intraoperative conversion during LPD. In comparative analysis with the OPD group, the cPD group had a longer operation time (516.8 min vs. 449.9 min, p =0.001), higher rate of postoperative hemorrhage (12.1% vs. 0.85%, p =0.008), higher reoperation rate (9.1% vs. 0%, p =0.01), and higher cost (21886.4 USD vs. 17168.9 USD, p =0.018)., Conclusion: Intraoperative conversion during LPD can have an adverse clinical impact on the postoperative course following LPD. Appropriate patients selection and improvement of surgical techniques will be crucial for unnecessary intraoperative conversion and safe LPD., Competing Interests: The authors have no potential conflicts of interest to disclose., (© Copyright: Yonsei University College of Medicine 2021.)

Larger left atrial appendage (LAA) volume is associated with a higher risk of late recurrence (LR) in patients undergoing radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). However, it is unclear whether LAA volume predicts LR, independent of established risk factors. We sought to evaluate the value of LAA volume in predicting LR after RFCA for AF and to develop a score prediction model including LAA volume for these patients. We retrospectively studied 992 patients who underwent RFCA for AF and cardiac computed tomography before RFCA at a single center. At 3 years after RFCA, 362 patients (36.5 %) experienced recurrence. The multivariate Cox regression model showed that age ≥ 75 years (10 points), non-paroxysmal AF (9 points), diabetes mellitus (4 points), left atrial volume index (1 point per 10 ml/m 2 rounded to the nearest integer), and the second (4.7 to < 7 ml/m 2 ; 4 points) and third (≥ 7 ml/m 2 ; 5 points) tertiles of the LAA volume index were independent risk factors LR. The above-mentioned risk factors were included in the integrated score model, and the C-index of the proposed score model was 0.715 (95 % confidence interval [CI] 0.679-0.752). LAA volume is an independent predictor of LR and the predictive model including LAA volume showed good discrimination power. These findings provide evidence for the inclusion of LAA volume in the risk stratification for AF recurrence in patients undergoing RFCA for AF.

Predicting the aggressiveness of solid pseudopapillary neoplasms (SPNs) remains an important goal. The present study aimed to identify perioperative factors that can predict patients who will develop clinically aggressive SPN. Records of individuals with pathologically confirmed SPN from 2006 to 2017 were obtained from the patient registry database of Yonsei University, Severance Hospital. For this study, aggressive behavior was defined as SPN that had recurred, metastasized, or involved adjacent organs. A total of 98 patients diagnosed with SPNs were analyzed retrospectively. Of these, 10 were reported to have SPNs with aggressive characteristics. We found that age (≥40 years; p = 0.039), symptomatic presentation ( p = 0.001), tumor size (>10 cm; p < 0.001), positron emission tomography/computed tomography (PET/CT) classification ( p < 0.001), and lymphovascular invasion ( p = 0.003) were significantly correlated with aggressive behavior of SPNs. Multivariate analysis showed that PET/CT configuration ( p = 0.002) (exp(β)111.353 (95% confidence interval (CI): 5.960-2081), age ≥40 years ( p = 0.015) (exp(β) 23.242 (95% CI: 1.854-291.4)), and lymphovascular invasion ( p = 0.021) (exp(β) 22.511 (95% CI: 1.595-317.6)) were the only independent factors associated with aggressive SPN. Our data suggest that age ≥40 years, PET/CT Type III configuration, and lymphovascular invasion are independent factors associated with aggressive SPN. This information can help clinicians develop individualized management and surveillance plans to manage patients more effectively.

Background: Laparoscopic major anatomical liver resection is challenging. The robotic liver resection (RLR) approach, with Firefly indocyanine green (ICG) imaging, was proposed to overcome the limitations of laparoscopy. The aim of this multi-centre international study was to evaluate the use of Firefly ICG imaging in anatomical RLR., Methods: A retrospective study of consecutive patients undergoing RLR anatomical resection with intra-operative ICG administration from January 2015 to July 2018 were enrolled. Patients who underwent simultaneous or en-bloc resections of other organs were excluded., Results: A total of 52 patients were recruited of which 32 patients were healthy donors, 17 with malignancy and 3 for benign conditions. 12 patients had cirrhosis. 28 patients underwent a right hepatectomy (53.8%) with left hepatectomy performed with 18 patients. 40 patients underwent negative staining and 12 patients via direct portal vein injection for positive staining. ICG demarcation line was visualized in 43 patients and was clearer than the ischaemic demarcation line in 29 patients. All resections for malignancy had clear margins. There were no 30-day/inpatient mortalities., Conclusion: Robotic ICG guided hepatectomy technique for anatomical liver resection is safe, feasible and has the benefit for improved visualization in healthy donors and cirrhotic patients., (Copyright © 2020. Published by Elsevier Ltd.)

Backgrounds/aims: Laparoscopic major liver resections are still considered innovative procedures despite the recent development of laparoscopic liver surgery. Robotic surgery has been introduced as an innovative system for laparoscopic surgery. In this study, we investigated surgical outcomes after major liver resections using robotic systems., Methods: From January 2009 to October 2018, 70 patients underwent robotic major liver resections, which included conventional major liver resections and right sectionectomy. The short-term and long-term outcomes were compared with 252 open major resections performed during the same period., Results: Operative time was longer in the robotic group (472 min vs. 349 min, p <0.001). However, estimated blood loss was lower in the robotic group compared with the open resection group (269 ml vs. 548 ml, p =0.009). The overall postoperative complication rate of the robotic group was lower than that of the open resection group (31.4% vs. 58.3%, p <0.001), but the major complication rate was similar between the two groups. Hospital stay was shorter in the robotic group (9.5 days vs. 15.1 days, p =0.006). Among patients with HCC, cholangiocarcinoma, and colorectal liver metastasis, there was no difference in overall and disease-free survival between the two groups. After propensity score matching in 37 patients with HCC for each group, the robotic group still showed a shorter hospital stay and comparable long-term outcomes., Conclusions: Robotic major liver resections provided improved perioperative outcomes and comparable long-term oncologic outcome compared with open resections. Therefore, robotic surgery should be considered one of the options for minimally invasive major liver resections.

Backgrounds/aims: Despite advances in surgical techniques and perioperative supportive care, radical resection of hilar cholangiocarcinoma is the only modality that can achieve long-term survival. We chronologically investigated surgical and oncological outcomes of hilar cholangiocarcinoma and analyzed the factors affecting overall survival., Methods: We retrospectively enrolled 165 patients with hilar cholangiocarcinoma who underwent liver resection with a curative intent. The patients were divided into groups based on the period when the surgery was performed: period I (2005-2011) and period II (2012-2018). The clinicopathological characteristics, perioperative outcomes, and survival outcomes were analyzed., Results: The patients' age, serum CA19-9 levels, and serum bilirubin levels at diagnosis were significantly higher in the period I group. There were no differences in pathological characteristics such as tumor stage, histopathologic status, and resection status. However, perioperative outcomes, such as estimated blood loss (1528.8 vs. 1034.1 mL, p =0.020) and postoperative severe complication rate (51.3% vs. 26.4%, p =0.022), were significantly lower in the period II group. Regression analysis demonstrated that period I (hazard ratio [HR]=1.591; 95% confidence interval [CI]=1.049-2.414; p =0.029), preoperative serum bilirubin at diagnosis (HR=1.585; 95% CI=1.058-2.374; p =0.026), and tumor stage (III, IV) (HR=1.671; 95% CI: 1.133-2.464; p =0.010) were significantly associated with poor prognosis. The 5-year survival rate was better in the period II patients than in the period I patients (35.1% vs. 21.0%, p =0.0071)., Conclusions: The surgical and oncological outcomes were better in period II. Preoperative serum bilirubin and advanced tumor stage were associated with poor prognosis in patients with hilar cholangiocarcinoma.

Background: Surgical complications for surgeons still in the learning phase of major laparoscopic liver resection (LLR) have been frequently observed. We aimed to compare perioperative and long-term outcomes of laparoscopic and open surgery based on the surgeons' learning curve for LLR after propensity score-matched (PSM) analysis., Methods: This was a retrospective study of all patients with a histologic diagnosis of hepatocellular carcinoma who underwent major hepatectomy between January 2013 and December 2018. A PSM analysis was used to compare the groups of patients who underwent LLR and open major liver resection (OLR) before and after the learning curve was maximized., Results: Among 405 patients, 106 underwent LLR and 299 underwent OLR. The learning curve was maximized after 42 cases. Compared with OLR, LLR had more liver-related injury and grade III or higher complications during the learning phase. The LLR group had less blood loss, fewer transfusion requirements, and fewer liver-related complications during the 'experienced' phase. Hospital stay was significantly shorter during and after maximization of the learning curve in LLR compared with OLR. Operative time was comparable in the two phases. Overall, LLR was associated with less blood loss, fewer complications, and shorter hospital stay compared with open surgery. There was no significant difference in long-term survival outcomes between the two groups., Conclusions: LLR had a higher incidence of liver-related complications during the surgeon's learning phase compared with OLR. This association was significantly diminished with surgeon experience. Overall perioperative outcomes such as estimated blood loss, surgical complications, and hospital stay remained better for LLR compared with OLR.

Background: Lymph node (LN) metastasis portends a worse prognosis following resection of intrahepatic cholangiocarcinoma (ICC); however, lymphadenectomy is not routinely performed, as its role remains controversial. Herein, we developed a risk model for LN metastasis by identifying its predictive factors and assessed a subset of patients who might not benefit from LN dissection (LND)., Methods: 210 patients who underwent curative-intent surgery for ICC were retrospectively reviewed. A preoperative risk model for LN metastasis was developed following identification of its preoperative predictive factors using the recursive partitioning method., Results: In the multivariable analysis, CA 19-9 level of >120 U/mL, an enlarged LN on computed tomography, and a tumor location abutting the Glissonean pedicles were independent predictors of LN metastasis. The preoperative risk model classified the patients according to their risk: high, intermediate, and low risks at a rate of LN metastasis on final pathology of 60.9%, 35%, and 2.3%, respectively. In the subgroup analysis among the low-risk patients, performance of LND had no survival advantage over non-performance of LND., Conclusion: Routine LND for preoperatively diagnosed ICC should be recommended to patients at an intermediate and a high risk of developing LN metastasis but may be omitted for low-risk patients., (Copyright © 2020 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: To improve patient safety, we standardized our surgical technique and implemented a stepwise strategy for surgeons learning to perform laparoscopic liver resection (LLR). The aim of the study is to describe how the stepwise training approach and standardized LLR affects surgical outcomes., Methods: Data from 272 consecutive patients who underwent LLR from January 2009 to December 2017 were retrospectively reviewed. The risk-adjusted cumulative sum (RA-CUSUM) of surgical failures (conversion to laparotomy, blood transfusion, or Clavien-Dindo grade ≥3) and the CUSUM of operative time were used to determine optimal number of operations needed to achieve the best surgical outcome., Results: As the surgeon moved from simple to complex procedures, the complication rates, need for transfusions, and conversion rates did not increase over time. After 53 cases of minor LLR, a learning curve of 21 cases was achieved for right hepatectomy. Blood loss and operative time significantly improved thereafter. For minor anterolateral and posterosuperior segment resections, blood loss, and operative time significantly improved at the 37th and 31st case, respectively, given that the anterolateral segments had more complex surgeries performed., Conclusion: Standardization of the operative technique and the implementation of a stepwise approach to training surgeons to perform LLRs could considerably improve surgical outcomes., (Copyright © 2019. Published by Elsevier Ltd.)

Backgrounds: Investigate whether intraoperative transfusion is a negative prognostic factor for oncologic outcomes of resected pancreatic cancer., Methods: From June 2004 to January 2014, the medical records of 305 patients were retrospectively reviewed, who underwent pancreatoduodenectomy, pylorus preserving pancreatoduodenectomy, total pancreatectomy, distal pancreatectomy for pancreatic cancer. Patients diagnosed with metastatic disease (n = 3) and locally advanced diseases (n = 15) were excluded during the analysis, and total of 287 patients were analyzed., Results: The recurrence and disease-specific survival rates of the patients who received intraoperative transfusion showed poorer survival outcomes compared to those who did not ( P = 0.031, P = 0.010). Through multivariate analysis, T status (HR (hazard ratio) = 2.04, [95% CI (confidence interval): 1.13-3.68], P = 0.018), N status (HR = 1.46 [95% CI: 1.00-2.12], P = 0.045), adjuvant chemotherapy (HR = 0.51, [95% CI: 0.35-0.75], P = 0.001), intraoperative transfusion (HR = 1.94 [95% CI: 1.23-3.07], P = 0.004) were independent prognostic factors of disease-specific survival after surgery. As well, adjuvant chemotherapy (HR = 0.67, [95% CI: 0.46-0.97], P = 0.035) was independently associated with tumor recurrence. Estimated blood loss was one of the most powerful factors associated with intraoperative transfusion ( P < 0.001)., Conclusions: Intraoperative transfusion can be considered as an independent prognostic factor of resected pancreatic cancer. As well, it can be avoided by following strict transfusion policy and using advanced surgical techniques to minimize bleeding during surgery., Competing Interests: The authors declare that they have no competing interests.

Introduction: Prognostic nutritional index (PNI) reflects the nutritional and immunologic status of the patients. The clinical application of PNI is already well-known in various kinds of solid tumors. However, there is no study investigating the relationship between PNI and oncological outcome of the resected ampulla of Vater (AoV) cancer., Materials and Methods: From January 2005 to December 2012, the medical records of patients who underwent pancreaticoduodenectomy for pathologically confirmed AoV cancer were retrospectively reviewed. Long-term oncological outcomes were compared according to the preoperative PNI value., Result: A total of 118 patients were enrolled in this study. The preoperative PNI was 46.13±6.63, while the mean disease-free survival was 43.88 months and the mean disease-specific survival was 55.3 months. In the multivariate Cox analysis, initial CA19-9 (p = 0.0399), lymphovascular invasion (p = 0.0031), AJCC 8th N-stage (p = 0.0018), and preoperative PNI (p = 0.0081) were identified as significant prognostic factors for resected AoV cancer. The disease-specific survival was better in the high preoperative PNI group (≤48.85: 40.77 months vs. >48.85: 68.05 months, p = 0.0015). A highly accurate nomogram was developed based on four clinical components to predict the 1, 3, and 5-year disease-specific survival probability (C-index 0.8169, 0.8426, and 0.8233, respectively)., Conclusion: In resected AoV cancer, preoperative PNI can play a significant role as an independent prognostic factor for predicting disease-specific survival., Competing Interests: The authors have declared that no competing interests exist.

Background: Both the technical and oncological safety of laparoscopic pancreaticoduodenectomy (LPD) remain controversial in treating pancreatic head cancer. We evaluated the oncologic benefit of LPD and compared the inflammatory score between LPD and open pancreaticoduodenectomy (OPD)., Methods: From January 2014 to March 2019, 61 patients with standard PD not combined with other organ resection were finally enrolled in this study. Among these patients, 27 underwent LPD and 34 underwent OPD (registered on 16 July 2019, and registration number is 2019-1411-001)., Results: The estimated blood loss (EBL) for the LPD group was less than that of the OPD group (P = 0.003). The operation time was similar, as was the incidence of complications such as postoperative fistula, delayed gastric emptying. Overall survival was not different between LPD and OPD (44.62 vs. 45.29 months, P = 0.223). However, a significant improvement in disease-free survival (DFS) was seen in the LPD group (34.19 vs. 23.27 months, P = 0.027). No statistically significant differences were found in terms of the postoperative change in inflammatory scores and differentiated white blood cell counts., Conclusions: LPD is not only safe and feasible in pancreatic head cancer patients but is associated with a reduced amount of EBL, favorable DFS., (© 2019 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Purpose: Unplanned conversion is sometimes necessary during minimally invasive liver resection (MILR) of hepatocellular carcinoma (HCC). The aims of this study were to compare surgical outcomes of planned MILR and unplanned conversion and to investigate the risk factors after unplanned conversion., Methods: We retrospectively analyzed 286 patients who underwent MILR with HCC from January 2006 to December 2017. All patients were divided into a MILR group and an unplanned conversion group. The clinicopathologic characteristics and outcomes were compared between the 2 groups. In addition, surgical outcomes in the conversion group were compared with the planned open surgery group (n = 505). Risk factors for unplanned conversion were analyzed., Results: Of the 286 patients who underwent MILR, 18 patients (6.7%) had unplanned conversion during surgery. The unplanned conversion group showed statistically more blood loss, higher transfusion rate and postoperative complication rate, and longer hospital stay compared to the MILR group, whereas no such difference was observed in comparison with the planned open surgery group. There were no significant differences in overall and disease-free survival among 3 groups. The right-sided sectionectomy (right anterior and posterior sectionectomy), central bisectionectomy and tumor size were risk factors of unplanned conversion., Conclusion: Unplanned conversion during MILR for HCC was associated with poor perioperative outcomes, but it did not affect long-term oncologic outcomes in our study. In addition, when planning right-sided sectionectomy or central bisectionectomy for a large tumor (more than 5 cm), we should recommend open surgery or MILR with an informed consent for unplanned open conversions., Competing Interests: CONFLICTS OF INTEREST: No potential conflict of interest relevant to this article was reported., (Copyright © 2020, the Korean Surgical Society.)

We investigated the potential application of preoperative serum metabolomes in predicting recurrence in patients with resected pancreatic cancer. From November 2012 to June 2014, patients who underwent potentially curative pancreatectomy for pancreatic ductal adenocarcinoma were examined. Among 57 patients, 32 were men; 42 had pancreatic head cancers. The 57 patients could be clearly categorized into two main clusters using 178 preoperative serum metabolomes. Patients within cluster 2 showed earlier tumor recurrence, compared with those within cluster 1 (p = 0.034). A nomogram was developed for predicting the probability of early disease-free survival in patients with resected pancreatic cancer. Preoperative cancer antigen (CA) 19-9 levels and serum metabolomes PC.aa.C38&#95;4, PC.ae.C42&#95;5, and PC.ae.C38&#95;6 were the most powerful preoperative clinical variables with which to predict 6-month and 1-year cancer recurrence-free survival after radical pancreatectomy, with a Harrell's concordance index of 0.823 (95% CI: 0.750-0.891) and integrated area under the curve of 0.816 (95% CI: 0.736-0.893). Patients with resected pancreatic cancer could be categorized according to their different metabolomes to predict early cancer recurrence. Preoperative detectable parameters, serum CA 19-9, PC.aa.C38&#95;4, PC.ae.C42&#95;5, and PC.ae.C38&#95;6 were the most powerful predictors of early recurrence of pancreatic cancer.

Background: A laparoscopic approach is increasingly being utilized in simultaneous colorectal and liver resection (SCLR) for colorectal cancer with liver metastasis. However, this approach is technically challenging and hence has not been widely adopted. Robotic surgical systems could potentially overcome this problem. We aim to describe the feasibility and outcomes of robotic SCLR for colorectal carcinoma with liver metastasis., Methods: The medical records of 12 patients who underwent robotic SCLR for colorectal cancer with liver metastasis between January 2008 and September 2018 were reviewed retrospectively., Results: The mean age was 59 years (range, 37-77 years). The liver resections were comprised of two right hepatectomies, one left hepatectomy, one left lateral sectionectomy, one segmentectomy of S3 and wedge resection (segment 7), one caudate lobectomy, one associated liver partition and portal vein ligation for staged hepatectomy, and five wedge resections involving segments 4, 5, 6, 7, or 8. The colorectal procedures involved seven low-anterior resections, two anterior resections, two right hemicolectomies, and one left hemicolectomy. The mean operative time was 449 min (range, 135-682 min) with a mean estimated blood loss of 274.3 mL (range, 40-780 mL). The mean length of hospital stay was 12 days (range, 5-28 days). No patients required conversion to laparotomy. Liver resection-related complications were two liver abscesses (Clavien-Dindo classification, one grade II and one grade III) and one case of ascites (grade I), whereas colorectal resection-related complications included one anastomosis leak (grade III) and one superficial wound infection (grade II). There were no deaths reported within 30 days of the procedure. With a mean follow-up duration of 31.5 ± 26.1 months, the overall survival and disease-free survival values were 75.2 and 47.1 months, respectively., Conclusion: Robotic SCLR for colorectal neoplasm with liver metastasis can be performed safely even in cases requiring major liver resections, especially in a specialized center with a well-trained team.

Background: To compare the effectiveness of a custom-made skills simulator (CMSS) with the commercially available da Vinci ® skills simulator (DVSS) that help improving surgical skills for effective and safe robotic surgical interventions., Methods: A randomized control study was conducted to determine the performance of participants after undergoing robotic surgical training. Total 64 students who had no previous experience with robotic surgery enrolled this study. After 5 min-introduction of robotic surgical system, the participants got random-assignment into two groups to perform either CMSS-or DVSS-exercises. After 15 min-practicing the corresponding simulator, task-execution performance and individual questionnaires were compared between participants trained with the CMSS and those trained with the DVSS., Results: Regardless of simulator the participants used, the system understanding and manipulation ability of the participants was found to be higher than after completing the simulation-based robotic surgical training (p < 0.05). However, there were no significant differences in terms of the required time to complete the tasks, and improvement of understanding the concept of robotic surgery, or surgical skill capacity between two groups (p > 0.05)., Conclusions: The training effectiveness of CMSS was not significantly different to DVSS. It can be synergetic tool to DVSS for novice trainees of robotic surgery to get accustomed to the robotic surgical system and to improve their basic robotic surgical skills.

Background: Solid pseudopapillary neoplasms (SPN) of the pancreas are rare pancreatic neoplasms where complete resection is the cornerstone in management. It has been demonstrated in previous studies that minimally invasive surgical approaches are effective management options in treating SPNs of the distal pancreas. The purpose of this study is to evaluate the feasibility of minimally invasive surgery in treating SPNs of the uncinate, head, and neck of the pancreas., Methods: Data from 2005 to 2017 at Severance Hospital of the Yonsei University Health systems in Seoul, South Korea, were retrospectively collected for 25 patients who were diagnosed with SPN of the uncinate, head, and neck of the pancreas and who underwent curative resection. Three groups of patients were considered, depending on the year of surgery, in order to determine trends in the surgical management of SPN. The patients were also divided into two groups corresponding to the type of operation done (minimally invasive surgery vs. open surgery). Perioperative patient data, including age, gender, body mass index (BMI), tumor size, and operation done, were compared and analyzed statistically. Long-term nutritional effects were measured using the Controlling Nutritional Status (CONUT) scoring system., Results: There were no statistically significant differences in age, gender, BMI, symptomatic presentation, operation type, tumor size, and tumor stage between the three time periods. In comparing between minimally invasive and open surgery, there were no statistically significant differences in age, gender, symptomatic presentation, BMI, tumor size, preoperative stage, type of operation, operation time, pancreatic duct size, post-operative pancreatic fistula (POPF) grade, death associated with disease, recurrence, pathological parameters, and change in CONUT score. There was a significant difference in tumor size (4.5 ± 1.8 vs. 2.6 ± 1.0 cm, p = 0.004), blood loss (664.2 ± 512.4 vs. 277.7 ± 250.8 mL, p = 0.024), need to transfuse (33% vs. 0%, p = 0.023), hospital length of stay (27.4 ± 15.3 vs. 11.5 ± 5.3 days, p = 0.002), and complication rate (75% vs. 30.8%, p = 0.027) between the two groups., Conclusions: In appropriately selected patients with SPNs of the uncinate, head, and neck of the pancreas, a minimally invasive surgical approach offers at least equal oncologic and nutritional outcomes, while demonstrating decreased complications and decreased hospital length of stay compared with that of an open surgical approach.

Background: Immunologic factors such as neutrophil-lymphocyte ratio and platelet-lymphocyte ratio play an important role in predicting the oncologic outcome of patients in pancreatic ductal adenocarcinoma (PDAC). It is hypothesized that host immunity represented by total lymphocyte count at diagnostic stage would influence oncologic outcome in left-sided PDAC., Methods: Between January 1992 and August 2017, total of 112 patients who underwent distal pancreatectomy for left-sided PDAC were included and analysed., Results: At the time of the diagnosis, total lymphocyte count at diagnosis of left-sided PDAC was 1.8 ± 0.7 10 3 /μL (mean value ± standard deviation). Among different cut-off values, 1.7 showed most powerful significant differences in long-term oncologic outcomes. The patients with preoperative lymphocyte count (≤1.7) was associated with early recurrence (median 8.4 months versus 18.1 months, P = 0.011) and shorter survival (median 18.6 months versus 35.9 months, P = 0.028). Patients with preoperative total lymphocyte count over 1.7 showed higher white blood cell count (P < 0.001), platelet count (P = 0.039), neutrophil count (P = 0.004) and monocyte count (P = 0.001). However, more interestingly, neutrophil-lymphocyte ratio (P < 0.001) and platelet-lymphocyte ratio (P < 0.001) were found to be significantly higher in those with total lymphocyte count less than 1.7. Lymphocyte to monocyte ratio was inversely related to preoperative total lymphocyte count (P < 0.001). Only age was identified to be significantly different (P = 0.007). However, other clinicopathological parameters generally known to be related to tumour aggressiveness, were not different between two groups., Conclusion: In conclusion, preoperative total lymphocyte at diagnostic stage is simple, and good prognostic factor in left-sided pancreatic cancer., (© 2019 Royal Australasian College of Surgeons.)

Laparoscopic pancreaticoduodenectomy (PD) has been reported to be technically feasible and safe. Successful pancreatico-enteric anastomosis in particular is important for safe PD. Intraoperative perfusion of the remnant pancreas can be evaluated with ICG technology and be applied in pancreatic reconstruction in PD. A 68-year old female patient with distal common bile duct cancer underwent laparoscopic pylorus-preserving pancreaticoduodenectomy. After pancreaticojejunostomy (PJ), we checked perfusion of the anastomosis line using an ICG imaging system and noticed a perfusion defect at the anterior wall. The patient developed a grade A postoperative pancreatic fistula, but was discharged without major sequelae. Even though pancreatic perfusion after laparoscopic PJ appeared adequate based on white light, hypo-perfusion was noted under infrared light. Our experience suggests that ICG technology may be more sensitive than white light for detecting pancreatic perfusion in pancreatic anastomoses. However, the clinical implications of this require further investigation.

Background/objectives: Our institutional experience has demonstrated that bloodless and margin-negative resection is the most potent prognostic factor in treating left-sided pancreatic cancer and we developed selection guideline. The Yonsei criteria (YC) is selection criteria for oncologically safe and effective resection of left-sided pancreatic cancer by a minimally invasive approach. In this study, we investigated whether left-sided pancreatic cancer with YC can be more individualized to predict long-term survival by using clinically and pathologically detectable parameters., Methods: From January 2000 to December 2015, 105 patients underwent distal pancreatectomy for left-sided pancreatic cancer. The medical records of the patients were retrospectively reviewed., Results: Among clinically and pathologically detectable parameters to predict tumor conditions, radiologically determined tumor size (p = 0.080) and SUV max (p = 0.086) were identified as predictors of early tumor recurrence with marginal significance. Among them, 20% of the patients with YC were identified as having the most favoring tumor condition, with an modified YC score of 3. The patient group with the lowest mYC score was found to have a very long disease-free survival time, with a mean of 108 months, which was statistically different from those with other mYC scores (mYC score = 4, mean 47.1 months [95% CI: 27.8-69.5] vs. mYC score = 5, mean 36.7 months [95% CI: 12.7-60.7], vs. mYC score = 6, mean 10.7 months [95% CI: 3.9-17.4])., Conclusions: Modified Yonsei criteria score can predict long-term survival in resected left-sided pancreatic cancer. And patients within YC with a mYC score = 3 could have a favorable survival outcome., (Copyright © 2018. Published by Elsevier B.V.)

Background: Doublet chemotherapy of platinum and 5-fluorouracil is a standard first-line treatment for patients with unresectable gastric cancer. Although the addition of taxane or irinotecan to this regimen has yielded promising efficacy, its use has been limited due to severe toxicities. To overcome this limitation, we evaluated the efficacy and safety of the combination of irinotecan, oxaliplatin, and S-1 (OIS) for the treatment of advanced gastric cancer., Methods: Chemotherapy-naïve patients with pathologically proven advanced gastric adenocarcinoma were assessed for eligibility. Irinotecan (135 mg/m 2 ) and oxaliplatin (65 mg/m 2 ) were administered intravenously on day 1, and S-1 (80 mg/m 2 /day) was administered orally on days 1-7 of every 2-week cycle., Results: Forty-four patients (median age 57 years) were enrolled and all but one patient had a good performance status (ECOG 0 or 1). A total of 529 cycles were administered, with a median of 9.5 (range 1-31) cycles per patient. The overall response rate was 61.4% (95% confidence interval [CI] 46.6-74.3). The median progression-free survival and overall survival were 10.8 months (95% CI 7.6-14.0) and 15.4 months (95% CI 12.6-18.2), respectively. Major toxicities included grade 3/4 neutropenia (38.6%), febrile neutropenia (13.6%), abdominal pain (9.1%), and diarrhea (9.1%)., Conclusion: These data suggest that the OIS regimen is effective and relatively well tolerated in patients with advanced gastric cancer. Given that all the patients treated, but one, had a good performance status, these results must be confirmed in a patient population more representative of regular clinical practice., Trial Registration: ClinicalTrials.gov Identifier: NCT02527785.

Background: During laparoscopic pancreaticoduodenectomy (LPD), dissecting uncinate process from the superior mesenteric artery (SMA) will determine one of the important surgical margins (retroperitoneal margin) for predicting oncological outcomes and the quality of LPD. However, clear identification of the division line for retroperitoneal margin is not easy as the uncinate process of the pancreas is anatomically very close to SMA and intermingled with the nerve plexus and soft tissues around SMA. In this study, we present data regarding the potential usefulness of indocyanine green (ICG)-enhanced approach in obtaining retroperitoneal margin during LPD., Methods: From January to September 2017, medical records of patients who underwent LPD for periampullary pathological conditions were retrospectively reviewed. ICG (5 mg/2 cm 3 ) was prepared and intravenously injected when dissecting uncinate process of the pancreas. Perioperative outcomes, including gender, age, diagnosis, body mass index, operation time, estimated blood loss, transfusion, presence of postoperative pancreatic fistulas (POPFs), and length of hospital stay, were evaluated., Results: During the study period, a total of 37 patients underwent LPD for periampullary pathological lesions. Among them, ICG-enhanced dissection of uncinate process of the pancreas was applied in 10 patients (27%). All patients were able to obtain margin-negative resection. There were no significant differences between the perioperative outcomes of patients who did and did not undergo ICG-enhanced approach., Discussion: ICG perfusion-based laparoscopic dissection of retroperitoneal margin is feasible and safe in LPD. This intraoperative visual difference can provide the surgeon with very helpful real-time visual information. Further study is mandatory.

Purpose: It is important to balance the appropriateness of active cancer treatments and end-of-life care to improve the quality of life for terminally ill cancer patients. This study describes the treatment patterns and end-of-life care in terminal gastric cancer patients., Materials and Methods: We retrospectively analyzed the records of 137 patients with advanced gastric cancer receiving chemotherapy and dying between June 1, 2006 and May 31, 2011. We recorded interval between last chemotherapy dose and death; frequency of emergency room visits or admission to the intensive care unit in the last month before death; rate of hospice referral and agreement with written do-not-resuscitate orders; and change in laboratory values in the last three months before death., Results: During the last six months of life, 130 patients (94.9%) received palliative chemotherapy; 86 (62.7%) during the final two months; 41 (29.9%) during the final month. During the final month, 53 patients (38.7%) visited an emergency room more than once; 21 (15.3%) were admitted to the intensive care unit. Hospice referral occurred in 54% (74 patients) of the patients; 93.4% (128 patients) gave written do-not-resuscitate orders. Platelets, aspartate aminotransferase and creatinine changed significantly two weeks before death; total bilirubin, one month before; and C-reactive protein, between four and two weeks before death., Conclusion: Our results demonstrated that a significant proportion of gastric cancer patients received palliative chemotherapy to the end of life and the patients who stopped the chemotherapy at least one month before death had a lower rate of intensive care unit admission and longer overall survival than those who sustained aggressive chemotherapy until the last months of their lives.

Purpose: The aim of this study was to assess the feasibility and safety of laparoscopic resection following the insertion of self-expanding metallic stents (SEMS) for the treatment of obstructing left-sided colon cancer., Methods: Between October 2006 and December 2012, laparoscopic resection following SEMS insertion was performed in 54 patients with obstructing left-sided colon cancer., Results: All 54 procedures were technically successful without the need for conversion to open surgery. The median interval from SEMS insertion to laparoscopic surgery was 9 days (range, 3-41 days). The median surgery time was 200 minutes (range, 57-444 minutes), and estimated blood loss was 50 mL (range, 10-3,500 mL). The median time to soft diet was 4 days (range, 2-8 days) and possible length of stay (hypothetical length of stay according to the discharge criteria) was 7 days (range, 4-22 days). The median total number of lymph nodes harvested was 23 (range, 8-71) and loop ileostomy was performed in 2 patients (4%). Six patients (11%) developed postoperative complications: 2 patients with anastomotic leakages, 1 with bladder leakage, and 3 with ileus. There was no mortality within 30 days., Conclusion: The present study shows that the presence of a SEMS does not compromise the laparoscopic approach. Laparoscopic resection following stent insertion for obstructing left-sided colon cancer could be performed with a favorable safety profile and short-term outcome. Large-scale comparative studies with long-term follow-up are needed to demonstrate a significant benefit of this approach.

Purpose: The purpose of this study was to evaluate efficacy and toxicity of irinotecan, leucovorin and 5-fluorouracil (FOLFIRI) as second-line treatment after failure of oxaliplatin, leucovorin and 5-fluorouracil (FOLFOX) for advanced gastric cancer., Materials and Methods: Patients who received modified FOLFOX-4 as first-line treatment and then received sequential modified FOLFIRI for disease progression were included in this study. The modified FOLFIRI regimen consisted of irinotecan 150 mg/m(2) in a 90-minute intravenous infusion on day 1, leucovorin (LV) 20 mg/m(2) and 5-fluorouracil (5-FU) 400 mg/m(2) as a bolus followed by 600 mg/m(2) as a 22-hour infusion on days 1 and 2 with the same dose of 5-FU/LV of modified FOLFOX-4 every 2 weeks., Results: A total of 32 patients received 126 courses of FOLFIRI chemotherapy. No complete response was achieved. Three patients (9.4%; 95% confidence interval [CI], 0 to 20.1%) achieved partial response, whereas 11 (34.4%; 95% CI, 17.0 to 51.8%) patients showed stable disease. Disease control rate (complete response, partial responses and stable diseases) was 43.8% (95% CI, 25.6 to 61.9%) and median follow up duration was 11.3 months (range, 2.23 to 37.9 months). Median time to progression was 2 months (95% CI, 1.49 to 2.51 months), and median overall survival from the start of FOLFIRI was 5.84 months (95% CI, 4.34 to 7.34 months). Toxicities were tolerable., Conclusion: Modified FOLFIRI as second-line chemotherapy after failure of the modified FOLFOX-4 in advanced gastric cancer was tolerable but showed a lower response rate. Further study about retrying 5-FU/LV with irinotecan after failure of the 5-FU/LV combined regimen is necessary in advanced gastric cancer.

Extraskeletal Ewing's sarcoma (ES) and primitive neuroectodermal tumor (PNET) are widely regarded as clinically and histologically identical tumors which consist of small blue round cells. Extraskeletal ESs/PNETs usually occur in the deep soft tissues of the paraspinal region, chest wall, or lower extremities. However, superficially located cases, so-called cutaneous ESs/PNETs, are exceedingly rare, and the vast majority of the reported cases present as a single small mass. We present magnetic resonance imaging (MRI) findings and clinical course of a unique case of primary cutaneous ES/PNET presenting as numerous huge masses with severe ulceration on them.

Background/aims: Bone marrow-derived cells (BMDC) contribute to tissue maintenance under many kinds of pathologic conditions. We carried out a study to see how BMDC play a role in the treatment of experimental murine colitis., Methods: We divided the animals into 3 groups and treated them with 50% ethanol (control group), 2,4,6-trinitrobenzene sulfinic acid colitis (TNBS group), and TNBS+bone marrow transplant (BMT group). To induce colitis, TNBS (5.0 mg/mouse) dissolved in 50% ethanol was injected into anus weekly for two weeks. Bone marrow transplantations were performed using bone marrow of male transgenic mouse (donor) with green fluorescence protein (GFP) into female wild type mouse (recipient) three weeks before TNBS instillation. All animals were sacrificed, and colons were extracted one week after the last TNBS instillation. We measured microscopic scores of mucosal injury and investigated the GFP expression for bone marrow engraftment. The immunostaining of vimentin and alpha-smooth muscle actin (alpha-SMA) for myofibroblasts was performed., Results: The score of mucosal injury in the TNBS group was much more severe than those in control, and reduced significantly by BMT (p<0.05). GFP-positive cells were almost deposited in pericryptal niche of BMT group but not at all in both control and TNBS group. Most of myofibroblasts stained with both vimentin and SMA also infiltrated into pericryptal niche. But, the number of myofibroblasts stained with vimentin and SMA in both control and TNBS group was smaller than that in BMT group., Conclusions: BMDC deposited on pericryptal niche might have a significant role in repairing acute experimental murine colitis.

Background: Malignant small intestine tumor accounts for 0.1-0.3% of all malignancies. Although primary adenocarcinoma is the most common histologic subtype, there is no report of the clinical characteristics and natural history in the Asian population., Methods: We conducted retrospective analysis for the patients with the small intestine adenocarcinoma to explore the clinical characteristics and prognosis. All patients with adenocarcinoma of small intestine diagnosed between March 1997 and March 2007 in the Catholic Medical Center in Korea were identified through the cancer registry. The medical records were reviewed for patient characteristics, treatment and outcome data., Results: Data on 53 patients were available. Twenty-six patients (49.0%) underwent curative resection and 13 patients receiving adjuvant chemotherapy. Fifteen patients received palliative chemotherapy. Median of overall survival of all patients was 12 months (95% confidence interval (CI): 8.5-15.1 months). Three-year survival and relapse-free survival rates after curative resection was 66.1 and 50.8%, respectively. Median survival of patients received palliative chemotherapy was 8.0 months (95% CI: 3.5-12.4)., Conclusions: The prognosis of primary adenocarcinoma of small intestine was poor, especially in cases where curative resection could not to be performed. Further study on the methods for early detection and effective systemic chemotherapy should be investigated.

Aim: To determine whether thalidomide prevents microvascular injury in acute radiation proctitis in white rats., Methods: Fourteen female Wistar rats were used: six in the radiation group, six in the thalidomide group, and two in normal controls. The radiation and thalidomide groups were irradiated at the pelvic area using a single 30 Gy exposure. The thalidomide (150 mg/kg) was injected into the peritoneum for 7 d from the day of irradiation. All animals were sacrificed and the rectums were removed on day 8 after irradiation. The microvessels of resected specimens were immunohistochemically stained with thrombomodulin (TM), von Willebrand Factor (vWF), and vascular endothelial growth factor (VEGF)., Results: The microscopic scores did not differ significantly between the radiation and thalidomide groups, but both were higher than in the control group. Expression of TM was significantly lower in the endothelial cells (EC) of the radiation group than in the control and thalidomide groups (P<0.001). The number of capillaries expressing vWF in the EC was higher in the radiation group (15.3+/-6.8) than in the control group (3.7+/-1.7), and the number of capillaries expressing vWF was attenuated by thalidomide (10.8+/-3.5, P<0.001). The intensity of VEGF expression in capillaries was greater in the radiation group than in the control group and was also attenuated by thalidomide (P=0.003)., Conclusion: The mechanisms of acute radiation-induced proctitis in the rats are related to endothelial cell injury of microvessel, which may be attenuated with thalidomide.

Purpose: Vascular endothelial growth factor (VEGF) levels in malignant ascites have high diagnostic value for their discrimination from ascites of non-malignant origin. However, there have been no reports on the comparison of VEGF levels between malignant ascites of chemonaive and chemotreated patients., Materials and Methods: VEGF levels were measured in 44 ascites patients (cirrhosis ascites, 10; chemonaive patients, 21; chemotreated patients, 13) and compared to the level of carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA 19-9). The diagnostic parameters of sensitivity, specificity, and correlation among 3 markers were evaluated., Results: VEGF levels in malignant ascites of chemonaive and chemotreated patients were significantly higher than those in cirrhotic ascites (p<0.05). VEGF levels in ascites of chemonaive patients were significantly higher than those in chemotreated patients (p<0.05). A cutoff value of 10.4 pg/mL was calculated using receiver operating characteristic curves (ROCs) for VEGF in chemotreated and chemonaive patients, which gave sensitivities of 75.0% and 53.8% and specificities of 69.6% and 47.1%, respectively. Positive correlations were observed between VEGF and CEA (r=0.353, p<0.05) as well as between VEGF and CA19-9 (r=0.367, p<0.05) in ascites., Conclusion: VEGF levels could be a useful tumor marker for malignant ascites, but its value should carefully be interpreted because of lesser reliability in chemotreated ones.

Purpose: High-dose chemotherapy (HDT) and autologous stem cell transplantation (ASCT) have been used for the treatment of clinically aggressive non-Hodgkin's lymphoma (NHL). However, the superiority of specific conditioning regimens has not yet been established. The present study evaluated the efficacy and toxicity of a conditioning regimen involving fractionated total body irradiation (TBI), and the use of Ara-C and melphalan (TAM) for clinically aggressive NHL., Materials and Methods: Between March 2002 and December 2004, 31 patients with aggressive NHL received fractionated TBI with a dose of 12 Gy over 3 days, and were administered 9 g/m(2) Ara-C and 100 mg/m(2) melphalan followed by autologous peripheral blood stem Cell Transplantation at the Catholic Hematopoietic Stem cell transplantation Center Korea. Patients that responded to first line chemotherapy and achieved complete remission (CR), or were in a first sensitive relapse were defined as having less advanced disease, while the other patients were defined as having more advanced disease., Results: Objective responses were obtained in 24 of 31 patients (77.4%), comprising complete remission in 19 patients (61.3%) and partial remission in 5 (16.1%) patients. The median follow-up time was 28 months (range 1 approximately 62 months). At 3 years, the overall survival and event-free survival (EFS) rates were 62.3% and 47.3%, respectively. Patients with less advanced disease and more advanced disease showed 3-year EFS rates of 73.3% and 22.5 %, respectively (p=0.006). Early (within the first 100 days) treatment-related mortality occurred in 3 (9.7%) patients. Of the 31 total patients, 15 (48.4%) developed grade 3 mucositis, 22 (70.9%) developed neutropenic fever, and two (6.5%) developed interstitial pneumonia syndrome>grade 3., Conclusion: The modified TAM conditioning regimen and ASCT appear to be a feasible treatment regimen for clinically aggressive NHL, particularly for patients with less advanced disease.

Endostatin is the C-terminal antiangiogenic fragment of the extracellular matrix protein collagen XVIII, and is generated by tumor-derived proteases. The presence of serum endostatin in patients with gastric cancer has not been reported. The authors assessed the serum levels of endostatin in patients with gastric carcinoma and evaluated their association with the levels of vascular endothelial growth factor (VEGF) and the clinical outcome. A total of 107 patients with gastric cancer were included in the study. Pretherapeutic serum levels of endostatin and VEGF were measured using an ELISA, and compared with those in 23 healthy controls. The serum levels of endostatin and VEGF were higher in gastric cancer patients than in healthy controls (endostatin, 70.1 +/- 16.6 vs. 52.2 +/- 6.2 ng/mL [p < 0.001]; VEGF, 55.1 +/- 7.6 vs. 32.1 +/- 2.4 ng/mL [p < 0.001]; mean +/- SD). Serum endostatin levels were significantly associated with the presence of distant metastases (r = 0.556, p < 0.001) and VEGF levels (r = 0.335, p < 0.001), but not with the depth of tumor invasion, differentiation, or regional lymph node status. A serum endostatin level above the 75th percentile of the distribution for the patients (79.2 ng/mL) was associated with a poor outcome (last follow-up at 42 months; median survival time, 9 vs. 20 months [log-rank, p = 0.017]; median time to progression, 5 vs. 10 months [log-rank, p = 0.022]) in the patients with metastatic gastric cancer. The results suggest for the first time that an elevated serum level of endostatin at the diagnosis of metastatic gastric cancer could be predictive of a poor outcome., (Copyright 2006 Wiley-Liss, Inc.)