Ho Kyoung Hwang

Clinical validation and risk factors for delayed gastric emptying based on the International Study Group of Pancreatic Surgery (ISGPS) Classification

BACKGROUND Delayed gastric emptying (DGE) is one of the most common complications after pancreatoduodenectomy (PD). Because an objective, universally accepted definition of DGE does not yet exist, it is impossible to compare complication rates and outcomes of new operative approaches, operative techniques, and clinical trials. The International Study Group of Pancreatic Surgery (ISGPS) has proposed a universal classification for DGE based on clinical outcomes, but this classification has not been tested rigorously and applied to clinical data. Therefore, the aim of this study was to analyze our experience and to identify predictive factors for DGE by applying the ISGPS classification at a high-volume hospital. METHODS From October 2002 to December 2007, 129 consecutive patients underwent PD at the Department of Surgery, Yonsei University Medical Center. The severity of DGE was determined according to the ISGPS classification, and risk factors were evaluated retrospectively. RESULTS The overall incidence of DGE was 33.3%, with 16 (12.4%) patients having grade A, 14 (10.9%) grade B, and 13 (10.1%) grade C. Clinical outcomes worsened progressively as clinical relevant DGE increased. In multivariate analysis, clinically relevant pancreatic fistula (grade B/C) and patients with benign pathology were identified as independent factors for DGE. CONCLUSION Pancreatic leakage is a serious complication after PD and is also associated with DGE. The ISGPS classification is a clear and useful tool to assess clinical outcomes.

Robotic anterior RAMPS in well-selected left-sided pancreatic cancer.

A relatively pancreas-confined tumor with an intact fascia layer between the pancreas and left adrenal gland/kidney is thought to be a potential indication for a minimally invasive approach in treating left-sided pancreatic cancer. Usually four or five trocars are needed for conventional laparoscopic radical antegrade modular pancreatosplenectomy (RAMPS) and the surgeon is able to perform all procedures aided by two assistants who help with camera control and counter traction. However, five ports are required for the robotic approach: one for the robotic camera, three for the working robotic arms, and one for the assistant surgeon for vessel clipping, suction, and endo-linear stapling. Four patients with pancreatic cancer were selected for robotic RAMPS. Four robotic arms were used while the patient was in a supine position with the patients head and left side elevated. Pancreatic dissection was performed from right to left after division of the pancreatic neck portion. Lymph nodes around the common hepatic artery and celiac axis were dissected during this procedure. Clinicopathologic characteristics and perioperative surgical outcomes, including interim oncologic outcomes, were analyzed.

Lymphoepithelial cysts in the pancreas: MRI of two cases with emphasis of diffusion-weighted imaging characteristics

Pancreatic lymphoepithelial cysts (LECs) are rare pancreatic cystic lesions filled with keratinized material, lined by mature, keratinizing squamous epithelium and surrounded by lymphoid tissue containing few lymphoid follicles. We report two cases of surgically confirmed pancreatic LECs showing a profound restriction of water molecules on diffusion‐weighted (DWI) magnetic resonance imaging (MRI). For pancreatic cystic lesions showing lack of molecular motion on DWI with or without thin marginal enhancement on contrast material‐enhanced imaging, LECs consisting of internally keratinized materials with restricted diffusion should be considered in differential diagnoses even though they cannot always be easy to distinguish from other focal pancreatic lesions containing mucin, blood clot, or nonliquefactive necrosis. J. Magn. Reson. Imaging 2010;32:692–696.

Use of TachoSil® patches to prevent pancreatic leaks after distal pancreatectomy: a prospective, multicenter, randomized controlled study

We performed a prospective, multicenter, randomized controlled study to investigate the clinical outcomes, including postoperative pancreatic fistulas (POPF), after using the TachoSil® patch in distal pancreatectomy (NCT01550406).

Comparison of Efficacy of Enucleation and Pancreaticoduodenectomy for Small (<3 cm) Branch Duct Type Intraductal Papillary Mucinous Neoplasm Located at the Head of Pancreas and the Uncinate Process

Purpose Accurate indications and the extent of surgery for branch duct intraductal papillary mucinous neoplasm (IPMN) of the pancreas are still debatable. In particular, small tumor is located at the head portion of pancreas presents a dilemma. The purpose of this study is to compare the efficacy of enucleation (EN) with that of pancreaticoduodenectomy (PD) in patients with small (2 cm<size<3 cm) branch duct IPMN located at the head of pancreas or uncinate process. Materials and Methods Among 155 patients who underwent pancreatic surgery due to pancreatic cystic tumors between January 2000 and December 2007 at Yonsei University Health System in Seoul, Korea, 14 patients with small (2 cm<size<3 cm) branch duct IPMN located at the head of pancreas or uncinate process were included in this study. Ten patients underwent PD, and four patients underwent EN. We compared short term surgical outcomes between the two groups. Correlation of the variables was analyzed using Mann-Whitney test and Fishers exact test (SPSS Window 12.0). p-values less than 0.05 were considered significant. Results The average age was 62.21 years (±6.71 years) and consisted of 8 men and 6 women. The mean operation time and blood loss were significantly lower in EN group. There were no significant differences in other surgical morbidities. Conclusion The result suggests that enucleation for small branch duct IPMN located at the head of pancreas or uncinate process is feasible and as safe as PD, despite a high rate of minor complications.

Laparoscopic extended (subtotal) distal pancreatectomy with resection of both splenic artery and vein

BackgroundSpleen-preserving distal pancreatectomy can be performed safely and effectively by resecting both splenic vessels (Warshaw procedure) [1–4]. This simplified spleen-preserving technique might also be applied to minimally invasive distal pancreatectomy of benign and borderline malignant tumor [5, 6].MethodsAlthough the conservation of both splenic vessels is paramount to preserving the spleen during laparoscopic distal pancreatectomy, preservation of the splenic vessels is not always possible, especially under the following conditions: (1) relatively large tumor, (2) associated with chronic pancreatitis, (3) tumor abutting splenic vascular structures, and (4) bleeding during the splenic vessel conserving procedure, which are potential indications of laparoscopic extended Warshaw procedure. Patient preparation and position was the same as that described in our previous study [7].ResultsDuring the study’s time period, 38 consecutive patients underwent laparoscopic spleen-preserving distal pancreatectomy. Of those, five patients underwent a laparoscopic extended Warshaw procedure, which all included among 16 patients of extended distal pancreatectomy by dividing the pancreas at the pancreatic neck. All patients were women with a median age of 55 (range, 38–75) years. Median total operation time and blood loss were 215 (range, 200–386) minutes and 100 (range, 0–300) ml, respectively. The median length of hospital stay was 8 (range, 5–15) days. All of postoperative complications (two grade A and two grade B postoperative pancreatic fistula; one grade A bleeding) were able to be treated conservatively. During the median follow-up period of 11 (range, 7–42) months, one focal splenic infarction and one gastric varix were noted; however, no clinically significant complications were reported.ConclusionsLaparoscopic spleen-preserving extended distal pancreatectomy with resection of both the splenic vessels is feasible and safe [8]. This surgical technique is thought to increase the chance of preservation of the spleen with minimally invasive distal pancreatectomy in well-selected benign or borderline malignant tumor of the distal pancreas.

Controversial issues of neoadjuvant treatment in borderline resectable pancreatic cancer

Pancreatic ductal adenocarcinoma is known as one of the most fatal malignant diseases in gastrointestinal system. Approximately 20% of patients are deemed resectable at the time of diagnosis. Preoperative neoadjuvant therapy to the borderline resectable pancreatic cancer (BRPC) has been challenged to achieve down-staging of cancer, to avoid unnecessary major operation if the pancreatic cancer progresses and distant metastasis develops during preoperative treatment, and to avoid delayed adjuvant treatment after major operation due to postoperative complications and poor general condition after major surgery. However, there are some controversial issues influencing the clinical interpretation of surgical and oncologic outcomes of pancreatectomy following neoadjuvant treatment in managing BRPC. This manuscript reviews the current controversial issues in managing BRPC in order to enhance proper understanding the current status and potential role of neoadjuvant treatment in managing BRPC.

Single-fulcrum laparoscopic cholecystectomy: a single-incision and multi-port technique.

Background:  Single‐incision laparoscopic cholecystectomy (LC) is still technically demanding and usually requires specially designed instruments. This article describes our own technique, a single‐fulcrum LC using only standard ports and instruments.

The First Experiences of Robotic Single-Site Cholecystectomy in Asia: A Potential Way to Expand Minimally-Invasive Single-Site Surgery?

Purpose Herein, we firstly present the robotic single-site cholecystectomy (RSSC) as performed in Asia and evaluate whether it could overcome the limitations of conventional laparoscopic single-site cholecystectomy. Materials and Methods From October 2013 to November 2013, RSSC for benign gallbladder (GB) disease was firstly performed consecutively in five patients. We evaluated these early experiences of RSSC and compared factors including clinicopathologic factors and operative outcomes with our initial cases of single-fulcrum laparoscopic cholecystectomy (SFLC). Results Four female patients and one male patient underwent RSSC. Neither open conversion nor bile duct injury or bile spillage was noted during surgery. In comparisons with SFLC, patient-related factors in terms of age, sex, Body Mass Index, diagnosis, and American Society of Anesthesiologist score showed no significant differences between two groups. There were no significant differences in the operative outcomes regarding intraoperative blood loss, bile spillage during operation, postoperative pain scale values, postoperative complications, and hospital stay between the two groups (p<0.05). Actual dissection time (p=0.003) and total operation time (p=0.001) were significantly longer in RSSC than in SFLC. There were no drain insertion or open conversion cases in either group. Conclusion RSSC provides a comfortable environment and improved ergonomics to laparoscopic single-site cholecystectomy; however, this technique needs to be modified to allow for more effective intracorporeal movement. As experience and technical innovations continue, RSSC will soon be alternative procedure for well-selected benign GB disease.

Estrogen Receptor α, Estrogen Receptor β, and Progesterone Receptor as Possible Prognostic Factor in Radically Resected Gallbladder Carcinoma

BACKGROUND Gallbladder carcinoma is a relatively rare malignancy with a poor prognosis. We have often encountered patients in whom the course of their disease differed substantially from what would be predicted based on their clinical staging, which highlights the needs to consider additional predictive factors. Gallbladder carcinoma occurs more frequently in women than men, yet expression of the estrogen receptor (ER) and progesterone (PR) have not been studied. We applied an immunohistochemical stain to examine the expression of ER(alpha), ER(beta), and PR in radically resected gallbladder carcinoma. MATERIAL AND METHODS We immunohistochemically investigated 30 specimens of gallbladder adenocarcinoma tissues using ER(alpha), ER(beta), and PR antibodies. RESULTS Adenocarcinoma of gallbladder is negative for both ER(alpha) and PR. However, 22 of 30 cases (73.3%) were confirmed positive for ER(beta), which was significantly correlated with tumor differentiation. Five-year survival rates of ER(beta) positive and negative patients were 53.3% and 31.1%, respectively (P = 0.034). In multivariate analysis, only a low proportion score of ER(beta) status was a statistically significant factor (P = 0.033). CONCLUSIONS Evaluation of ER(beta) expression in gallbladder carcinoma may be an important factor in identifying a poor prognostic group of gallbladder carcinoma.