Hoon Sang Chi

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.

Clinical Significance of p16 Protein Expression Loss and Aberrant p53 Protein Expression in Pancreatic Cancer.

Pancreatic cancer is a disease with poor prognosis mainly due to low resection rates and late diagnosis. To increase resectability and improve survival rates, a better understanding of pancreatic cancer pathogenesis and more effective screening techniques are required. New methods, such as genetic and molecular alterations, may suggest novel approaches for pancreatic cancer diagnosis and treatment. We immunohistochemically investigated 44 formalin-fixed, paraffin-embedded specimens of pancreatic ductal adenocarcinoma using monoclonal anti-p16 antibodies and monoclonal anti-p53 antibodies. The expressions of p16 and p53 proteins were compared using the Chi-square test with SPSS. Disease-free survival was analyzed using the Kaplan-Meier method, verified by the Log-Rank test. Loss of p16 expression was noted in 20 (45.5%) cases and aberrant p53 protein expression was detected in 14 (31.8%) cases. Loss of p16 expression was associated with a higher incidence of lymph node metastasis (p=0.040) and a more advanced stage (p=0.015), although there was no significant correlation between p16 expression and survival. Aberrant p53 protein expression correlated with histologic grade (p=0.038). Disease-free survival rate was significantly lower in the aberrant p53 protein positive group compared to the negative group (p=0.029). From our results, we suggest that p53 is not a prognostic factor; however, p16 and p53 genes do play important roles in the progression of pancreatic ductal adenocarcinoma.

Laparoscopic modified anterior RAMPS in well-selected left-sided pancreatic cancer: technical feasibility and interim results

BackgroundLaparoscopic distal pancreatectomy with splenectomy is regarded as a safe and effective treatment for benign and borderline malignant pancreatic lesions [1, 2]. However, its application for left-sided pancreatic cancer is still debatable [3, 4]. No general consensus, no standardized technique, and no surgical indication exist in applying the laparoscopic approach to left-sided pancreatic cancer.MethodsAccording to our institutional experiences of treating left-sided pancreatic cancer, bloodless and margin-negative resection was found to be important. Bloodless and margin-negative laparoscopic distal pancreatosplenectomy would be technically possible in suspicious pancreatic cancers with these tentative conditions: (1) pancreas-confined suspicious pancreatic cancer on preoperative image study (cT2), (2) intact fascia layer between the pancreas and left adrenal gland/left kidney, and (3) tumor more than 1 cm from the celiac axis. A 59-year-old female patient was found to have suspicious left-sided pancreatic cancer. Therefore, we performed laparoscopic anterior radical antegrade modular pancreatosplenectomy (RAMPS) [5, 6] with a curative intent based on selection criteria.ResultsThe margin-negative (resectional and tangential) curative resection could be obtained by applying laparoscopic anterior RAMPS in well-selected left-sided pancreatic cancer. The operation time was 180 min and estimated blood loss was 100 ml. The diagnosis from pathology was that the tumor was ductal adenocarcinoma of the pancreas (pT3) with lymph node metastasis (pN1, 2 of 23 lymph nodes). The patient went home on the 7th postoperative day. Adjuvant chemotherapy began within 2 weeks after surgery. From June 2007 to August 2010, nine patients underwent minimally invasive (5 laparoscopic and 4 robot-assisted) anterior RAMPS based on the selection criteria. The perioperative outcomes and short-term oncologic results are summarized.ConclusionLaparoscopic modified anterior RAMPS is thought to be technically feasible for curative resection in well-selected pancreatic cancer. The oncologic feasibility of this technique needs to be investigated based on long-term follow-up. More careful study is necessary.

The first experience of robot assisted spleen-preserving laparoscopic distal pancreatectomy in Korea.

Spleen-preservation has recently been emphasized in benign and borderline malignant pancreatic diseases requiring distal pancreatectomy. Reports to suggest that laparoscopic distal pancreatectomy is feasible and safe have been increasingly published. Robotic surgical system has been introduced and is expected to provide unique advantages in laparoscopic surgery. However, robot-assisted pancreatic surgery has not yet been performed by many surgeons. A 45-year-old female patient with abdominal discomfort was found to have pancreatic cyst in the body of the pancreas. Mucinous cystic tumor of the pancreas was the most favourable preoperative diagnosis. She underwent spleen-preserving laparoscopic distal pancreatectomy by using da Vinci surgical robot system. Splenic artery and vein were so tightly adherent to the pancreatic cyst that segmental resection of splenic vessels was required. Postoperative course was uneventful. She was able to come home in 5 days after surgery. Postoperative follow up color doppler ultrasound scan, taken on 2 weeks after surgery, showed minimal fluid collection around surgical field and no evidence of splenic infarction with good preservation of splenic perfusion. Robot-assisted spleen preserving distal pancreatectomy is thought to be feasible and safe. Several unique advantages of robotic system are expected to enhance safer and more precise surgical performance in near future. More experiences are mandatory to confirm real benefit of robot surgery in pancreatic disease.

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.

Robotic total mesorectal excision for the treatment of rectal cancer.

Robotic techniques have been developed to facilitate endoscopic surgery and to overcome its disadvantages. Thus, we performed robotic total mesorectal excison (TME) in a patient with rectal cancer, using the da Vinci® Surgical System. To our knowledge, this is the first robotic low anterior resection, based on standard TME principles, with pelvic autonomic nerve preservation. In conclusion, this robotic system is an excellent instrument for performing the standard TME procedure in rectal cancer patients.

CT of retroperitoneal extension of hepatoma mimicking adrenal tumor

Objective The anatomy of the superior aspect of the renal fascia is still controversial. We recently saw three cases of hepatoma extension into perirenal space and believed the bare area of the liver communicated with the perirenal space. Materials and Methods We reviewed the CT of the three cases of hepatoma with retroperitoneal extension. One was pedunculated and the others were exophytic. Results One pedunculated hepatoma was operated upon while we were under the impression that it was an adrenal carcinoma. The others were initially mistaken for a metastatic or primary adrenal carcinoma. Conclusion The bare area of the liver opens widely into the superior aspect of the perirenal space and permits easy extension of pedunculated or exophytic masses of the liver arising in this location, mimicking an adrenal mass.

Extrahepatic bile duct hepatocellular carcinoma without primary hepatic parenchymal lesions--a case report.

Obstructive jaundice is rarely a presenting symptom of hepatocelluar carcinoma (HCC). Most of the cases in the literature describing obstructive jaundice by HCC have a major hepatic component. Extrahepatic HCCs without primary hepatic parenchymal lesions are extremely rare. We encountered a case of extrahepatic HCC without primary hepatic parenchymal lesions in a 36-year-old man who presented with jaundice. We extensively sought primary hepatic parenchmal lesions preperatively and postoperatively with hepatic angiography and combined computed tomography (CT) studies, such as CT arterioportography and lipiodol-CT. The patient has been followed up for 1 year without definite evidence of recurrence. We herein report an unusual manifestation of HCC.

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.

Left hemihepatectomy and caudate lobectomy and complete extrahepatic bile duct resection using transduodenal approach for hilar cholangiocarcinoma arsing from Biliary Papillomatosis

Biliary papillomatosis (BP) is a rare disease characterized by multiple papillary lesions of variable distribution and extent in the intra and extrahepatic bile duct. Hepatopancreatoduodenectomy (HPD) can be indicated for the resection of diffuse intra and extrahepatic BP that extended to the distal bile duct and ampullary region. The mortality rate for HPD has recently decreased but HPD still has a high morbidity rate. In this study, we present a safe procedure for concomitant intrahepatic and extrahepatic BP.