S.-W. Kim

Clinical outcomes compared between laparoscopic and open distal pancreatectomy

BackgroundLaparoscopic surgery for pancreatic disease has gained increasing popularity. A laparoscopic distal pancreatectomy is technically simple and has been adopted as the preferred method in many centers. However, there is limited information on the outcomes of the laparoscopic surgery compared with open surgery. Therefore, this study aimed to investigate the clinical outcomes of laparoscopic distal pancreatectomy and to evaluate its efficacy compared with open distal pancreatectomy.MethodsFrom February 1995 to March 2006, 31 patients underwent laparoscopic distal pancreatectomy, and 167 patients underwent open distal pancreatectomy at Seoul National University Hospital and Bundang Seoul National University Hospital. A case–control design was used with 2:1 matching to compare laparoscopic surgery with open surgery. Among 167 patients who underwent open distal pancreatectomy, 62 patients whose age, gender, and pathology were similar to those of patients who underwent laparoscopic surgery were selected for this study. The operation time, intraoperative transfusion requirements, duration of postoperative hospitalization, complications, mortality, recurrence, and hospital charges were analyzed.ResultsThere were no significant differences in operation time, rate of intraoperative transfusions, complications, recurrence, or mortality between the two groups. Laparoscopic distal pancreatectomy was associated with a statistically significant shorter hospital stay (11.5 days vs 13.5 days; p = 0.049), but with more expensive hospital charges than open distal pancreatectomy (p < 0.01).ConclusionLaparoscopic distal pancreatectomy is a clinically safe and effective procedure for benign and borderline pancreatic tumors.

Comparison of Pancreatogastrostomy and Pancreatojejunostomy after Pancreatoduodenectomy Performed by One Surgeon

AbstractPancreatogastrostomy (PG) for restoringnpancreaticoenteric continuity after pancreatoduodenectomy (PD) has beennrecommended by a few surgeons on the basis of certain theoretic andnpractical advantages of this procedure over pancreatojejunostomy (PJ).nThe purpose of this study was to determine whether PG can be a safenalternative to PJ. Eighty-six PDs performed by the same surgeon fornperiampullary carcinoma were analyzed to compare early and latenpostoperative results of PJ (nn= 38) and PGn(n= 48). The two groups were comparable for age, sex,ndiagnosis, stage, and operation time. PJ leakage developed in sixnpatients (15.8%) and PG leakage in one (2.1%) (p <n0.05). Overall rates of morbidity/hospital mortality were 34.2/7.9%nand 18.8/4.2% in the PJ and PG groups, respectively. In conclusion, PGnshowed a more favorable early outcome than PJ. PG is recommended fornsurgeons who encounter difficulties with PJ for reconstruction afternPD.

Genetic alterations in gallbladder adenoma, dysplasia and carcinoma

Adenoma and dysplasia in the gallbladder (GB) have been reported as precancerous lesions, but the genetic evidence of this is not clearly defined. The purpose of this study was to analyze the frequencies of K-ras, p53, and p16 gene mutations, of microsatellite instability (MI) and of loss of heterozygosity (LOH) in GB cancer, dysplasia, and adenoma. Tissues from 15 GB cancers, five dysplasias around cancerous tumors, and three adenomas were collected prospectively. The mutation rates of K-ras, p53, and p16 were 20.0, 35.7, and 30.7%, respectively, in GB cancers. However, no mutations were found in dysplasia or adenoma. Reduced staining for p16 was seen in 23% of carcinomas. All of the GB carcinomas and four out of five (80%) of the dysplasias showed LOH in a minimum of one locus, but one out of three (33%) cases of adenoma displayed LOH in only one locus. All of the loci of LOH in the dysplasias, except one, showed the same patterns of allelic loss as the adjacent carcinomas. Only one dysplasia showed multiple MI. In conclusion, multiple LOH may be associated with the development of dysplasia and the malignant transformation of GB carcinoma. Gene alterations of K-ras, p53, and p16 are important steps in the malignant changes of dysplasia. However, MI seems to have only a limited role in GB cancer development.

Effects of pancreatectomy on nutritional state, pancreatic function and quality of life

There are concerns about the extent of impaired endocrine and exocrine pancreatic function and poor quality of life (QoL) after pancreatectomy, but there is little information from large prospective follow‐up studies.

Clinicopathologic Correlation of p53 Protein Overexpression in Adenoma and Carcinoma of the Ampulla of Vater

It has been well documented that ampullary carcinoma arises from a precancerous lesion, but there have been few studies concerning changes at the molecular level during the adenoma-carcinoma sequence. In this study, p53 overexpression during the progression of carcinoma was compared and the relation between p53 expression and prognosis was analyzed. Ninety-four cases of adenocarcinoma of the ampulla of Vater were reviewed histopathologically and examined for overexpression of p53 protein using the DO-7 (mouse monoclonal; DAKO, Glostrup, Denmark) antibody. The correlation of p53 overexpression with the existence of adenoma, clinical stage, histologic grade, and overall survival was investigated. The proportion of p53-positive cases among normal mucosa, adenoma, early stage carcinoma (I and II), advanced stage carcinoma (III and IV), and metastatic lesion was 0% (0/94), 14.3% (6/42), 32.3% (20/62), 53.1% (17/32), and 63.3% (19/30), respectively. The existence of adenoma or histologic grade of carcinoma did not correlate with p53 overexpression. The carcinoma having adenomatous component was more common in early stages (54.8% in stages I and II, 25% in stages III and IV; p= 0.006) and in well-differentiated carcinoma (p= 0.001). The existence of adenoma or p53 overexpression did not independently correlate with prognosis. In contrast, the p53 overexpressed group without adenoma showed a worse prognosis than the remaining patients (p= 0.0006) and this trend was still demonstrable when the groups were compared stage by stage. In ampullary carcinoma, p53 abnormality occurs during malignant transformation from the adenoma and continues during the tumor progression in carcinoma. The clinical prognosis of de novo carcinomas with p53 overexpression was worse than that of the remaining patients.

Changing patterns of gallstone disease in Korea

The aim of this study was to investigate the epidemiologic characteristics and changing patterns of gallstone disease in Korea over a recent 20-year period. A total of 4020 gallstone patients who had undergone surgery at Seoul National University Hospital during 1981–2000 were analyzed according to periods: period I (1981–1985: 831 cases); period II (1986–1990: 888 cases); period III (1991–1995: 1040 cases); period IV (1996–2000:1261 cases). The literature from 13 institutes in Korea reporting a total of 13,101 gallstone cases were reviewed to elucidate the nation-wide trend. The number of gallstone cases gradually increased. A female predominance was not noted (F/M = 1.17–1.37) as is seen in Western countries. The patients with common bile duct (CBD) stones were older than those with gallbladder (GB) stones or intrahepatic duct (IHD) stones. Over time, the relative proportion of those with a GB stone increased, plateauing (80–85%) during the 1990s; that of patients with CBD stones decreased (34% → 19%); and that of those with IHD stones remained unchanged (11–15%). Over the entire period, the rural pattern of gallstone formation (low number of GB stones, high numbers of CBD and IHD stones) has become similar to the urban pattern. The body mass index (BMI) of the GB stone group was above average, as were the BMIs of the CBD stone and IHD stone groups. Throughout the literature review, this same changing pattern of the relative proportion of gallstone disease was confirmed. Thus the pattern of gallstone disease in Korea has become similar to that seen in Western countries except for a high prevalence of hepatolithiasis.RésuméLe but de cette étude a été de déterminer les caractéristiques épidémiologiques et leurs éventuels aspects évolutifs de la maladie lithiasique en Corée pendant les 20 dernières années. On a analysé les dossiers de 4020 patients présentant une lithiase à l’Hôpital National Universitaire de Seoul (1981–2000) pendant plusieurs périodes différentes: période I 1981–1985:831 cas), période II (1986–1990:888 cas), période III (1991–1995:1040 cas) et période IV (1996–2000:1261 cas). La littérature provenant de 13 institutions en Corée rapportant 13101 cas de lithiase a été revue pour élucider la tendance nationale. Le nombre de cas de lithiase a augmenté. Comme dans les pays Occidentaux, on a noté une prédominance féminine (F/M = 1.17–137). Les patients ayant une lithiase de la voie biliaire principale (VBP) était plus âgés que les patients ayant une lithiase biliaire simple ou les patients ayant une lithiase intrahépatique (LIH). Avec le temps, la proportion relative de patients ayant une lithiase vésiculaire a augmenté pour atteindre un plateau (80–85%) dans les années 1990, la proportion de patients porteur de lithiase de la VBP a diminué (34% → 19%) et le groupe de patients porteurs de LIH est restée inchangée (11–15%). De même, le site de la lithiase (bas, haut, intrahépatique) dans la population rurale s’est rapproché de ce que l’on observe en ville. L’indexe de masse corporelle dans le groupe porteur de lithiase vésiculaire était plus élevé que la moyenne, et plus élevé que celui des patients porteur de lithiase de la VBP ou de LIH. A travers une revue de la littérature, cette même tendance s’est confirmée en ce qui concerne la proportion relative de patients porteurs de maladie lithiasique. Les tendances de la maladie lithiasique en Corée sont devenues similaires à celles des pays occidentaux sauf en ce qui concerne la prévalence élevée de lithiase intrahépatique.ResumenInvestigar la evolución de las características epidemiológicas de la litiasis biliar a lo largo de los últimos 20 años en Corea. Se analizaron 4020 pacientes con litiasis biliar tratados quirúrgicamente en el Hospital Nacional Universitario de Seoul. Se dividieron, de acuerdo con diferentes periodos de tiempo: periodo I (1981–1985; n = 831), periodo II (1986–1990; n = 888) periodo III (1991–1995, n = 1,040) y periodo IV (1996–2000; n = 1,261). Además, se revisaron 13,101 casos de litiasis biliar de 13 Instituciones Hospitalarias de Corea, con objeto de averiguar la tendencia de esta enfermedad a escala nacional. La incidencia de la litiasis biliar se ha incrementando paulatinamente; sin embargo, no se constató una predominancia por el sexo femenino (M/V = 1.77–137) como ocurre en países occidentales. Los pacientes con coledocolitiasis (CBD) eran más viejos que los que aquejaban una colelitiasis (GB) o una hepatolitiasis (IHD). A lo largo del tiempo, los pacientes con GB aumentaron hasta alcanzar una meseta (80–85%) en los años noventa. La coledocolitiasis disminuyó (34% → 19%) y la hepatolitiasis no se modificó (11–15%). A lo largo de estos 20 años, las características de la litiasis biliar en zonas rurales (escasos casos de GB y muchos de CBD y IHD) se fue equiparando a los de las ciudades. El índice de masa corporal era superior en pacientes con GB que en los que presentaron una CBD o IHD. Nuestras observaciones coinciden con las referidas en la literatura mundial al respecto. Las características de la litiasis biliar en Corea son semejantes a las observadas en los países occidentales, excepto por lo que a la alta incidencia de hepatolitiasis (IHD) se refiere.

Totally laparoscopic management of choledochal cysts using a four-hole method

BackgroundCholedochal cyst is a rare benign disease of the biliary tract. However, once diagnosed, it must be excised with the gallbladder because of the risk for cancer developing in the biliary tree, including the gallbladder. This report introduces a new surgical technique for totally laparoscopic excision of choledochal cyst and hepaticojejunostomy using a four-hole method.MethodsBetween October 2003 and May 2005, the authors performed totally laparoscopic choledochal cyst excision for 12 patients. All the patients except one were women, and the mean age was 37.3 years (range, 17–62 years). According to the Todani classification, there were five type Ia cases, four type Ic cases, and three type IV cases. Choledochal cyst excision and Roux-en-Y hepaticojejunostomy were performed laparoscopically using the four-port technique.ResultsThe mean operation time was 228 min (range, 150–330 min). No operative or postoperative transfusion was required. An oral diet was started on postoperative day 3. The average length of hospital stay was 5.8 days. There was no major complication associated with anastomosis leakage or obstruction. No patient had an adverse response, as determined by clinical or laboratory evaluation during a 2- to 19-month follow-up period.ConclusionsConsidering that choledochal cyst is common among young women, who are especially interested in cosmetic results in addition to complete resolution of medical problems, the laparoscopic management of choledochal cyst may be an attractive treatment option.

Phenotypic alterations of mucins and cytokeratins during gallbladder carcinogenesis

In order to evaluate the significance of altered expression of mucin and cytokeratin during gallbladder carcinogenesis, we characteriazed the expressional profiles of MUC1, MUC2, MUC5AC, MUC6, CK7 and CK20 in 33 normal mucosa, 31 adenomas, 55 dysplasias and 131 carcinomas of the gallbladder. In normal gallbladder mucosa, the expressions of MUC5AC and MUC6 were diffuse and MUC1 expression was absent. However, in adenomas, dysplasias and carcinomas, the expressions of MUC5AC and MUC6 tended to decrease, whereas MUC1 expression was elevated. MUC2 and CK20 were infrequently expressed in all of the gallbladder epithelia, but adenomas expressing MUC2 and/or CK20 were more frequently associated with carcinomas and showed a higher grade of atypia than those without these antigens. In carcinomas, MUC1 expression was related to invasive growth, lymph node metastasis and a non‐papillotubular type, whereas MUC6 expression was related to non‐invasive growth. CK7 was diffusely expressed in almost all lesions, but carcinomas with a loss of CK7 expression showed poor survival. In conclusion, normal gallbladder mucosa has a gastric phenotype, but during carcinogenesis and tumor progression, the gastric phenotype is gradually lost and the aberrant expression of MUC1 occurs. The intestinal phenotype is not common in the gallbladder.

Lack of microsatellite instability in neoplasms of ampulla of Vater

To clarify the genetic background of ampullary neoplasm, we investigated the occurrence of microsatellite instability (MSI) in 64 samples of neoplasm of the ampulla of Vater. Eight out of 22 adenomas (34.6%), nine out of 32 carcinomas (28.1%) and one metastatic lesion (10.0%) showed MSI in 1–3 of the nine dinucleotide markers; those cases are categorized into microsatellite instability‐low (MSI‐L). The remaining samples were stable with respect to all of the tested markers. None of the samples showed a frameshift mutation in the poly A‐tract of BAT‐26 or transforming growth factor‐β type II receptor, which are frequently mutated in gastric or colorectal cancers showing microsatellite instability. To confirm our finding, we stained 93 ampullary neoplasms with antibodies against the mismatch repair proteins: hMLH1 and hMSH2. All tumors were found to express mismatch repair proteins. In contrast to gastric or colorectal cancers, MSI does not play an important role in the carcinogenesis of ampullary carcinoma.

Randomized multicentre trial comparing external and internal pancreatic stenting during pancreaticoduodenectomy.

There is no consensus on the best method of preventing postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy (PD). This multicentre, parallel group, randomized equivalence trial investigated the effect of two ways of pancreatic stenting after PD on the rate of POPF.