Sae Byeol Choi

Portal venous invasion: The single most independent risk factor for immediate postoperative recurrence of hepatocellular carcinoma

Background and Aim:  Despite improvements of treatment in hepatocellular carcinoma (HCC), the recurrence rate after curative hepatic resection still remains remarkably high. An immediate recurrence of HCC after surgery is frustrating. We tried to clarify risks of immediate postoperative recurrence of HCC; that is, within 4 months after curative hepatic resection.

Management of umbilical hernia complicated with liver cirrhosis: An advocate of early and elective herniorrhaphy

BACKGROUND Patients with umbilical hernias complicated by liver cirrhosis have an increased likelihood of complications following herniorrhaphy. The aim of this study was to investigate the clinical outcomes in patients with umbilical hernias complicated by liver cirrhosis. METHODS Between 2001 and 2010, 44 patients were enrolled in this study. The comparison between non-operative and operative group was performed. Patients who underwent emergency versus elective surgery were also compared. RESULTS Of the 44 patients, there were 33 men and 11 women. Thirty-one patients (70.5%) underwent surgery and 13 patients (29.5%) were treated conservatively. Overall morbidity and mortality rates following herniorrhaphy were 42% and 6.5%. The mean albumin level was significantly lower and total bilirubin, creatinine and mean model of end-stage liver disease score were significantly higher in non-operative group than in operative group. Combined resection was performed more frequently in the emergency group than in elective group. A significantly higher proportion of patients in emergency operation group had postoperative complications (P=0.01), especially ascites (P=0.02). The operative time and postoperative hospital stay were significantly shorter in the elective operation group than in emergency operation group. CONCLUSIONS Early, elective repair of umbilical hernias in cirrhotic patients should be advocated considering the hepatic reserve and patients condition. Ascites control is the mainstay of post-operative management.

Single-Incision Multiport Laparoscopic Cholecystectomy: Things to Overcome

OBJECTIVES To report on our initial experience with single-incision multiport laparoscopic cholecystectomy, together with its clinical outcomes. DESIGN Nonrandomized prospective study. SETTING University department of surgery. PATIENTS Sixty-four patients with gallstones and gallbladder polyps were enrolled after providing informed consent. Based on our experience, we excluded patients with acute cholecystitis, concomitant choledocholithiasis, a history of previous upper abdominal surgery, and a suspicion of gallbladder cancer. MAIN OUTCOME MEASURES We analyzed the outcomes and complications, based on our experience, according to the clinicopathologic and operative factors. We also compared patients who underwent single-incision multiport laparoscopic cholecystectomy with those who were converted to conventional laparoscopic cholecystectomy. RESULTS There were 2 bile duct injuries and 4 surgical site infections. We had difficulties in visualizing the Calot triangle in 22 patients. Higher levels of inflammatory markers, longer operation times, and more frequent bile juice spillage were significantly observed in those patients. Ten patients were converted to conventional laparoscopic cholecystectomy. The mean age of patients who underwent conversion surgery was significantly older than that of the no-conversion group. The more the body mass index increased, the more the conversion rate increased. CONCLUSIONS Experienced laparoscopic surgeons can safely perform cholecystectomy using conventional and curved laparoscopic instruments in selected patients. We recommend that you consider performing conventional laparoscopic cholecystectomy or that you use additional retraction devices for patients with a higher body mass index or acute cholecystitis.

Single-incision multiport laparoscopic cholecystectomy for a patient with situs inversus totalis: Report of a case

Laparoscopic cholecystectomy has become the standard treatment for symptomatic cholelithiasis in patients with situs inversus totalis (SIT). Nowadays, singleincision multiport laparoscopic surgery is safe and feasible for treating benign gallbladder disease. We report a case of successful single-incision multiport laparoscopic cholecystectomy for a patient with SIT, and describe its technical advantages.

Clinical characteristics of incidental or unsuspected gallbladder cancers diagnosed during or after cholecystectomy: A systematic review and meta-analysis

AIM To perform a systematic review of incidental or unsuspected gallbladder (GB) cancer diagnosed during or after cholecystectomy. METHODS Data in PubMed, EMBASE, and Cochrane Library were reviewed and 26 publications were included in the meta-analysis. The inclusion criterion for incidental GB cancer was GB cancer diagnosed during or after cholecystectomy that was not suspected at a preoperative stage. Pooled proportions of the incidence, distribution of T stage, and revisional surgery of incidental GB cancer were analyzed. RESULTS The final pooled population comprised 2145 patients with incidental GB cancers. Incidental GB cancers were found in 0.7% of cholecystectomies performed for benign gallbladder diseases on preoperative diagnosis (95%CI: 0.004-0.012). Nearly 50% of the incidental GB cancers were stage T2 with a pooled proportion of 47.0% (95%CI: 0.421-0.519). T1 and T3 GB cancers were found at a similar frequency, with pooled proportions of 23.0% (95%CI: 0.178-0.291) and 25.1% (95%CI: 0.195-0.317), respectively. The pooled proportion that completed revisional surgery for curative intent was 40.9% (95%CI: 0.329-0.494). The proportion of patients with unresectable disease upon revisional surgery was 23.0% (95%CI: 0.177-0.294). CONCLUSION A large proportion of incidental GB cancers were T2 and T3 lesions. Revisional surgery for radical cholecystectomy is warranted in T2 and more advanced cancers.

Molecular mechanism of HIF-1-independent VEGF expression in a hepatocellular carcinoma cell line

Hypoxia-inducible factor-1 (HIF-1) is a master transcription factor that plays a central role in the hypoxic expression of various genes. Vascular endothelial growth factor (VEGF), a known target gene of HIF-1α, has been shown to be induced by hypoxia through a HIF-1α-independent pathway. HIF-1α dominant-negative lentiviral vectors were introduced to decrease the expression of HIF in Hep3B cells. Cells were incubated under normoxic or hypoxic conditions. We performed a VEGF enzyme-linked immunosorbent assay (ELISA) using cell culture supernatants, and Western blotting using cell lysates. To validate signaling via HIF-1-dependent or HIF-1-independent pathways, we treated cells with an extracellular signal-regulated kinase (ERK) kinase inhibitor, a phosphoinositide 3-kinase (PI3K) inhibitor, and transfected cells with siSP1. HIF-1α protein expression was induced and the levels of VEGF increased under hypoxic conditions. Cells were transfected with siHIF-1α and incubated under normoxic or hypoxic conditions. We found that a significant amount of VEGF was produced by a HIF-1-independent pathway. PI3K inhibitor treatment and siSP1 transient transfection decreased VEGF expression in siHIF-1α-transfected cells. Therefore, VEGF regulation in Hep3B cells is primarily controlled by the Akt/PI3K and SP1 pathways and is independent of HIF-1 under hypoxic conditions.

Influence of clinically significant portal hypertension on surgical outcomes and survival following hepatectomy for hepatocellular carcinoma: a systematic review and meta‐analysis

Surgical resection is not indicated in patients with portal hypertension in the current guideline of Barcelona Clinic Liver Cancer (BCLC) stage. We report a systematic review and meta‐analysis to determine the impact of clinically significant portal hypertension on survival in patients with hepatocellular carcinoma (HCC) following hepatectomy. Searched data in PubMed, EMBASE, and the Cochrane Library were reviewed and 11 publications were included in the meta‐analysis. The inclusion criteria of clinically significant portal hypertension were esophageal varices and/or thrombocytopenia with splenomegaly. Pooled data were extracted and computed into odds ratios (ORs) for clinical outcome and hazard ratios (HRs) for overall survival. The final pooled data were composed of 2,285 patients. There were 775 patients with clinically significant portal hypertension (PHT group) and 1,510 patients without clinically significant portal hypertension (non‐PHT group). Pooled proportion of mortality was 6.1% (95% confidence interval [CI] 0.032–0.116) in PHT group and 2.8% (95% CI 0.014–0.054) in the non‐PHT group. The pooled proportion of morbidity was 41.7% (95% CI 0.274–0.575) in PHT group and 34.7% (95% CI 0.243–0.467) in non‐PHT group. Pooled data confirmed a significantly higher postoperative mortality in the PHT group, with OR 3.02 (P < 0.001). The PHT group also demonstrated significantly higher occurrence of postoperative complications (OR 1.39, P = 0.008), liver‐related morbidity (OR 3.10, P < 0.00001), and liver failure (OR 2.14, P = 0.0005) compared to the non‐PHT group. According to the overall survival, pooled analysis demonstrated that the PHT group demonstrated poorer survival than the non‐PHT group (HR 1.48, P = 0.007). The analyses support significantly higher rates of postoperative mortality, complications, liver‐related morbidity, liver failure, and poorer overall survival in PHT group compared with the non‐PHT group. Surgical resection should be selected carefully with strict surgical strategy in patients with clinically significant portal hypertension when surgical resection is planned.

Clinicopathological Characteristics in Combined Hepatocellular-Cholangiocarcinoma: A Single Center Study in Korea

Purpose Combined hepatocellular-cholangiocarcinoma (CHCC) is an uncommon form of cancer, and its clinicopathological features have rarely been reported in detail. This study was undertaken to evaluate the clinicopathological characteristics and prognostic factors of CHCC. Materials and Methods The clinicopathological features of patients diagnosed with CHCC at Severance Hospital between January 1996 and December 2007 were retrospectively studied by comparing them with the features of patients with hepatocellular carcinoma (HCC) or cholangiocarcinoma (CC) who had undergone a hepatic resection during the same period. Results Forty-three patients diagnosed with CHCC were included in this study (M : F=35 : 8, median age, 55 years). According to the parameters of the American Joint Committee on Cancer staging, there were 6 (14.0%), 9 (20.9%), 25 (58.1%), and 3 (7.0%) patients with stages I, II, III, and IV cancer, respectively. Thirty-two of the 43 patients underwent resection with curative intent. After resection, 27 patients (84.4%) had tumor recurrence during the follow-up period of 18 months (range: 6-106 months), and the median time to recurrence was 13 months. Overall median survival periods after hepatic resection of CHCC, HCC and CC were 34, 103 and 38.9 months, respectively (p<0.001). The median overall survival for all patients with CHCC was 21 months, and the 5-year survival rate was 18.1%. The presence of portal vein thrombosis and distant metastasis were independent prognostic factors of poor survival. Conclusion Even after curative hepatic resection, the presence of a cholangiocellular component appeared to be a poor prognostic indicator in patients with primary liver cancer.

Primary Squamous Cell Carcinoma of the Stomach That Developed with Menetrier's Disease

Primary squamous cell carcinoma (SCC) of the stomach is an exceedingly rare disease [1]. The pathogenesis of this neoplasm remains rather obscure, and its etiology and the prognosis are controversial. Gastric cancer, mainly adenocarcinoma, occasionally arises from Menetrier’s disease, and this has generally been described as hypertrophic gastropathy [2]. To the best of our knowledge, we report here on the first case of primary gastric SCC associated with Menetrier’s disease.

Adjuvant Hepatic Arterial Infusional Chemotherapy with 5-Fluorouracil and Cisplatin after Curative Resection of Hepatocellular Carcinoma

Objectives: We investigated whether adjuvant hepatic arterial infusional chemotherapy (HAIC) with 5-fluorouracil (5-FU) and cisplatin reduces the recurrence of hepatocellular carcinoma (HCC) after curative resection. Methods: Between January 2006 and December 2008, 31 HCC patients received four cycles of adjuvant HAIC with 5-FU and cisplatin via port system after curative resection. During the same period, 62 patients, who did not take any adjuvant therapy, were selected as controls. Results: Tumor characteristics, such as distribution of TNM stage, pathologic differentiation, portal vein invasion, or microscopic invasion did not differ between control and adjuvant groups. During follow-up, recurrence developed in 11 adjuvant (35.5%) and 24 control patients (38.7%; p = 0.823). Tumor progression after recurrence was the cause of death in 2 adjuvant (28.6%) and 7 control patients (38.8%; p = 0.912). The 2-year recurrence rate was 9.1% in the adjuvant group and 4.2% in the control group, with the median recurrence-free survival time being 10.5 and 7.5 months, respectively (p = 0.324). The 3-year cumulative survival rate was 73.3% in the adjuvant group and 68.3% in the control group (p = 0.355). Conclusion: Adjuvant HAIC with 5-FU and cisplatin did not offer any beneficial effect on the recurrence after curative resection of HCC.