Sang Jae Park

Clinicopathologic analysis of early ampullary cancers with a focus on the feasibility of ampullectomy.

Objective:The purpose of this study was to evaluate whether ampullectomy can substitute for pancreatoduodenectomy (PD) in early ampullary cancer by clinicopathologic study. Summary Background Data:Although ampullectomy has been attempted in early ampullary cancer (pTis, pT1), the indication and extent of resection have not been established. Methods:Of 201 patients who had undergone PD for ampullary cancer between 1986 and 2002, 67 patients with a histologic diagnosis of pTis (n = 5) or pT1 (n = 62) cancer were analyzed retrospectively. Pathologic PD specimens were reviewed to analyze the cancer spread pattern, and medical records were reviewed for clinical outcomes. Results:The 5-year survival rate of the 66 patients with early ampullary cancer (excluding one mortality) was 83.7%. Recurrence was confirmed in 12 patients (18.2%) and all died because of the recurrence. Pathologic review showed that 22 patients (32.8%) had at least one risk factor for failure after ampullectomy: lymph node metastasis (n = 6, 9.0%), perineural invasion (n = 1), or mucosal tumor infiltration along the CBD or P-duct (n = 15, 22.4%). Mean lengths of invasion into the CBD or the P-duct beyond the sphincter of Oddi were 7.7 mm (range, 1–25 mm) or 6.3 mm (range, 2–18 mm), respectively. Moreover, these risk factors were not correlated with tumor size, histologic grade, or the gross morphology of the primary tumor, although pTis cancer or pT1 cancer sized 1.0 cm or less was found to be least associated with risk factors. Conclusions:Ampullectomy for early ampullary cancer should not be considered an alternative operation to PD because of the high possibility of recurrence. PD should be preferably performed for adequate radical resection, even in early ampullary cancer, and ampullectomy should be reserved for those who have pTis or pT1 cancer sized 1.0 cm or less with high operative risk.

A Prospective Randomized Controlled Study Comparing Outcomes of Standard Resection and Extended Resection, Including Dissection of the Nerve Plexus and Various Lymph Nodes, in Patients With Pancreatic Head Cancer

Objective:To prospectively evaluate the survival benefit of dissection of the nerve plexus and lymphadenectomy in patients with pancreatic head cancer. Background:Despite randomized controlled trials on the extent of surgery in pancreatic cancer, attempts have been made to perform more extended resections. Methods:A total of 244 patients were enrolled; of these, 200 were randomized to undergo standard resection or extended resection, with the latter including the dissection of additional lymph nodes and the right half of the nerve plexus around the superior mesenteric artery and celiac axis. We evaluated 167 patients from 7 centers who fulfilled all of the required criteria. Result:Operation time was longer and estimated blood loss was higher in the extended resection group than in the standard resection group, but the R0 resection rate was comparable. The mean number of lymph nodes retrieved per patient was higher in the extended resection group than in the standard resection group (33.7 vs 17.3; P < 0.001). The morbidity rate was slightly higher in the extended resection group than in the standard resection group. Two patients in the extended resection group died in hospital. Median survival after R0 resection was similar in the extended resection and standard resection groups (18.0 vs 19.0 months; P = 0.239) regardless of lymph node metastasis. Adjuvant chemoradiation had a positive impact on overall survival. Conclusions:This study suggests that extended lymphadenectomy with dissection of the nerve plexus does not provide a significant survival benefit compared with standard resection in pancreatic head cancer. Standard resection can be performed safely and efficiently, without negatively affecting oncologic efficacy or long-term survival, when compared with extended pancreaticoduodenal resection. (NCT00679913)?

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.

Risk of Pancreatic Cancer in Relation to ABO Blood Group and Hepatitis C Virus Infection in Korea: A Case-Control Study

Several studies have reported that ABO blood group, hepatitis B virus (HBV) and hepatitis C virus (HCV) infection contribute to the development of pancreatic cancer. The aim of this study was to evaluate the association between these factors and pancreatic cancer in the Korean population. We retrospectively recruited 753 patients with pancreatic cancer and 3,012 healthy controls, matched 4 to 1 with cancer patients for age and sex, between 2001 and 2011, at the National Cancer Center, Korea. A multivariate logistic regression analysis was employed to estimate adjusted odds ratios (AORs). The AOR for pancreatic cancer in subjects with non-O blood types (A, AB, and B), compared to blood type O, was 1.29 (95% CI, 1.05-1.58; P = 0.01). Seropositivity for hepatitis B virus surface antigen was not significantly related to pancreatic cancer, either in univariate (odds ratio 1.03; 95% CI, 0.69-1.53; P = 0.91) or multivariate analysis (AOR, 1.02; 95% CI, 0.67-1.56; P = 0.93). The AOR for pancreatic cancer in subjects displaying seropositivity for anti-HCV was 2.30 (95% CI, 1.30-4.08; P < 0.01). Our results suggest that the non-O blood types and anti-HCV seropositivity, but not HBV infection, may increase the risk of developing pancreatic cancer in Korea, where HBV is endemic.

Clinical features of 20 patients with curatively resected biliary neuroendocrine tumours.

BACKGROUND Neuroendocrine tumours very rarely occur in the biliary tract; information about them is limited. AIMS To present the clinical characteristics and prognosis of curatively resected biliary neuroendocrine tumours. METHODS Review of medical records dated between 2000 and 2010 of 20 patients from three medical centres with biliary neuroendocrine tumour based on curative resection. RESULTS Based on the World Health Organization 2010 classification, five and one patients had neuroendocrine tumour grades 1 and 2, seven had neuroendocrine carcinoma, and seven were diagnosed with mixed adenoneuroendocrine carcinoma. The locations were the following: seven in the gallbladder, four in the extrahepatic bile duct, and nine in the ampulla of Vater. Lymph node and hepatic metastases were noted in 11 and 4 patients, respectively. Fourteen patients experienced recurrence; most had recurrence in the liver. Patients with neuroendocrine tumour grade 1 had a lower rate of recurrence compared to others (p=0.001). The median disease-free and overall survival times were 5.8 (0.4-53.6) and 13.7 (1.9-102.1) months for all four subtypes. However, the median disease free and overall survival rates of neuroendocrine tumours were significantly longer than those of neuroendocrine carcinomas or mixed adenoneuroendocrine carcinoma. CONCLUSIONS Patients with biliary neuroendocrine tumour showed extremely different clinical outcomes according to histopathologic subtypes by World Health Organization 2010 classification.

Current Status of Laparoscopic Liver Resection in Korea

Since laparoscopic liver resection was first introduced in 2001, Korean surgeons have chosen a laparoscopic procedure as one of the treatment options for benign or malignant liver disease. We distributed and analyzed a nationwide questionnaire to members of the Korean Laparoscopic Liver Surgery Study Group (KLLSG) in order to evaluate the current status of laparoscopic liver resection in Korea. Questionnaires were sent to 24 centers of KLLSG. The questionnaire consisted of operative procedure, histological diagnosis of liver lesions, indications for resection, causes of conversion to open surgery, and postoperative outcomes. A laparoscopic liver resection was performed in 416 patients from 2001 to 2008. Of 416 patients, 59.6% had malignant tumors, and 40.4% had benign diseases. A total laparoscopic approach was performed in 88.7%. Anatomical laparoscopic liver resection was more commonly performed than non-anatomical resection (59.9% vs 40.1%). The anatomical laparoscopic liver resection procedures consisted of a left lateral sectionectomy (29.3%), left hemihepatectomy (19.2%), right hemihepatectomy (6%), right posterior sectionectomy (4.3%), central bisectionectomy (0.5%), and caudate lobectomy (0.5%). Laparoscopy-related serious complications occurred in 12 (2.8%) patients. The present study findings provide data in terms of indication, type and method of liver resection, and current status of laparoscopic liver resection in Korea.

Lipid profiles for intrahepatic cholangiocarcinoma identified using matrix-assisted laser desorption/ionization mass spectrometry

BACKGROUND We evaluated whether direct tissue matrix-assisted laser desorption/ionization (MALDI) mass spectrometry (MS) analysis of lipids may distinguish intrahepatic cholangiocarcinomas from adjacent normal tissue and from other adenocarcinomas that frequently metastasize to liver. METHODS Four pairs of frozen surgical specimens of cholangiocarcinomas and adjacent normal tissue were analyzed using histology-directed, MALDI MS analysis. 2,5-dihydroxybenzoic acid / α-cyano-4-hydroxycinnamic acid were manually deposited on tumor-rich areas, and mass spectra were acquired using a MALDI-time of flight instrument. RESULTS Cholangiocarcinomas and adjacent normal tissue samples demonstrated different lipid profiles, as evidenced by permutation P value<0.05 for the cross-validated misclassification rate. Cancer-associated lipid alteration was similar between cholangiocarcinomas and pancreatic cancers, but not between cholangiocarcinomas and colorectal cancers. Baseline lipid profiles were different between cholangiocarcinoma and colorectal cancers. CONCLUSIONS MALDI MS analysis of lipid distinguishes cancerous epithelium of cholangiocarcinoma from adjacent normal tissue, and between cholangiocarcinomas and colorectal cancers.

The association of self-leadership, health behaviors, and posttraumatic growth with health-related quality of life in patients with cancer.

We tried to evaluate the association of self‐leadership, effective health behaviors, and posttraumatic growth with health‐related quality of life (HRQOL).

The Impact of a Surgical Protocol for Enhanced Recovery on Living Donor Right Hepatectomy: A Single-Center Cohort Study.

AbstractThe concept of surgery for enhanced recovery (SFER) program has never been an issue in the context of living donor right hepatectomy (LDRH), much less its effects. The purpose of this study was to evaluate outcomes after the establishment of an SFER protocol for LDRH in a single center.A single-center cohort study was performed in 500 consecutive living donors who underwent right hepatectomy from January 2005 to June 2014 by analyzing the outcomes before and after an established SFER protocol that evolved with continuous refinements in surgical technique and management over 300 LDRHs, being in place on September 2011. Donor characteristics, operative outcomes, and postoperative complications divided into 2 groups (group 1, stepwise adjustment; group 2, complete adherence to the protocol) were compared.Donor characteristics were comparable in the 2 groups. Overall complication rate was 10.0% with no mortality. In group 2, operative time, hospital stay, and overall complication rate decreased significantly, and the morbidity was 1% and confined in grade I complication without reoperation, perioperative blood transfusion, or readmission. All donors in this series recovered fully and returned to the previous functional lifestyle.An SFER protocol on LDRH can be established by the gradual implementation of various refinements of surgical technique, and the recent outcomes achieved after the establishment of an SFER protocol could provide a current guidance on LDRH toward the ultimate goal of zero morbidity.

A survival benefit of major hepatectomy for hepatocellular carcinoma identified by preoperative [18F] fluorodeoxyglucose positron emission tomography in patients with well-preserved hepatic function

AIMS Hepatic resection can cure hepatocellular carcinoma (HCC). However, the optimal extent of resection remains controversial. Major hepatectomy could minimize a tumor recurrence, but it is harmful due to decreased hepatic functional reserve. [18F] fluorodeoxyglucose positron emission tomography (FDG-PET) scans are known as their reflection tumor differentiation and biological activity in HCC. To evaluate a benefit of major hepatectomy for HCC, we performed this retrospective analysis in patients with well-preserved hepatic function, and further analyzed in the subset identified by preoperative FDG-PET. METHODS We reviewed the medical records of 189 patients with HCC who underwent curative resection between August 2004 and December 2010 at two institutes. All patients underwent anatomical resection, either by major or minor hepatectomy. RESULTS Median overall survival did not differ significantly between the major and minor hepatectomy groups (29.4 versus 26.3 months, p = 0.269). However, the major hepatectomy group had a better recurrence-free survival (24.5 versus 19.9 months, p = 0.004). On multivariate analysis, the presence of intrahepatic metastasis independently predicted overall survival (p = 0.009), but other examined variables did not. Overall survival and recurrence-free survival were significantly better following major hepatectomy rather than minor hepatectomy in patients whose preoperative FDG-PET indicated that the maximum standardized uptake value of the tumor (SUVtumor) was ≥4 and the tumor-to-nontumor SUV ratio (TNR) was ≥1.5. CONCLUSIONS Our findings suggest that preoperative FDG-PET may be useful in identifying patients with favorable hepatic reserve who are most likely to benefit from major rather than minor hepatectomy.