Song Cheol Kim

Single-center experience of laparoscopic left pancreatic resection in 359 consecutive patients: changing the surgical paradigm of left pancreatic resection

AbstractBackgroundLaparoscopic distal pancreatectomy (LDP) is increasingly performed for lesions of the body and tail of the pancreas. We analyzed the clinical characteristics of the largest series of patients to date who underwent LDP at a single center, as well as their outcomes, to reassess the surgical paradigm for left pancreatic resection.MethodsWe retrospectively reviewed the records of 359 patients who underwent LDP at Asan Medical Center, Seoul, Korea, for pancreatic neoplasms between March 2005 and December 2010.ResultsOf the 359 patients, 323 (90%) had benign or low-grade malignant neoplasms and 36 (10%) had malignancies. The most common diagnosis was intraductal papillary mucinous neoplasm (IPMN) in 72 patientsn(21.2%). There were 24 patients (6.7%) with pancreatic ductal adenocarcinoma (PDAC). We found that 178 patients (49.6%) underwent spleen-preserving LDP (SP-LDP): 150 (84.3%) by main splenic vessel preservation, and 28 (15.7%) supported by short gastric and gastroepiploic vessels (Warshaw technique). Postoperative complications occurred in 43 (12%) patients, including 25 (7%) with pancreatic fistula (ISGPF grade B, C), but there was no death. Median operative time was 195 (range, 78–480) min, and median postoperative hospital stay was 8 (range, 4–37) days. The proportion of patients with pancreatic lesions who underwent LDP increased from 8.6% in 2005 to 66.9% in 2010. Kaplan–Meier analysis showed that the 1- and 2-year overall survival rates in the 24 patients with PDAC were 85.2% each.ConclusionsLDP is feasible, safe, and effective for the treatment of benign and low-grade malignant lesions of the pancreas. The increased use of LDP for left-sided pancreatic lesions, including malignant lesions, represents a paradigm shift from open distal pancreatectomy.

Enucleation for benign or low-grade malignant lesions of the pancreas: Single-center experience with 65 consecutive patients

INTRODUCTIONnStandard resection for benign and borderline neoplasms of the pancreas is associated with a substantial risk of postoperative morbidity and long-term functional impairment, whereas enucleation leads to less morbidity and preserves healthy parenchyma as well as pancreatic function. The aim of this study was to evaluate the postoperative clinical outcomes and long-term functional and oncologic results after pancreatic enucleation, and to compare the clinical results of laparoscopic and open enucleation.nnnMETHODSnFrom March 2005 to December 2013, 65 cases of enucleation of benign tumors in the pancreas were identified through a retrospective review of medical records.nnnRESULTSnMost of the patients were women (73.8 %), and the median age was 52.7 years (interquartile range 43.1-60.9 years). Median tumor size was 2.5 cm (interquartile range 1.6-3.8 cm). The most common indication for enucleation was pancreatic neuroendocrine tumor (24, 36.9%). A clinically relevant pancreatic fistula (International Study Group on Pancreatic Fistula grade B, C) was reported in 6 patients (9.2%). The patients with tumors of the pancreatic neck had more complications after enucleation than those with tumors at other locations (3/4, 75%). There were no differences of clinical outcomes between open and laparoscopic enucleation groups. At a median follow-up of 58.7 months there was one case of new-onset diabetes, and there were no recurrences or deaths.nnnCONCLUSIONnEnucleation is a safe and effective procedure for the treatment of benign and borderline pancreatic neoplasms. It preserves pancreatic function and is not associated with recurrence. The incidence of postoperative complications, including pancreatic fistula, is acceptable. Laparoscopic enucleation seems to be a feasible and safe approach associated with favorable perioperative outcomes for the selected patients.

Laparoscopic Spleen-Preserving Distal Pancreatectomy: Comparative Study of Spleen Preservation with Splenic Vessel Resection and Splenic Vessel Preservation

BackgroundSpleen-preserving laparoscopic distal pancreatectomy (SPLDP) can be performed with splenic vessel resection (SVR) or splenic vessel preservation (SVP). The purpose of this comparative study was to evaluate the clinical outcomes of patients who underwent SPLDP with SVR or SVP at a single institution.MethodsWe retrospectively reviewed the records of 246 patients who underwent SPLDP at Asan Medical Center, Seoul, Korea, for benign or low-grade malignant tumors found in the body or tail of the pancreas between November 2005 and November 2011.ResultsIn total, 206 patients (83.7xa0%) were managed by SVP. SVR was performed in the remaining 40 (16.3xa0%) cases. There were no significant differences between the SVP and SVR groups in terms of intraoperative blood loss (378xa0±xa0240 vs. 328xa0±xa0204xa0ml, respectively; Pxa0=xa00.240) and operating time (193.4xa0±xa059.1 vs. 204.4xa0±xa051.8xa0min, respectively; Pxa0=xa00.492). Sixty-seven (32.5xa0%) and 10 patients (25xa0%) had complications in the SVP and SVR groups, respectively (Pxa0=xa00.347). At 3xa0days after surgery, the rates of splenic infarction were 16.0xa0% (33/206) in the SVP group and 52.5xa0% (21/40) in the SVR group, but all recovered within 12xa0months on postoperative computed tomography. The time of recovery from splenic infarction was 3.6xa0±xa03.1 and 4.7xa0±xa03.7xa0months in the SVP and SVR groups, respectively. At 6xa0months, the rates of gastric varices were 1.9xa0% in the SVP group and 35xa0% in the SVR group (Pxa0<xa00.001) with no progression at 12xa0months. No gastrointestinal bleeding occurred at a median follow-up of 34xa0months (rangexa0=xa012–84).ConclusionsSPLDP with SVR can be used for patients with large and benign or low-grade malignant tumors that distort and compress vessel course, as the higher rate of early splenic ischemia and perigastric varices is acceptable.

Laparoscopic central pancreatectomy for benign or low-grade malignant lesions in the pancreatic neck and proximal body

IntroductionLaparoscopic central pancreatectomy (LCP) is a parenchyma-sparing minimally invasive surgical technique for removal of benign or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this study was to compare the short- and long-term clinical outcomes of LCP with those of other pancreatectomies.MethodsDuring the study period, January 2007 to December 2010 (median follow-up 40.6xa0months), 287 pancreatectomies were performed for lesions in the neck and proximal body of the pancreas. To compare the clinical outcomes of LCP and other pancreatectomies, 26 cases of LCP, 14 cases of open central pancreatectomy (OCP), and 96 cases of extended laparoscopic distal pancreatectomy (E-LDP) were selected.ResultsTumor sizes in the LCP (2.2xa0cm) and OCP (2.9xa0cm) groups were smaller than in the E-LDP (4.0xa0cm) group. Mean operation time in the LCP group (350.2xa0min) was longer than in the OCP (270.3xa0min) and E-LDP groups (210.6xa0min). There were more surgical complications in the LCP (38.5xa0%) and OCP groups (50xa0%) than in the E-LDP group (14.6xa0%). Mean duration of postoperative hospital stay was 13.8xa0days for the LCP group, which was significantly shorter than for the OCP group (22.4xa0days). New-onset diabetes was less frequent after LCP than after E-LDP (11.5 vs. 30.8xa0%).ConclusionsIn selected patients with small and benign tumors in the pancreatic neck and proximal body LCP leads to increased postoperative morbidity but earlier postoperative recovery than OCP, and excellent postoperative pancreatic function (compared with E-LDP). LCP should, therefore, be considered a valid therapeutic option for selected patients.

Alternative lengthening of telomeres in primary pancreatic neuroendocrine tumors is associated with aggressive clinical behavior and poor survival

Purpose: Alternative lengthening of telomeres (ALT), a telomerase-independent telomere maintenance mechanism, is strongly associated with ATRX and DAXX alterations and occurs frequently in pancreatic neuroendocrine tumors (PanNET). Experimental Design: In a Korean cohort of 269 surgically resected primary PanNETs and 19 sporadic microadenomas, ALT status and nuclear ATRX and DAXX protein expression were assessed and compared with clinicopathologic factors. Results: In PanNETs, ALT or loss of ATRX/DAXX nuclear expression was observed in 20.8% and 19.3%, respectively, whereas microadenomas were not altered. ALT-positive PanNETs displayed a significantly higher grade, size, and pT classification (all, P < 0.001). ALT also strongly correlated with lymphovascular (P < 0.001) and perineural invasion (P = 0.001) and the presence of lymph node (P < 0.001) and distant metastases (P = 0.002). Furthermore, patients with ALT-positive primary PanNETs had a shorter recurrence-free survival [HR = 3.38; 95% confidence interval (CI), 1.83–6.27; P < 0.001]. Interestingly, when limiting to patients with distant metastases, those with ALT-positive primary tumors had significantly better overall survival (HR = 0.23; 95% CI, 0.08–0.68; P = 0.008). Similarly, tumors with loss of ATRX/DAXX expression were significantly associated with ALT (P < 0.001), aggressive clinical behavior, and reduced recurrence-free survival (P < 0.001). However, similar to ALT, when limiting to patients with distant metastases, loss of ATRX/DAXX expression was associated with better overall survival (P = 0.003). Conclusions: Both primary ALT-positive and ATRX/DAXX-negative PanNETs are independently associated with aggressive clinicopathologic behavior and displayed reduced recurrence-free survival. In contrast, ALT activation and loss of ATRX/DAXX are both associated with better overall survival in patients with metastases. Therefore, these biomarkers may be used as prognostic markers depending on the context of the disease. Clin Cancer Res; 23(6); 1598–606. ©2016 AACR.

Prognostic factors in 151 patients with surgically resected non-functioning pancreatic neuroendocrine tumours.

Recently, non‐functioning pancreatic neuroendocrine tumors (NF‐PNETs) are increasing. It is important to know about the prognostic factors and long‐term survival rates in patients with NF‐PNET for the management of these diseases.

Differentiation of human adipose tissue-derived stem cells into aggregates of insulin-producing cells through the overexpression of pancreatic and duodenal homeobox gene-1.

The pancreatic and duodenal homeobox gene 1 (Pdx-1) plays a key role in normal pancreas development and is required for maintaining the normal function of islets. In this study, we examined whether human adipose tissue-derived stem cells (hASCs) could differentiate into insulin-producing cells by exogenously expressed Pdx-1. hASCs were infected with recombinant adenovirus encoding the mouse Pdx-1 gene and differentiated under high-glucose conditions. Insulin transcript levels and the expression of key transcription factors required for pancreatic development including FoxA2, Nkx2.2, and NeuroD were significantly increased by exogenous Pdx-1 overexpression. The expression of Nkx6.1 was found only in Pdx-1-induced hASCs. In addition to transcripts for transcription factors involved in pancreatic development, transcripts for the GLP-1 receptor, glucokinase, and glucose transporter, which are required for maintaining the function of pancreatic β-cells, were observed only in Pdx-1-induced hASCs. Pdx-1-induced hASCs exhibited insulin secretion in response to glucose challenge in vitro. When Pdx-1-induced hASCs were transplanted into streptozotocin (STZ)-induced diabetic mice, they reduced blood glucose levels, although they did not restore normoglycemia. These results demonstrate that the expression of exogenous Pdx-1 is sufficient to induce pancreatic differentiation in vitro but does not induce the fully functional, mature insulin-producing cells that are required for restoring normoglycemia in vivo.

What is the Better Choice for T1b Gallbladder Cancer: Simple Versus Extended Cholecystectomy

AbstractBackgroundnThere is debate over whether T1b gallbladder cancer (GBC) should be treated by simple cholecystectomy (SC) or by extended cholecystectomy (EC). The aim of this study is to compare and analyze the results of these two procedures.Patients and methodsnThe archived medical records of 805 patients with GBC who had undergone surgical resection in Asan Medical Center, or were referred from other hospitals after undergoing surgery, between 1997 and 2010 were retrospectively reviewed. Of these, 85 patients were diagnosed with pathologic stage T1b (muscular layer) GBC. By using propensity scoring, the EC group and the SC group were matched in the proportion of 1:2; so, 54 patients were enrolled in this study.ResultsnAmong the 54 pathologic stage T1b cancer patients, SC was performed in 36 (66.7xa0%) and EC in 18 (33.4xa0%). The mean operation time and hospital stay after surgery of the SC group was significantly shorter than in the EC group (83.2 vs. 356.4xa0min, 7.8 vs. 15.2xa0days; both pxa0=xa00.000). Disease recurrence was noted in four cases (11.1xa0%), all in the SC group; 50xa0% of recurred patients experienced recurrence at the lymph node. There was no significant intergroup difference in the 5-year survival rate (5-YSR) (88.8xa0% for SC vs. 93.3xa0% for EC, pxa0=xa00.521).ConclusionsIn this study, for stage T1b GBC, both EC and SC offered similar cure rates. However, recurrence is associated with SC and inadequate lymph node dissection (LND). Therefore, EC including regional LND may be justified and preferred because of the possibility of lymph node metastasis and the accurate assessment of stage (LN status), except that the patients have a high risk of operation.

Surgical impact of an inferior right hepatic vein on right anterior sectionectomy and right posterior sectionectomy

In hepatocellular carcinoma, anatomical resection is important because of portal spread. In right anterior sectionectomy (RAS) and right posterior sectionectomy (RPS), the right hepatic vein (RHV) may not correspond with the intersectional plane if an inferior RHV (IRHV) is present. The aim of this study was to evaluate the influence of the IRHV on the exposure of the RHV retrospectively.