Ye Rim Chang

Validation of international consensus guidelines for the resection of branch duct‐type intraductal papillary mucinous neoplasms

Classifications of intraductal papillary mucinous neoplasm (IPMN) remain ambiguous, especially for the mixed type. Factors predicting malignancy remain unclear. The aim of this study was to evaluate the usefulness of factors predicting malignancy in the new international consensus guidelines for resection of branch duct‐type (BD)‐IPMN and to compare them with those in the previous version.

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.

Mucinous cystic neoplasm of the pancreas: Is surgical resection recommended for all surgically fit patients?

BACKGROUNDnSurgical removal of mucinous cystic neoplasms (MCNs) is usually recommended because of the risk of malignancy. However, increased experience of MCNs suggests that the incidence of invasion is lower than had been thought. This study was designed to establish more reasonable surgical indications for MCN through re-assessment using strict pathologic diagnostic criteria.nnnMETHODSnNinety-four patients who underwent surgical removal of MCNs at Seoul National University Hospital from 1991 to 2012 were retrospectively analyzed. Pathologic results were re-evaluated by an experienced pathologist. Medical records and radiologic images were reviewed to determine factors predicting malignancy.nnnRESULTSnOf the 94 patients, 4 were found to have intraductal papillary mucinous neoplasms (IPMNs). Of the 90 MCNs, 60 (66.7%) were low-grade, 21 (23.3%) were intermediate-grade, and 5 (5.5%) were high-grade dysplasias; and 4 (4.4%) were invasive carcinoma. Mural nodules on CT scan (pxa0=xa00.005) and abnormal serum CA19-9 concentration (pxa0=xa00.029) were significant predictors of malignancy. All MCNs less than 3xa0cm in size with normal serum tumor markers were benign and all malignant MCNs had cyst fluid CA19-9 over 10,000xa0units/ml. The five year disease specific survival rates were 98.8% for all patients and 75.0% for those with invasive MCNs.nnnCONCLUSIONnMCNs had a low prevalence of malignancy. Regardless of the histological grade, long-term outcome was excellent. Therefore, in the absence of specific symptoms, surgery may not be indicated for MCNs <3xa0cm without mural nodules or elevated serum tumor markers. Validation by a prospective study with very careful design is needed.

Laparoscopic excision of a choledochal cyst in 82 consecutive patients

IntroductionDespite it being a benign disease, a choledochal cyst must be removed with the gallbladder (GB) due to the risk of cancer in the biliary tract. Most patients are young females or children, all of whom express strong interest in the cosmetic results in addition to the complete resolution of their medical problems. Here, we introduce a laparoscopic management technique for a choledochal cyst.MethodsBetween 2003 and 2011, we performed a laparoscopic choledochal cyst excision procedure on 82 patients using a four-hole method. There were three open-conversion cases, one case involving robotic surgery, and one case involving combined laparoscopic liver resection because the cyst had affected the liver. Excision of the cyst and anastomosis were performed laparoscopically. We will present our method with a video.ResultsThe mean operation time was 230xa0min. The estimated blood loss was 197xa0ml. The average hospital stay was 8.6xa0days. The most common complications were minor bile leakage (7xa0%) and fluid collection (2.5xa0%), both of which were managed conservatively.ConclusionsLaparoscopic management can be a treatment of choice for the most instances of choledochal cyst considering its good cosmetic results and its feasible level of operative safety.

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.

Portal vein patency after pancreatoduodenectomy for periampullary cancer.

The fate of the portal vein (PV) after pancreatoduodenectomy, especially its long‐term patency and associated complications, has received little attention. The aim of this study was to explore the long‐term patency rate of the PV after pancreatoduodenectomy, focusing on risk factors for PV stenosis/occlusion and associated complications.

Surgical outcome of pancreatic cancer using radical antegrade modular pancreatosplenectomy procedure

AIMnTo evaluate the surgical outcomes following radical antegrade modular pancreatosplenectomy (RAMPS) for pancreatic cancer.nnnMETHODSnTwenty-four patients underwent RAMPS with curative intent between January 2005 and June 2009 at the National Cancer Center, South Korea. Clinicopathologic data, including age, sex, operative findings, pathologic results, adjuvant therapy, postoperative clinical course and follow-up data were retrospectively collected and analyzed for this study.nnnRESULTSnTwenty-one patients (87.5%) underwent distal pancreatectomy and 3 patients (12.5%) underwent total pancreatectomy using RAMPS. Nine patients (37.5%) underwent combined vessel resection, including 8 superior mesenteric-portal vein resections and 1 celiac axis resection. Two patients (8.3%) underwent combined resection of other organs, including the colon, stomach or duodenum. Negative tangential margins were achieved in 22 patients (91.7%). The mean tumor diameter for all patients was 4.09 ± 2.15 cm. The 2 patients with positive margins had a mean diameter of 7.25 cm. The mean number of retrieved lymph nodes was 20.92 ± 11.24 and the node positivity rate was 70.8%. The median survival of the 24 patients was 18.23 ± 6.02 mo. Patients with negative margins had a median survival of 21.80 ± 5.30 mo and those with positive margins had a median survival of 6.47 mo (P = 0.021). Nine patients (37.5%) had postoperative complications, but there were no postoperative mortalities. Pancreatic fistula occurred in 4 patients (16.7%): 2 patients had a grade A fistula and 2 had a grade B fistula. On univariate analysis, histologic grade, positive tangential margin, pancreatic fistula and adjuvant therapy were significant prognostic factors for survival.nnnCONCLUSIONnRAMPS is a feasible procedure for achieving negative tangential margins in patients with carcinoma of the body and tail of the pancreas.

Does Preoperative Portal Vein Embolization Have Any Impact on the Outcome of Right-Side Hepatectomy for Klatskin Tumor?

Background and AimThe clinical usefulness of portal vein embolization (PVE) for Klatskin tumor is not well established. The authors explored the change in liver volume and function before and after major hepatectomy and evaluated the effect of PVE.MethodsThirty-three consecutive patients who underwent right hepatectomy with an initial future liver remnant (FLR)u2009≤u200930xa0% for Klatskin tumors at Seoul National University Hospital were included.ResultsEleven patients underwent PVE, and eight patients received right trisectionectomy. PVE induced a mean FLR increase of 19.3xa0% after a mean of 15.8xa0days. At postoperative month 1, liver volume and liver hypertrophy ratio was comparable between PVE and no-PVE group. For patients with an initial FLRu2009≤u200920xa0%, postoperative liver hypertrophy rate of PVE group was comparable to no-PVE group. Liver function tests were not affected by PVE or the initial FLR. Postoperative liver hypertrophy ratio was negatively correlated with the initial FLR (hypertrophy ratio (%)u2009=u2009326.7–0.4×initial FLR (ml), Pu2009=u20090.001). There was no severe PVE-related morbidity, and postoperative morbidity rate was comparable in PVE and no-PVE group.ConclusionThe postoperative liver hypertrophy ratio, final liver volume, or liver function tests were not affected by PVE. Postoperative liver hypertrophy was related to the initial FLR.

Cancer cells with p53 deletion detected by fluorescent in situ hybridization in peritoneal drainage fluid is correlated with early peritoneal seeding in resectable pancreatic cancer

Purpose Free tumor cells in peritoneal fluid in patients with pancreatic cancer may have prognostic significance but there are few reports on methods for the effective detection of free tumor cells. The aims of this study were to identify free cancer cells in peritoneal fluid with fluorescent in situ hybridization (FISH) technique and to investigate its prognostic significance. Methods Twenty-eight patients with resectable pancreatic cancer who underwent surgical resection were included. Peritoneal washing and peritoneal drainage fluid were examined by FISH for p53 deletion. Results Among the study subjects, the R0 resection rate was 75%. None of the patients had positive cytology with Papanicolaous method. p53 deletion was detected in 9 peritoneal washings (32.1%) and in 5 peritoneal drainage fluids (17.9%). After a median of 18 months of follow-up, 25 patients (89.3%) experienced recurrence and 14 patients (50.0%) had peritoneal seeding. Patients with p53 deletion detected in the peritoneal drainage fluid had positive radial margin (60.0% vs. 17.4%, P = 0.046) more frequently and a lower peritoneal metastasis free survival (median, 11.1 months vs. 30.3 months; P = 0.030). Curative resection (P < 0.001) and p53 deletion in peritoneal drainage fluid (P = 0.030) were independent risk factors of peritoneal metastasis free survival after multivariate analysis. Conclusion FISH technique detects free cancer cells with higher sensitivity compared to Papanicolaous method. p53 deletion detected in peritoneal drainage fluid is correlated with positive radial resection margin and results in early peritoneal seeding. Patients with p53 deletion in peritoneal drainage fluid need more aggressive adjuvant treatment.

Clinical features and survival outcome of locally advanced extrahepatic cholangiocarcinoma

Backgrounds/Aims Little is known about clinical features and survival outcome in locally advanced unresectable extrahepatic cholangiocarcinoma (EHC). The aim was to investigate the clinical features and the survival outcome in these patients, and to evaluate the role of palliative resections in locally advanced unresectable EHC. Methods Between 1995 and 2007, 280 patients with locally advanced unresectable EHC were identified. Clinical, pathologic, and survival data were investigated. A comparative analysis was done between those who received palliative resection (PR) and those who were not operated on (NR). Results The overall median survival of the study population was 10±1 months, and the 3- and 5-year survival rates (YSR) were 8.5% and 2.5%, respectively. The median survival, 3- and 5-YSR of PR were 23 months, 32.1% and 13.1%, respectively. For NR, they were 9 months, 3.9% and 0%, which were significantly worse than PR (p<0.001). In univariate analysis, T classification, N classification, tumor location, palliative resection, adjuvant treatment, chemotherapy, and radiation therapy were factors that showed survival difference between PR and NR. Regional lymph node metastasis (RR, 2.084; 95% CI, 1.491-2.914; p<0.001), non-resections (RR, 2.270; 95% CI, 1.497-3.443; p<0.001), and no chemotherapy (RR, 1.604; 95% CI, 1.095-2.349; p=0.015) were identified as risk factors for poor outcome on multivariate analysis. Conclusions Without evidence of systemic disease, palliative resection may provide some survival benefit in selected locally advanced unresectable EHCs and adjuvant treatment may further improve survival outcome.