ng Kyoung You

Transumbilical single-port laparoscopic cholecystectomy : scarless cholecystectomy.

BackgroundMany laparoscopic surgeons have been attempting to reduce incisional morbidity and improve cosmetic outcomes by using fewer and smaller ports. We performed transumbilical single-port laparoscopic cholecystectomy (TUSPLC) in 15 patients with cholelithiasis by using a special “single-port” with virtually no scar.MethodsWe used an extra-small wound retractor and a surgical glove as the “single-port.” The wound retractor was set up through the small umbilical incision and the surgical glove attached with one trocar and two pipes was then fixed to the outer ring of the wound retractor. The commonly used trocar and two slim pipes attached to the surgical glove served as three working channels. Using this single-port and conventional laparoscopic instruments, such as a straight 5-mm dissector, grasper, scissors, and a 30-degree 5-mm rigid laparoscope, we performed TUSPLC in 15 patients with cholelithiasis. The overall procedure was similar to three-port laparoscopic cholecystectomy.ResultsFifteen well-selected patients with cholelithiasis underwent TUSPLC (4 males and 11 females; mean age, 39 (range, 29–63) years). Body mass index ranged from 20 to 34 (mean, 25.2). No case required extra-umbilical skin incisions or conversion to standard laparoscopy. The mean operative time was 79 (range, 35–165) min. Blood loss was minimal in all cases. The mean postoperative hospital stay was 1.6 (range, 1.0–2.5) days. No postoperative complications were observed.ConclusionsThe results of our initial experience of TUSPLC in 15 well-selected patients with cholelithiasis are encouraging. All procedures were completed successfully within a reasonable time. No extra-umbilical incisions were used and virtually no scar remained. TUSPLC could be a promising alternative method for the treatment of some patients with symptomatic gallstone disease as scarless abdominal surgery.

Single-port transumbilical laparoscopic cholecystectomy: a preliminary study in 37 patients with gallbladder disease.

INTRODUCTION Since the introduction of laparoscopic surgery, surgeons have not only been concerned about clinical outcomes, but also surgical scars. Although natural orifice transluminal endoscopic surgery (NOTES) is promising, it is not applicable to clinical practice thus far due to safety concerns. As a transitional procedure between standard laparoscopic surgery and NOTES, single-port transumbilical laparoscopic surgery might be an ideal alternative. The main advantage of single-port transumbilical laparoscopic surgery is that it is performed with existing instruments. Thus, we applied single-port surgery for cholecystectomies and the clinical outcomes were analyzed. METHODS Between July and October 2008, 37 adults with gallbladder pathologies were enrolled in this study. Only one transumbilical incision was made for accessing the abdominal cavity and a multichannel port system was assembled with existing devices. Standard laparoscopic instruments were used to perform the cholecystectomy. RESULTS There were 13 males and 24 females. The mean age of the patients was 47.5 +/- 12.2 years. Twenty-nine patients had gallbladder stones, 7 patients had gallbladder polyps, and 1 patient had biliary dyskinesia. The mean operative time was 83.6 +/- 40.2 minutes. Gallbladder perforations occurred in 11 patients. In 5 patients, the procedure was converted to a standard laparoscopic technique due to technical difficulties. Complications occurred in 2 patients; specifically, a mesenteric injury was caused by the inadvertent grasping of the small-bowel mesentery during the removal of the wound retractor and an inadvertent injury of the right hepatic duct. The mean hospital stay was 2.7 +/- 1.5 days. CONCLUSIONS Our series has demonstrated the feasibility and safety of single-port transumbilical laparoscopic cholecystectomy. When technical difficulties arise, early conversion to a standard laparoscopic technique is advised to avoid serious complications. Additional studies randomizing standard laparoscopic cholecystectomy and single-port transumbilical cholecystectomy are necessary for defining the exact role of this procedure.

Serum C‐reactive protein is a useful biomarker for predicting outcomes after liver transplantation in patients with hepatocellular carcinoma

Liver transplantation (LT) is a curative modality for hepatocellular carcinoma (HCC), especially in patients with cirrhosis. However, there are still risks of recurrence. C‐reactive protein (CRP), an acute‐phase inflammatory reactant that is synthesized by hepatocytes, has been related to the prognosis of various malignancies, including HCC. In this study, we investigated the role of a high CRP level in predicting the posttransplant outcomes of HCC patients. We analyzed 85 patients undergoing LT between August 2000 and July 2010 whose pretransplant serum CRP levels were available. Only 2 patients underwent deceased donor LT, and the remaining patients underwent living donor LT. With 1 mg/dL used as a cutoff value, 27 patients showed high CRP levels (≥1 mg/dL) at the time of LT, and 58 showed low CRP levels (<1 mg/dL). The total bilirubin level, Child‐Pugh grade, Model for End‐Stage Liver Disease score, maximal tumor size, and frequency of intrahepatic metastasis were significantly higher in the high‐CRP group. According to multivariate analyses, HCC beyond the Milan criteria, a high CRP level, and microvascular invasion were related to tumor recurrence, and a high CRP level and microvascular invasion were related to poor overall survival. When a subgroup analysis was performed according to the Milan criteria, a high CRP level was an independent factor for predicting poor outcomes in patients with HCC beyond the Milan criteria (P = 0.02 for recurrence and P < 0.001 for survival) but not in patients with HCC within the criteria. Serum CRP could be considered a useful and cost‐effective biomarker for predicting outcomes after LT for HCC, particularly in patients beyond the Milan criteria. Liver Transpl, 2012.

Biliary Stricture after Adult Right-Lobe Living-Donor Liver Transplantation with Duct-to-Duct Anastomosis: Long-Term Outcome and Its Related Factors after Endoscopic Treatment

BACKGROUND/AIMS Biliary stricture is the most common and important complication after right-lobe living-donor liver transplantation (RL-LDLT) with duct-to-duct biliary anastomosis. This study evaluated the efficacy and long-term outcome of endoscopic treatment for biliary stricture after LDLT, with the aim of identifying the factors that influence the outcome. METHODS Three hundred and thirty-nine adults received RL-LDLTs with duct-to-duct biliary anastomosis between January 2000 and May 2008 at Kangnam St. Marys Hospital. Endoscopic retrograde cholangiography (ERC) was performed in 113 patients who had biliary stricture after LDLT. We evaluated the incidence of post-LDLT biliary stricture and the long-term outcome of endoscopic treatment for biliary stricture. The factors related to the outcome were analyzed. RESULTS Biliary strictures developed in 121 (35.7%) patients, 95 (78.5%) of them within 1 year of surgery. The mean number of ERCs performed per patient was 3.2 (range, 1 to 11). The serum biochemical markers decreased significantly after ERC (p<0.001). Stent insertion or stricture dilatation during ERC was successful in 90 (79.6%) patients. After a median follow-up period of 33 months from the first successful treatment with ERC, 48 (42.5%) patients achieved treatment success and 12 (10.6%) patients remained under treatment. The factors related to the outcome of endoscopic treatment were nonanastomotic stricture and stenosis of the hepatic artery (p=0.016). CONCLUSIONS Endoscopic treatment is efficacious and has an acceptable long-term outcome in the management of biliary strictures related to RL-LDLT with duct-to-duct biliary anastomosis. Nonanastomotic stricture and stenosis of the hepatic artery are correlated with a worse outcome of endoscopic treatment.

Laparoscopic pancreaticoduodenectomy assisted by mini-laparotomy.

Purpose: Pancreaticoduodenectomy (PD) is the treatment of choice for periampullary disease. Even with the increasing number of successful reports from around the globe, laparoscopic pancreaticoduodenectomy (LPD) is still not fully accepted. We report the results of our experience of LPD assisted by mini-laparotomy. Method: This retrospective review study included 42 patients who received LPD assisted by mini-laparotomy between March 2009 and April 2012. Clinical outcomes, such as patient age, pathologic diagnosis, pancreas nature, operation time, conversion rate, hospital stay, postoperative complication, and mortality rates, were reviewed. Results: A total of 42 patients (age range, 42 to 70 y ) received LPD assisted by mini-laparotomy. The mean incision length for the laparotomy was 5.2 cm. Mean operative time was 404 minutes, and 3 cases required conversion to open surgery. Mean postoperative hospital stay was 17 days. There were 3 cases of pancreaticogastrostomy leakage, 2 cases of postoperative bleeding, 4 cases of delayed gastric emptying, 1 case of bile leakage, and 5 cases of pulmonary complications. Of the 5 patients with pulmonary complications, 1 died. Conclusions: When performed by a surgeon with ample experience in laparoscopic surgery, LPD assisted by mini-laparotomy is a safe, feasible alternative to conventional PD for select cases. The method described in this study can be used to perform pancreaticoenteric anastomosis in the same manner as an open PD, while taking advantage of the merits of minimally invasive surgery.

Usefulness of the Rendezvous Technique for Biliary Stricture after Adult Right-Lobe Living-Donor Liver Transplantation with Duct-To-Duct Anastomosis

BACKGROUND/AIMS Replacement of a percutaneous transhepatic biliary drainage (PTBD) catheter with inside stents using endoscopic retrograde cholangiography is difficult in patients with angulated or twisted biliary anastomotic stricture after living donor liver transplantation (LDLT). We evaluated the usefulness and safety of the rendezvous technique for the management of biliary stricture after LDLT. METHODS Twenty patients with PTBD because of biliary stricture after LDLT with duct-to-duct anastomosis underwent the placement of inside stents using the rendezvous technique. RESULTS Inside stents were successfully placed in the 20 patients using the rendezvous technique. The median procedure time was 29.6 (range, 7.5-71.8) minutes. The number of inside stents placed was one in 12 patients and two in eight patients. One mild acute pancreatitis and one acute cholangitis occurred, which improved within a few days. Inside stent related sludge or stone was identified in 12 patients during follow-up. Thirteen patients achieved stent-free status for a median of 281 (range, 70-1,351) days after removal of the inside stents. CONCLUSIONS The rendezvous technique is a useful and safe method for the replacement of PTBD catheter with inside stent in patients with biliary stricture after LDLT with duct-to-duct anastomosis. The rendezvous technique could be recommended to patients with angulated or twisted strictures.

Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid–enhanced magnetic resonance imaging predicts the histological grade of hepatocellular carcinoma only in patients with child-pugh class a cirrhosis†

The aim of this study was to investigate the role of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd‐EOB‐DTPA)–enhanced magnetic resonance imaging (MRI) in predicting the histological grade of hepatocellular carcinoma (HCC) according to the hepatic function. Eighty‐one consecutive patients with 122 histologically proven HCCs who underwent Gd‐EOB‐DTPA–enhanced MRI before resection (45 HCCs in 42 patients) or transplantation (77 HCCs in 39 patients) were analyzed retrospectively. We calculated the relative enhancement ratios (RER), which is the ratio of the relative intensity of a tumor versus the surrounding parenchyma on hepatobiliary phase images to the relative intensity on unenhanced MRI scans. We then analyzed the correlation between the RER and the tumor differentiation grade in patients with various degrees of hepatic function. The degree of tumor enhancement, which included the precontrast relative intensity ratio (RIR), the postcontrast RIR, and the RER, for well‐differentiated (WD) HCCs was significantly higher than the degree of tumor enhancement for moderately differentiated and poorly differentiated (PD) HCCs (P = 0.001 and P = 0.001, respectively, for precontrast RIRs; P < 0.001 and P < 0.001, respectively, for postcontrast RIRs; and P = 0.01 and P = 0.001, respectively, for RERs). In a subgroup analysis based on liver function, the correlation between the histological grade and the enhancement ratio was demonstrated only in the group of patients with Child‐Pugh class A cirrhosis. The accuracy of postcontrast RIRs for predicting WD and PD HCCs was favorable; the areas under the receiver operating characteristic curves were 0.896 [95% confidence interval (CI) = 0.817‐0.974] and 0.769 (95% CI = 0.658‐0.879), respectively. In conclusion, the hepatobiliary phase of Gd‐EOB‐DTPA–enhanced MRI may help to predict the differentiation of HCCs, especially in HCC patients with Child‐Pugh class A cirrhosis before liver transplantation or resection. Liver Transpl, 2012.

Dual-incision laparoscopic spleen-preserving distal pancreatectomy

Laparoscopic spleen-preserving distal pancreatectomy has been widely performed for benign and borderline malignancy in the body or tail of the pancreas when there are not oncologic indications for splenectomy. As the need for minimally invasive procedures to reduce postoperative morbidity and improve the quality of life is increasing, many surgeons have attempted to reduce the number of trocars and incision size to minimize access trauma and scarring. Single-port laparoscopic spleen-preserving distal pancreatectomy is the result of these efforts; however it has many limitations such as technical difficulty and prolonged operation time. In this article, we report the first case of dual-incision laparoscopic spleen-preserving distal pancreatectomy, proving that it can be a safe and feasible minimally invasive procedure for benign or borderline malignant tumors in the body or tail of the pancreas.

Performance of Posttransplant Model for End-Stage Liver Disease (MELD) and Delta-MELD Scores on Short-Term Outcome After Living Donor Liver Transplantation

The performance of the Model for End-stage Liver Disease (MELD) and delta-MELD scores in predicting posttransplant survival has been variable and the results are conflicting, suggesting that posttransplantational factors are more important than pre- or peritransplantational factors in outcomes following liver transplantation (OLT). We assessed the value of posttransplant MELD and delta-MELD scores to predict short-term (90-day) posttransplant survival. We evaluated 279 consecutive patients undergoing living donor OLTs. The MELD scores were calculated serially from pretransplantation as well as 3, 7, and 14 days after transplantation. Twenty-seven (9.7%) among 279 patients died within 90 days after transplantation. Pretransplant MELD score was not associated with short-term posttransplant mortality. The area under the receiver operating characteristic (AUROC) curve in predicting 90-day mortality was 0.637 for posttransplant 3-day MELD, 0.746 for posttransplant 7-day MELD, and 0.859 for posttransplant 14-day MELD score (P = .047, <.001, and <.001, respectively); AUROC was 0.582, 0.646, and 0.784 for 3-day, 7-day, and 14-day delta-MELD scores (P = .235, .034, <.001, respectively). Upon multivariate analysis, posttransplant 14-day MELD (> or =20 vs <20), and 14-day delta-MELD scores (> or =-3 vs <-3) were independent short-term prognostic factors with risk ratios of 18.875 (95% confidential interval [CI]: 4.625-77.028, P < .001) and 13.577 (95% CI: 2.641-69.791, P = .002), respectively. In conclusion, determination of posttransplant 14-day MELD and 14-day delta-MELD scores may afford suitable short-term prognostic predictors for patients following living donor OLT.

Inflammatory markers as selection criteria of hepatocellular carcinoma in living-donor liver transplantation.

AIM To investigate that inflammatory markers can predict accurately the prognosis of hepatocelluar carcinoma (HCC) patients in living-donor liver transplantation (LDLT). METHODS From October 2000 to November 2011, 224 patients who underwent living donor liver transplantation for HCC at our institution were enrolled in this study. We analyzed disease-free survival (DFS) and overall survival (OS) after LT in patients with HCC and designed a new score model using pretransplant neutrophil-lymphocyte ratio (NLR) and C-reactive protein (CRP). RESULTS The DFS and OS in patients with an NLR level ≥ 6.0 or CRP level ≥ 1.0 were significantly worse than those of patients with an NLR level < 6.0 or CRP level < 1.0 (P = 0.049, P = 0.003 for NLR and P = 0.010, P < 0.001 for CRP, respectively). Using a new score model using the pretransplant NLR and CRP, we can differentiate HCC patients beyond the Milan criteria with a good prognosis from those with a poor prognosis. CONCLUSION Combined with the Milan criteria, new score model using NLR and CRP represent new selection criteria for LDLT candidates with HCC, especially beyond the Milan criteria.