Publications by authors named "In Seok Choi"

39 Publications

Elective Laparoscopic Cholecystectomy Is Better than Conservative Treatment in Elderly Patients with Acute Cholecystitis After Percutaneous Transhepatic Gallbladder Drainage.

J Gastrointest Surg 2021 Jun 25. Epub 2021 Jun 25.

Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, 158, Gwanjeodong-ro, Seo-gu, Daejeon, 35365, South Korea.

Background: It is unclear whether cholecystectomy is beneficial after percutaneous transhepatic gallbladder drainage (PTGBD) in elderly patients with acute cholecystitis (AC).

Methods: This single-center, retrospective study included 202 patients aged >80 years with AC without common bile duct (CBD) stones who underwent PTGBD between January 2010 and December 2019.

Results: One hundred and forty-two patients underwent elective laparoscopic cholecystectomy (ELC), and 60 underwent conservative treatment, specifically PTGBD removal (PTGBD-R) in 36 patients and PTGBD maintained (PTGBD-M) in 24 patients. The postoperative major complication (POMC) rate in the ELC group was 8.5%. The cumulative incidence for recurrence of biliary events (BE) in the PTGBD-R group was 22.2%. The cumulative incidence for PTGBD-related complication in the PTGBD-M group was 70.8%. Mortality after initial treatment was not significantly different between the three groups (2.8% vs. 2.8% vs. 8.3%, p=0.381). In multivariate analysis, a Charlson age comorbidity index ≥6 and body mass index ≤19 were significant risk factors for POMC after ELC, and a closed cystic duct was a significant risk factor for recurrent BE after PTGBD-R.

Conclusion: ELC is recommended in AC after PTGBD for selected patients aged >80 years without CBD stones due to the high recurrence rate of BE after PTGBD-R and the difficulty associated with PTGBD-M.
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http://dx.doi.org/10.1007/s11605-021-05067-1DOI Listing
June 2021

A comparative study of postoperative outcomes between minimally invasive living donor hepatectomy and open living donor hepatectomy: The Korean organ transplantation registry.

Surgery 2021 07 10;170(1):271-276. Epub 2021 Apr 10.

Department of Surgery, Jeonbuk National University Medical School, Jeonju, Korea. Electronic address:

Background: This study evaluated the safety and effectiveness of minimally invasive living donor hepatectomy in comparison with the open procedure, using Korean Organ Transplantation Registry data.

Methods: We reviewed the prospectively collected data of all 1,694 living liver donors (1,071 men, 623 women) who underwent donor hepatectomy between April 2014 and December 2017. The donors were grouped on the basis of procedure type to the minimally invasive procedure group (n = 304) or to the open procedure group (n = 1,390) and analyzed the relationships between clinical data and complications.

Results: No donors died after the procedure. The overall complication rates after operation in the minimally invasive procedure group and the open procedure group were 6.2% and 3.5%, respectively. Biliary complications were the most frequent events in both groups (minimally invasive procedure group, 2.4%; open procedure group, 1.6%). The majority of complications occurred within 7 days after surgery in both groups. The duration of hospitalization was shorter in the minimally invasive procedure group than in the open procedure group (9.04 ± 3.78 days versus 10.29 ± 4.01 days; P < .05).

Conclusion: Based on its similar outcomes in our study, minimally invasive donor hepatectomy cannot be an alternative option compared with the open procedure method. To overcome this, we need to ensure better surgical safety, such as lower complication rate and shorter duration of hospitalization.
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http://dx.doi.org/10.1016/j.surg.2021.03.002DOI Listing
July 2021

New-onset diabetes after adult liver transplantation in the Korean Organ Transplantation Registry (KOTRY) study.

Hepatobiliary Surg Nutr 2020 Aug;9(4):425-439

Department of Surgery, Yonsei University College of Medicine, Seoul, South Korea.

Background: New-onset diabetes after transplantation (NODAT) is a serious complication following liver transplantation (LT). The present study aimed to investigate the incidence of and risk factors for NODAT using the Korean Organ Transplantation Registry (KOTRY) database.

Methods: Patients with history of pediatric transplantation (age ≤18 years), re-transplantation, multi-organ transplantation, or pre-existing diabetes mellitus were excluded. A total of 1,919 non-diabetic adult patients who underwent a primary LT between May 2014 and December 2017 were included. Risk factors were identified using Cox regression analysis.

Results: NODAT occurred in 19.7% (n=377) of adult liver transplant recipients. Multivariate analysis showed steroid use, increased age, and high body mass index (BMI) in recipients, and implantation of a left-side liver graft was closely associated with NODAT in adult LT. In living donor liver transplant (LDLT) patients (n=1,473), open donor hepatectomy in the living donors, steroid use, small for size liver graft (graft to recipient weight ratio ≤0.8), increased age, and high BMI in the recipient were predictive factors for NODAT. The use of antimetabolite and basiliximab induction reduced the incidence of NODAT in adult LT and in adult LDLT.

Conclusions: Basiliximab induction, early steroid withdrawal, and antimetabolite therapy may prevent NODAT after adult LT. High BMI or advanced age in liver recipients, open donor hepatectomy in living donors, and small size liver graft can predict the occurrence of NODAT after adult LT or LDLT.
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http://dx.doi.org/10.21037/hbsn.2019.10.29DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7423540PMC
August 2020

The chronological change of indications and outcomes for single-incision laparoscopic cholecystectomy: a Korean multicenter study.

Surg Endosc 2021 06 24;35(6):3025-3032. Epub 2020 Jun 24.

Department of Surgery, College of Medicine, Konyang University Hospital, Kunyang University, 158, Gwanjeodong-ro, Seo-gu, Daejeon, 35365, Republic of Korea.

Background: Although single-incision laparoscopic cholecystectomy (SILC) is a common procedure, the change in its surgical indications and perioperative outcomes has not been analyzed.

Methods: We collected the clinical data of patients who underwent pure SILC in 9 centers between 2009 and 2018 and compared the perioperative outcomes.

Results: In this period, 6497 patients underwent SILC. Of these, 2583 were for gallbladder (GB) stone (39.7%), 774 were for GB polyp (11.9%), 994 were for chronic cholecystitis (15.3%), and 1492 were for acute cholecystitis (AC) (23%). 162 patients (2.5%) experienced complication, including 20 patients (0.2%) suffering from biliary leakage. The number of patients who underwent SILC for AC increased over time (p = 0.028), leading to an accumulation of experience (27.4 vs 23.7%, p = 0.002). The patients in late period were more likely to have undergone a previous laparotomy (29.5 vs 20.2%, p = 0.006), and to have a shorter operation time (47.0 vs 58.8 min, p < 0.001). Male (odds ratio [OR]; 1.673, 95% confidence interval [CI] 1.090-2.569, p = 0.019) and moderate or severe acute cholecystitis (OR; 2.602, 95% CI 1.677-4.037, p < 0.001) were independent predictive factors for gallbladder perforation during surgery, and open conversion (OR; 5.793, 95% CI 3.130-10.721, p < 0.001) and pathologically proven acute cholecystitis or empyema (OR; 4.107, 95% CI 2.461-6.854, p < 0.001) were related with intraoperative gallbladder perforation CONCLUSION: SILC has expanded indication in late period. In this period, the patients had shorter operation times and a similar rate of severe complications, despite there being more numerous patients with AC.
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http://dx.doi.org/10.1007/s00464-020-07748-5DOI Listing
June 2021

Effects of remifentanil preconditioning on factors related to uterine contraction in WISH cells.

J Dent Anesth Pain Med 2019 Dec 27;19(6):343-351. Epub 2019 Dec 27.

Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Korea.

Background: Preterm labor and miscarriage may occur in stressful situations, such as a surgical operation or infection during pregnancy. Pharyngeal and buccal abscess and facial bone fractures are inevitable dental surgeries in pregnant patients. Remifentanil is an opioid analgesic that is commonly used for general anesthesia and sedation. Nonetheless, no study has investigated the effects of remifentanil on amniotic epithelial cells. This study evaluated the effects of remifentanil on the factors related to uterine contraction and its mechanism of action on amniotic epithelial cells.

Methods: Amniotic epithelial cells were preconditioned at various concentrations of remifentanil for 1 h, followed by 24-h lipopolysaccharide (LPS) exposure. MTT assays were performed to assess the cell viability in each group. The effects of remifentanil on factors related to uterine contractions in amniotic epithelial cells were assessed using a nitric oxide (NO) assay, western blot examinations of the expression of nuclear factor-kappa B (NF-κB), cyclooxygenase 2 (COX2), and prostaglandin E2 (PGE), and RT-PCR examinations of the expression of the proinflammatory cytokines interleukin (IL)-1β and tumor necrosis factor-alpha (TNF-α).

Results: Remifentanil did not affect viability and nitric oxide production of amniotic epithelial cells. Western blot analysis revealed that remifentanil preconditioning resulted in decreased expressions of NF-κB and PGE in the cells in LPS-induced inflammation, and a tendency of decreased COX2 expression. The results were statistically significant only at high concentration. RT-PCR revealed reduced expressions of IL-1β and TNF-α.

Conclusions: Preconditioning with remifentanil does not affect the viability of amniotic epithelial cells but reduces the expression of factors related to uterine contractions in situations where cell inflammation is induced by LPS, which is an important inducer of preterm labor. These findings provide evidence that remifentanil may inhibit preterm labor in clinical settings.
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http://dx.doi.org/10.17245/jdapm.2019.19.6.343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6946832PMC
December 2019

A large-cohort comparison between single incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy from a single center; 2080 cases.

Ann Hepatobiliary Pancreat Surg 2018 Nov 27;22(4):367-373. Epub 2018 Nov 27.

Department of Surgery, Konyang University Hospital, Daejeon, Korea.

Backgrounds/aims: This study was conducted to verify and compare the safety and feasibility of single incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC).

Methods: A total of 2,080 patients underwent laparoscopic cholecystectomy in a single center, Konyang University Hospital, between 2010 and 2016. We retrospectively compared the demographics, perioperative outcome, and postoperative complication results between the CLC and SILC groups.

Results: Among the 2,080 patients who underwent laparoscopic cholecystectomy, 1,080 had CLC and 1,000 had SILC. When retrospectively reviewed, the SILC group had significantly higher percentages of patients who were aged under 80 years, who were women, and had the American Society of Anesthesiologist score of lower than 3 points compared to those of the CLC group. Furthermore, the CLC group had a higher percentage of patients with acute cholecystitis or empyema, whereas the SILC group had a higher percentage of patients with chronic cholecystitis. Preoperative percutaneous transhepatic gallbladder drainage insertion or H-vac insertion was more frequently conducted, bleeding loss was more common, and hospital stay was longer in the CLC group. Postoperative complications such as wound infection, biloma, bile duct injury, and duodenal perforation were not significantly different between the two groups.

Conclusions: In conclusion, if performed after preoperative patient selection such as in younger and female patients with no abdominal operation history at the time of benign gallbladder surgery, SILC can be considered feasible and safe without additional complications when compared with CLC.
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http://dx.doi.org/10.14701/ahbps.2018.22.4.367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6295377PMC
November 2018

Fabrication of 4 × 1 signal combiner for high-power lasers using hydrofluoric acid.

Opt Express 2018 Nov;26(23):30667-30677

We report a new method to fabricate a 4 × 1 signal combiner that comprises an output fiber port and a tapered fused bundle (TFB) with four input fiber ports. The TFB is etched in a solution of hydrofluoric acid and spliced with an output fiber of core diameter 105 μm and cladding diameter 125 μm. Each cladding of the four input optical fiber is etched to approximately 72.5 μm. The etched TFB was fabricated by tapering after forming a bundle of four etched optical fibers. Subsequently, the 4 × 1 signal combiner is fabricated by fusion splicing between the fabricated TFB and output optical fiber with a numerical aperture of 0.15. The efficiency of each port of the fabricated 4 × 1 signal combiner is in the range of 93.3-98.3%. When an optical power of approximately 624.5 W was input to the signal combiner, the maximum output was ~612 W and the efficiency was ~98%. The beam quality factor, M 2is measured to be approximately 14.6, which is calculated as the beam parameter product (BPP) of 5.02 mm·mrad.
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http://dx.doi.org/10.1364/OE.26.030667DOI Listing
November 2018

Preliminary Findings on the Effectiveness of Meaning-Centered Psychotherapy in Patients with Pancreatobiliary Cancer.

Yonsei Med J 2018 Nov;59(9):1107-1114

Department of Surgery, Yonsei University College of Medicine, Seoul, Korea.

Purpose: This study investigated the effectiveness of meaning-centered psychotherapy (MCP), which is known to be a helpful psychotherapeutic intervention in distressing conditions, for patients with pancreatobiliary cancer.

Materials And Methods: We recruited 37 patients with pancreatobiliary cancer from three university general hospitals and assessed their psychological characteristics. Patients who reported clinically significant emotional distress were recommended to undergo MCP. Patients who consented to MCP were provided four sessions of the therapy. Patient psychological characteristics were assessed again 2 months after MCP. For statistical comparison, outcome variables included anxiety, depression, mental adjustment to cancer, and quality of life (QoL), as well as the degree of stress and physical symptoms.

Results: Sixteen patients completed the MCP and the final assessment 2 months later. In the initial assessment, the patients receiving MCP showed higher levels of anxiety and depression than those not receiving MCP, and QoL was also lower in terms of role function, emotional function, social function, and global QoL. At the 2-month follow-up, the MCP group showed a significant improvement in anxiety (=0.007), depression (=0.010), and anxious preoccupation (<0.001). In addition, QoL significantly improved in the MCP group, while there was no significant change in the non-MCP group.

Conclusion: In this study, MCP showed potential therapeutic benefits against emotional distress in patients with pancreatobiliary cancer, improving their QoL.
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http://dx.doi.org/10.3349/ymj.2018.59.9.1107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6192895PMC
November 2018

Evolution of the Konyang Standard Method for single incision laparoscopic cholecystectomy: the result from a thousand case of a single center experience.

Ann Surg Treat Res 2018 Aug 30;95(2):80-86. Epub 2018 Jul 30.

Department of Surgery, Konyang University Hospital, Daejeon, Korea.

Purpose: Single incision laparoscopic cholecystectomy (SILC) is increasingly performed worldwide. Accordingly, the Konyang Standard Method (KSM) for SILC has been developed over the past 6 years. We report the outcomes of our procedures.

Methods: Between April 2010 and December 2016, 1,005 patients underwent SILC at Konyang University Hospital. Initially 3-channel SILC with KSM was changed to 4-channel SILC using a modified technique with a snake retractor for exposure of Calot triangle; we called this a modified KSM (mKSM). Recently, we have used a commercial 4-channel (Glove) port for simplicity.

Results: SILC was performed in 323 patients with the KSM, in 645 with the mKSM, and in 37 with the commercial 4-channel port. Age was not significantly different between the 3 groups (P = 0.942). The postoperative hospital days (P = 0.051), operative time (P < 0.001) and intraoperative bleeding volume (P < 0.001) were significantly improved in the 3 groups. Drain insertion (P = 0.214), additional port insertion (P = 0.639), and postoperative complications (P = 0.608) were not significantly different in all groups. Postoperative complications were evaluated with the Clavien-Dindo classification. There were 3 cases (0.9%) over grade IIIb (bile duct injury, incisional hernia, duodenal perforation, or small bowel injury) with KSM and 3 (0.5%) with mKSM.

Conclusion: We evaluated the evolution of the KSM for SILC. The use of the mKSM with a commercial 4-channel port may be the safest and most effective method for SILC.
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http://dx.doi.org/10.4174/astr.2018.95.2.80DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6073040PMC
August 2018

Surgical Strategy for T2 Gallbladder Cancer: Nationwide Multicenter Survey in Korea.

J Korean Med Sci 2018 Jul 30;33(28):e186. Epub 2018 May 30.

Department of Surgery, Seoul National University College of Medicine, Seoul, Korea.

Background: Although all guidelines suggest that T2 gallbladder (GB) cancer should be treated by extended cholecystectomy (ECx), high-level scientific evidence is lacking because there has been no randomized controlled trial on GB cancer.

Methods: A nationwide multicenter study between 2000 and 2009 from 14 university hospitals enrolled a total of 410 patients with T2 GB cancer. The clinicopathologic findings and long-term follow-up results were analyzed after consensus meeting of Korean Pancreas Surgery Club.

Results: The 5-year cumulative survival rate (5YSR) for the patients who underwent curative resection was 61.2%. ECx group showed significantly better 5YSR than simple cholecystectomy (SCx) group (65.4% vs. 54.0%, = 0.016). For N0 patients, there was no significant difference in 5YSR between SCx and ECx groups (68.7% vs. 73.6%, = 0.173). Systemic recurrence was more common than locoregional recurrence (78.5% vs. 21.5%). Elevation of cancer antigen 19-9 level preoperatively and lymph node (LN) metastasis were significantly poor prognostic factors in a multivariate analysis.

Conclusion: ECx including wedge resection of GB bed should be recommended for T2 GB cancer. Because systemic recurrence was more common and recurrence occurred more frequently in patients with LN metastasis, postoperative adjuvant therapy should be considered especially for the patients with LN metastasis.
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http://dx.doi.org/10.3346/jkms.2018.33.e186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033102PMC
July 2018

Effect of remifentanil on pre-osteoclast cell differentiation in vitro.

J Dent Anesth Pain Med 2018 Feb 27;18(1):9-17. Epub 2018 Feb 27.

Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Republic of Korea.

Background: The structure and function of bone tissue is maintained through a constant remodeling process, which is maintained by the balance between osteoblasts and osteoclasts. The failure of bone remodeling can lead to pathological conditions of bone structure and function. Remifentanil is currently used as a narcotic analgesic agent in general anesthesia and sedation. However, the effect of remifentanil on osteoclasts has not been studied. Therefore, we investigated the effect of remifentanil on pre-osteoclast (pre-OCs) differentiation and the mechanism of osteoclast differentiation in the absence of specific stimulus.

Methods: Pre-OCs were obtained by culturing bone marrow-derived macrophages (BMMs) in osteoclastogenic medium for 2 days and then treated with various concentration of remifentanil. The mRNA expression of NFATc1 and c-fos was examined by using real-time PCR. We also examined the effect of remifentanil on the osteoclast-specific genes TRAP, cathepsin K, calcitonin receptor, and DC-STAMP. Finally, we examined the influence of remifentanil on the migration of pre-OCs by using the Boyden chamber assay.

Results: Remifentanil increased pre-OC differentiation and osteoclast size, but did not affect the mRNA expression of NFATc1 and c-fos or significantly affect the expression of TRAP, cathepsin K, calcitonin receptor, and DC-STAMP. However, remifentanil increased the migration of pre-OCs.

Conclusions: This study suggested that remifentanil promotes the differentiation of pre-OCs and induces maturation, such as increasing osteoclast size. In addition, the increase in osteoclast size was mediated by the enhancement of pre-OC migration and cell fusion.
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http://dx.doi.org/10.17245/jdapm.2018.18.1.9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858013PMC
February 2018

Highlights of the Third Expert Forum of Asia-Pacific Laparoscopic Hepatectomy; Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017.

Ann Hepatobiliary Pancreat Surg 2018 Feb 26;22(1):1-10. Epub 2018 Feb 26.

Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.

The application of laparoscopy for liver surgery is rapidly increasing and the past few years have demonstrated a shift in paradigm with a trend towards more extended and complex resections. The development of instruments and technical refinements with the effective use of magnified caudal laparoscopic views have contributed to the ability to overcome the limitation of laparoscopic liver resection. The Endoscopic and Laparoscopic Surgeons of Asia (ELSA) Visionary Summit 2017 and the 3 Expert Forum of Asia-Pacific Laparoscopic Hepatectomy organized hepatobiliary pancreatic sessions in order to exchange surgical tips and tricks and discuss the current status and future perspectives of laparoscopic hepatectomy. This report summarizes the oral presentations given at the 3 Expert Forum of Asia-Pacific Laparoscopic Hepatectomy.
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http://dx.doi.org/10.14701/ahbps.2018.22.1.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5845605PMC
February 2018

Tokyo Guidelines 2018: surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos).

J Hepatobiliary Pancreat Sci 2018 Jan 10;25(1):73-86. Epub 2018 Jan 10.

Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan.

In some cases, laparoscopic cholecystectomy (LC) may be difficult to perform in patients with acute cholecystitis (AC) with severe inflammation and fibrosis. The Tokyo Guidelines 2018 (TG18) expand the indications for LC under difficult conditions for each level of severity of AC. As a result of expanding the indications for LC to treat AC, it is absolutely necessary to avoid any increase in bile duct injury (BDI), particularly vasculo-biliary injury (VBI), which is known to occur at a certain rate in LC. Since the Tokyo Guidelines 2013 (TG13), an attempt has been made to assess intraoperative findings as objective indicators of surgical difficulty; based on expert consensus on these difficulty indicators, bail-out procedures (including conversion to open cholecystectomy) have been indicated for cases in which LC for AC is difficult to perform. A bail-out procedure should be chosen if, when the Calot's triangle is appropriately retracted and used as a landmark, a critical view of safety (CVS) cannot be achieved because of the presence of nondissectable scarring or severe fibrosis. We propose standardized safe steps for LC to treat AC. To achieve a CVS, it is vital to dissect at a location above (on the ventral side of) the imaginary line connecting the base of the left medial section (Segment 4) and the roof of Rouvière's sulcus and to fulfill the three criteria of CVS before dividing any structures. Achieving a CVS prevents the misidentification of the cystic duct and the common bile duct, which are most commonly confused. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.517DOI Listing
January 2018

Tokyo Guidelines 2018: management bundles for acute cholangitis and cholecystitis.

J Hepatobiliary Pancreat Sci 2018 Jan 16;25(1):96-100. Epub 2017 Dec 16.

Department of Surgical Oncology, Lilavati Hospital and Research Centre, Mumbai, India.

Management bundles that define items or procedures strongly recommended in clinical practice have been used in many guidelines in recent years. Application of these bundles facilitates the adaptation of guidelines and helps improve the prognosis of target diseases. In Tokyo Guidelines 2013 (TG13), we proposed management bundles for acute cholangitis and cholecystitis. Here, in Tokyo Guidelines 2018 (TG18), we redefine the management bundles for acute cholangitis and cholecystitis. Critical parts of the bundles in TG18 include the diagnostic process, severity assessment, transfer of patients if necessary, and therapeutic approach at each time point. Observance of these items and procedures should improve the prognosis of acute cholangitis and cholecystitis. Studies are now needed to evaluate the dissemination of these TG18 bundles and their effectiveness. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.519DOI Listing
January 2018

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis.

J Hepatobiliary Pancreat Sci 2018 Jan 9;25(1):3-16. Epub 2018 Jan 9.

Department of Surgery, Hospital Italiano, University of Buenos Aires, Buenos Aires, Argentina.

Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.518DOI Listing
January 2018

Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis.

J Hepatobiliary Pancreat Sci 2018 Jan 20;25(1):55-72. Epub 2017 Dec 20.

Director, Mie Prefectural Ichishi Hospital, Mie, Japan.

We propose a new flowchart for the treatment of acute cholecystitis (AC) in the Tokyo Guidelines 2018 (TG18). Grade III AC was not indicated for straightforward laparoscopic cholecystectomy (Lap-C). Following analysis of subsequent clinical investigations and drawing on Big Data in particular, TG18 proposes that some Grade III AC can be treated by Lap-C when performed at advanced centers with specialized surgeons experienced in this procedure and for patients that satisfy certain strict criteria. For Grade I, TG18 recommends early Lap-C if the patients meet the criteria of Charlson comorbidity index (CCI) ≤5 and American Society of Anesthesiologists physical status classification (ASA-PS) ≤2. For Grade II AC, if patients meet the criteria of CCI ≤5 and ASA-PS ≤2, TG18 recommends early Lap-C performed by experienced surgeons; and if not, after medical treatment and/or gallbladder drainage, Lap-C would be indicated. TG18 proposes that Lap-C is indicated in Grade III patients with strict criteria. These are that the patients have favorable organ system failure, and negative predictive factors, who meet the criteria of CCI ≤3 and ASA-PS ≤2 and who are being treated at an advanced center (where experienced surgeons practice). If the patient is not considered suitable for early surgery, TG18 recommends early/urgent biliary drainage followed by delayed Lap-C once the patient's overall condition has improved. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.516DOI Listing
January 2018

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholecystitis (with videos).

J Hepatobiliary Pancreat Sci 2018 Jan 9;25(1):41-54. Epub 2018 Jan 9.

Mt Elizabeth Novena Hospital, Singapore Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.

The Tokyo Guidelines 2013 (TG13) for acute cholangitis and cholecystitis were globally disseminated and various clinical studies about the management of acute cholecystitis were reported by many researchers and clinicians from all over the world. The 1 edition of the Tokyo Guidelines 2007 (TG07) was revised in 2013. According to that revision, the TG13 diagnostic criteria of acute cholecystitis provided better specificity and higher diagnostic accuracy. Thorough our literature search about diagnostic criteria for acute cholecystitis, new and strong evidence that had been released from 2013 to 2017 was not found with serious and important issues about using TG13 diagnostic criteria of acute cholecystitis. On the other hand, the TG13 severity grading for acute cholecystitis has been validated in numerous studies. As a result of these reviews, the TG13 severity grading for acute cholecystitis was significantly associated with parameters including 30-day overall mortality, length of hospital stay, conversion rates to open surgery, and medical costs. In terms of severity assessment, breakthrough and intensive literature for revising severity grading was not reported. Consequently, TG13 diagnostic criteria and severity grading were judged from numerous validation studies as useful indicators in clinical practice and adopted as TG18/TG13 diagnostic criteria and severity grading of acute cholecystitis without any modification. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.515DOI Listing
January 2018

Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos).

J Hepatobiliary Pancreat Sci 2018 Jan 5;25(1):17-30. Epub 2018 Jan 5.

Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan.

Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large-scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30-day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30-day mortality among patients with Grade I or Grade III AC, but significantly lower 30-day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.512DOI Listing
January 2018

Tokyo Guidelines 2018: management strategies for gallbladder drainage in patients with acute cholecystitis (with videos).

J Hepatobiliary Pancreat Sci 2018 Jan 21;25(1):87-95. Epub 2017 Nov 21.

Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan.

Since the publication of the Tokyo Guidelines in 2007 and their revision in 2013, appropriate management for acute cholecystitis has been more clearly established. Since the last revision, several manuscripts, especially for alternative endoscopic techniques, have been reported; therefore, additional evaluation and refinement of the 2013 Guidelines is required. We describe a standard drainage method for surgically high-risk patients with acute cholecystitis and the latest developed endoscopic gallbladder drainage techniques described in the updated Tokyo Guidelines 2018 (TG18). Our study confirmed that percutaneous transhepatic gallbladder drainage should be considered the first alternative to surgical intervention in surgically high-risk patients with acute cholecystitis. Also, endoscopic transpapillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage can be considered in high-volume institutes by skilled endoscopists. In the endoscopic transpapillary approach, either endoscopic naso-gallbladder drainage or gallbladder stenting can be considered for gallbladder drainage. We also introduce special techniques and the latest outcomes of endoscopic ultrasound-guided gallbladder drainage studies. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.
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http://dx.doi.org/10.1002/jhbp.504DOI Listing
January 2018

Delphi consensus on bile duct injuries during laparoscopic cholecystectomy: an evolutionary cul-de-sac or the birth pangs of a new technical framework?

J Hepatobiliary Pancreat Sci 2017 Nov 23;24(11):591-602. Epub 2017 Oct 23.

Surgical Gastroenterology/Hepatopancreatobiliary Unit, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.

Bile duct injury (BDI) during laparoscopic cholecystectomy remains a serious iatrogenic surgical complication. BDI most often occurs as a result of misidentification of the anatomy; however, clinical evidence on its precise mechanism and surgeons' perceptions is scarce. Surgeons from Japan, Korea, Taiwan, and the USA, etc. (n = 614) participated in a questionnaire regarding their BDI experience and near-misses; and perceptions on landmarks, intraoperative findings, and surgical techniques. Respondents voted for a Delphi process and graded each item on a five-point scale. The consensus was built when ≥80% of overall responses were 4 or 5. Response rates for the first- and second-round Delphi were 60.6% and 74.9%, respectively. Misidentification of local anatomy accounted for 76.2% of BDI. Final consensus was reached on: (1) Effective retraction of the gallbladder, (2) Always obtaining critical view of safety, and (3) Avoiding excessive use of electrocautery/clipping as vital procedures; and (4) Calot's triangle area and (5) Critical view of safety as important landmarks. For (6) Impacted gallstone and (7) Severe fibrosis/scarring in Calot's triangle, bail-out procedures may be indicated. A consensus was reached among expert surgeons on relevant landmarks and intraoperative findings and appropriate surgical techniques to avoid BDI.
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http://dx.doi.org/10.1002/jhbp.503DOI Listing
November 2017

An opportunity in difficulty: Japan-Korea-Taiwan expert Delphi consensus on surgical difficulty during laparoscopic cholecystectomy.

J Hepatobiliary Pancreat Sci 2017 Apr 19;24(4):191-198. Epub 2017 Mar 19.

Division of General Surgery, Lin-Kou Chang Gung Memorial Hospital, Tauyuan, Taiwan.

Background: We previously identified 25 intraoperative findings during laparoscopic cholecystectomy (LC) as potential indicators of surgical difficulty per nominal group technique. This study aimed to build a consensus among expert LC surgeons on the impact of each item on surgical difficulty.

Methods: Surgeons from Japan, Korea, and Taiwan (n = 554) participated in a Delphi process and graded the 25 items on a seven-stage scale (range, 0-6). Consensus was defined as (1) the interquartile range (IQR) of overall responses ≤2 and (2) ≥66% of the responses concentrated within a median ± 1 after stratification by workplace and LC experience level.

Results: Response rates for the first and the second-round Delphi were 92.6% and 90.3%, respectively. Final consensus was reached for all the 25 items. 'Diffuse scarring in the Calot's triangle area' in the 'Factors related to inflammation of the gallbladder' category had the strongest impact on surgical difficulty (median, 5; IQR, 1). Surgeons agreed that the surgical difficulty increases as more fibrotic change and scarring develop. The median point for each item was set as the difficulty score.

Conclusions: A Delphi consensus was reached among expert LC surgeons on the impact of intraoperative findings on surgical difficulty.
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http://dx.doi.org/10.1002/jhbp.440DOI Listing
April 2017

The "right" way is not always popular: comparison of surgeons' perceptions during laparoscopic cholecystectomy for acute cholecystitis among experts from Japan, Korea and Taiwan.

J Hepatobiliary Pancreat Sci 2017 Jan 22;24(1):24-32. Epub 2017 Jan 22.

Division of General Surgery, Lin-Kou Chang Gung Memorial Hospital, Tauyuan, Taiwan.

Background: Generally, surgeons' perceptions of surgical safety are based on experience and institutional policy. Our recent pilot survey demonstrated that the acceptable duration of surgery and criteria for open conversion during laparoscopic cholecystectomy (LC) vary among workplaces.

Methods: A web-based survey was distributed to 554 expert LC surgeons in Japan, Korea, and Taiwan. The questionnaire covered LC experience, safety measures and recognition of landmarks, decision-making regarding conversion to open/partial cholecystectomy and the implications of this decision. Overall responses were compared among nations, and then stratified by LC experience level (lifetime cases 200-499, 500-999, and ≥1,000).

Results: The response rate was 92.6% (513/554); 67 surgeons with ≤199 LCs were excluded, and responses from 446 surgeons were analyzed. We observed significant differences among nations on almost all questions. Differences that remained after stratification by LC experience were on questions related to acceptable duration of surgery, adoption rates of intraoperative cholangiography, the "critical view of safety" technique, identification of Rouvière's sulcus, recognition of the SS-Inner layer theory, and intraoperative judgment to abandon conventional LC.

Conclusions: Even among experts, surgeons' perceptions during LC are workplace-dependent. A novel grading system of surgical difficulty and standardized LC procedures are paramount to generate high-level evidence.
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http://dx.doi.org/10.1002/jhbp.417DOI Listing
January 2017

What are the appropriate indicators of surgical difficulty during laparoscopic cholecystectomy? Results from a Japan-Korea-Taiwan multinational survey.

J Hepatobiliary Pancreat Sci 2016 Sep 5;23(9):533-47. Epub 2016 Sep 5.

Division of General Surgery, Lin-Kou Chang Gung Memorial Hospital, Taoyuan, Taiwan.

Background: Serious complications continue to occur in laparoscopic cholecystectomy (LC). The commonly used indicators of surgical difficulty such as the duration of surgery are insufficient because they are surgeon and institution dependent. We aimed to identify appropriate indicators of surgical difficulty during LC.

Methods: A total of 26 Japanese expert LC surgeons discussed using the nominal group technique (NGT) to generate a list of intraoperative findings that contribute to surgical difficulty. Thereafter, a survey was circulated to 61 experts in Japan, Korea, and Taiwan. The questionnaire addressed LC experience, surgical strategy, and perceptions of 30 intraoperative findings listed by the NGT.

Results: The response rate of the survey was 100%. There was a statistically significant difference among nations regarding the duration of surgery and adoption rate of safety measures and recognition of landmarks. The criteria for conversion to an open or subtotal cholecystectomy were at the discretion of each surgeon. In contrast, perceptions of the impact of 30 intraoperative findings on surgical difficulty (categorized by factors related to inflammation and additional findings of the gallbladder and other intra-abdominal factors) were consistent among surgeons.

Conclusions: Intraoperative findings are objective and considered to be appropriate indicators of surgical difficulty during LC.
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http://dx.doi.org/10.1002/jhbp.375DOI Listing
September 2016

Risk factors for conversion to conventional laparoscopic cholecystectomy in single incision laparoscopic cholecystectomy.

Ann Surg Treat Res 2016 Jun 30;90(6):303-8. Epub 2016 May 30.

Department of Surgery, Konyang University Hospital, Daejeon, Korea.

Purpose: The aim of this study was to investigate the risk factors for conversion to conventional laparoscopic cholecystectomy (CLC) in single incision laparoscopic cholecystectomy (SILC) along with the proposal for procedure selection guidelines in treating patients with benign gallbladder (GB) diseases.

Methods: SILC was performed in 697 cases between April 2010 and July 2014. Seventeen cases (2.4%) underwent conversion to conventional LC. We compared these 2 groups and analyzed the risk factors for conversion to CLC.

Results: In univariate analysis, American Society of Anesthesiologist score > 3, preoperative percutaneous transhepatic GB drainage status and pathology (acute cholecystitis or GB empyema) were significant risk factors for conversion (P = 0.010, P = 0.019 and P < 0.001). In multivariate analysis, pathology (acute cholecystitis or GB empyema) was significant risk factors for conversion to CLC in SILC (P < 0.001).

Conclusion: Although SILC is a feasible method for most patients with benign GB disease, CLC has to be considered in patients with acute cholecystitis or GB empyema because it is likely to result in inadequate visualization of the Calot's triangle and greater bleeding risk.
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http://dx.doi.org/10.4174/astr.2016.90.6.303DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4891520PMC
June 2016

Effects of propofol-induced autophagy against oxidative stress in human osteoblasts.

J Dent Anesth Pain Med 2016 Mar 31;16(1):39-47. Epub 2016 Mar 31.

Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Gyeongnam, Korea.

Background: Oxidative stress occurs during the aging process and other conditions such as bone fracture, bone diseases, and osteoporosis, but the role of oxidative stress in bone remodeling is unknown. Propofol exerts antioxidant effects, but the mechanisms of propofol preconditioning on oxidative stress have not been fully explained. Therefore, the aim of this study was to evaluate the protective effects of propofol against HO-induced oxidative stress on a human fetal osteoblast (hFOB) cell line via activation of autophagy.

Methods: Cells were randomly divided into the following groups: control cells were incubated in normoxia (5% CO, 21% O, and 74% N) without propofol. Hydrogen peroxide (HO) group cells were exposed to HO (200 µM) for 2 h, propofol preconditioning (PPC)/HO group cells were pretreated with propofol then exposed to HO, 3-methyladenine (3-MA)/PPC/HO cells were pretreated with 3-MA (1 mM) and propofol, then were exposed to HO. Cell viability and apoptosis were evaluated. Osteoblast maturation was determined by assaying bone nodular mineralization. Expression levels of bone related proteins were determined by western blot.

Results: Cell viability and bone nodular mineralization were decreased significantly by HO, and this effect was rescued by propofol preconditioning. Propofol preconditioning effectively decreased HO-induced hFOB cell apoptosis. However, pretreatment with 3-MA inhibited the protective effect of propofol. In western blot analysis, propofol preconditioning increased protein levels of collagen type I, BMP-2, osterix, and TGF-β1.

Conclusions: This study suggests that propofol preconditioning has a protective effect on HO-induced hFOB cell death, which is mediated by autophagy activation.
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http://dx.doi.org/10.17245/jdapm.2016.16.1.39DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5564117PMC
March 2016

Risk factors for prolonged operative time in single-incision laparoscopic cholecystectomy.

Ann Surg Treat Res 2015 Nov 28;89(5):247-53. Epub 2015 Oct 28.

Department of Surgery, Konyang University Hospital, Konyang University School of Medicine, Daejeon, Korea.

Purpose: We performed 3-channel single incision laparoscopic cholecystectomy (SILC) in earlier period of this study and modified our method to 4-channel SILC using a snake retractor for better operative field in later period. This study has been designed to evaluate the risk factors for prolonged operative time in SILC.

Methods: From April 2010 to August 2014, 323 cases of 3-channel SILC (Konyang standard method [KSM] group) and 399 cases of 4-channel SILC (modified KSM [mKSM] group) using a snake retractor were performed.

Results: The clinical characteristics were not significantly different between KSM and mKSM group except preoperative percutaneous transhepatic gallbladder drainage (PTGBD) treatment (9.6% vs. 16.5%, P < 0.007). The mean operation time was longer in mKSM group than KSM group (55.8 ± 19.7 minutes vs. 51.7 ± 20.1 minutes, P = 0.006). The estimated blood loss of KSM group was more than mKSM group (24.6 ± 54.1 mL vs. 16.9 ± 27.0 mL, P = 0.013). According to the histopathologic findings, acute cholecystitis or empyema were confirmed more in mKSM group as compared with KSM group (28% vs. 14.0%, P = 0.025). In multivariate analysis, the risk factors for prolonged operation time were drainage insertion, histopathologic findings (acute cholecystitis or empyema), surgeons' technical expertise, body mass index > 30 kg/m(2) as well as the 4-channel SILC.

Conclusion: Among patients with these risk factors, conventional laparoscopic cholecystectomy could be considered as well although SILC might be safe and feasible modality for benign gallbladder disease.
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http://dx.doi.org/10.4174/astr.2015.89.5.247DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4644905PMC
November 2015

Feasibility of implementing a surgical student internship program in South Korea.

Ann Surg Treat Res 2015 Apr 26;88(4):181-6. Epub 2015 Mar 26.

Department of Surgery, Hanyang University College of Medicine, Seoul, Korea.

Purpose: Despite recommendations for introducing student internships (SI) in undergraduate medical education in Korea, the feasibility of surgical SIs has not been demonstrated in the Korean context. We thus identified tasks that could be performed by surgical student interns in a Korean education hospital.

Methods: The opinions of surgery clerkship directors of medical schools nationwide, regarding the tasks, symptoms and signs, disease entities, and procedures that student interns could perform in their hospitals, were subjected to descriptive analysis.

Results: Out of the 41 medical schools in Korea, 32 responded. Five implemented an optimal-quality SI program. Two schools considered third-year clerkship as SI. The respondents replied that student interns could be involved in basic nonspecific tasks such as history taking, physical examination, medial recording, reporting patients' status, and assisting during surgery. However, more surgery-specific tasks such as perioperative management or caring for a patient with acute abdominal pain were considered difficult for student interns to encounter in the Korean context.

Conclusion: Surgical educators should determine a specific role for student interns and encourage them to perform surgery-specific tasks. We recommend societal and system support, and curriculum renovation to establish an SI program in Korea.
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http://dx.doi.org/10.4174/astr.2015.88.4.181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4384287PMC
April 2015

Acute mediastinitis arising from pancreatic mediastinal fistula in recurrent pancreatitis.

World J Gastroenterol 2014 Oct;20(40):14997-5000

In Soo Choe, Yong Seok Kim, Tae Hee Lee, Sun Moon Kim, Kyung Ho Song, Hoon Sup Koo, Jung Ho Park, Jin Sil Pyo, Ji Yeong Kim, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Konyang University College of Medicine, Daejeon 302-718, South Korea.

Acute mediastinitis is a fatal disease that usually originates from esophageal perforation and surgical infection. Rare cases of descending necrotizing mediastinitis can occur following oral cavity and pharynx infection or can be a complication of pancreatitis. The most common thoracic complications of pancreatic disease are reactive pleural effusion and pneumonia, while rare complications include thoracic conditions, such as pancreaticopleural fistula with massive pleural effusion or hemothorax and extension of pseudocyst into the mediastinum. There have been no reports of acute mediastinitis originating from pancreatitis in South Korea. In this report, we present the case of a 50-year-old female suffering from acute mediastinitis with pleural effusion arising from recurrent pancreatitis that improved after surgical intervention.
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http://dx.doi.org/10.3748/wjg.v20.i40.14997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4209565PMC
October 2014

Four-channel single incision laparoscopic cholecystectomy using a snake retractor: comparison between 3- and 4-channel SILC 4-channel single incision cholecystectomy.

Ann Surg Treat Res 2014 Aug 29;87(2):81-6. Epub 2014 Jul 29.

Department of Surgery, Konyang University Hospital, Konyang University College of Medicine, Daejeon, Korea.

Purpose: Single incision laparoscopic cholecystectomy (SILC) is a widely used method of performing cholecystectomy. A common technique used in SILC is a 3-channel method. However, exposure of Calot's triangle is limited in conventional 3-channel SILC. Therefore, we herein report the adequacy and feasibility of 4-channel SILC using a snake retractor.

Methods: Four hundred and fifteen SILC cases were performed between April 2010 and February 2013. We performed 326 SILC cases between April 2010 and September 2012 using the 3-channel method. We introduced a snake retractor for liver traction in October 2012, and 89 cases of 4-channel SILC using snake retractor have been performed since.

Results: Thirty patients (9.2%) in the 3-channel SILC group, and 23 patients (25.8%) in the 4-channel SILC group, were treated with percutaneous transhepatic gallbladder drainage insertion because of acute inflammation of the gallbladder (GB) before operation (P < 0.001). The mean operating time was 53.0 ± 25.8 minutes in the 3-channel SILC group and 51.9 ± 18.6 minutes in the 4-channel SILC group (P = 0.709). In the 3-channel SILC group, mean hospital stay was 3.0 ± 3.3 days whereas it was 2.6 ± 0.9 days in the 4-channel SILC group (P = 0.043). There were a total 9 cases (2.1%) of additional port usages, 6 cases (1.8%) in the 3-channel SILC group and 3 cases (3.4%) in the 4-channel SILC group (P = 0.411), due to cystic artery bleeding and bile leakage from gallbladder bed, but there were no open conversions.

Conclusion: Benign diseases of the GB can be operated on using SILC with the 4-channel method using a snake retractor.
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http://dx.doi.org/10.4174/astr.2014.87.2.81DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4127901PMC
August 2014

Effects of laparoscopic versus open surgery on splenic vessel patency after spleen and splenic vessel-preserving distal pancreatectomy: a retrospective multicenter study.

Surg Endosc 2015 Mar 9;29(3):583-8. Epub 2014 Jul 9.

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 166 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea,

Background: The aims of this study were to compare splenic vessel patency between laparoscopic and open spleen and splenic vessel-preserving distal pancreatectomy (SSVpDP), and to identify possible risk factors for poor splenic vessel patency.

Methods: This retrospective multicenter study included 116 patients who underwent laparoscopic (n = 70) or open (n = 46) SSVpDP at seven Korean tertiary medical institutions between 2004 and 2011. Clinical parameters and the splenic vessel patency assessed by abdominal computed tomography were compared between the two surgical procedures.

Results: The clinical parameters were not significantly different between both groups, except for postoperative hospital stay, which was significantly shorter in the laparoscopic group (10.4 vs. 13.5 days, P = 0.024). The splenic artery patency rate was similar in both groups (90.0 vs. 97.8 %), but the splenic vein patency rate was significantly lower in the laparoscopic group (64.3 vs. 87.0 %, P = 0.022). Univariate and multivariate analyses revealed surgical procedure [odds ratio (OR) 3.085, P = 0.043] and intraoperative blood loss (OR 4.624, P = 0.002) as independent risk factors for compromised splenic vein patency (partial or total occlusion). The splenic vein patency rate was significantly better in the late group (n = 34) than in the early period (n = 35) (79.4 vs. 48.6 %, P = 0.008).

Conclusions: Although laparoscopic SSVpDP had an advantage of shorter hospital stay compared with open surgery, it was associated with greater risk of poor splenic vein patency. However, this risk could decrease with increasing surgical experience and with efforts to minimize blood loss.
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http://dx.doi.org/10.1007/s00464-014-3701-9DOI Listing
March 2015
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