Publications by authors named "Jae Yool Jang"

26 Publications

  • Page 1 of 1

Nrf2 induces Ucp1 expression in adipocytes in response to β3-AR stimulation and enhances oxygen consumption in high-fat diet-fed obese mice.

BMB Rep 2021 Mar 11. Epub 2021 Mar 11.

Department of Food Science and Biotechnology, Sungkyunkwan University, Suwon 16419, Republic of Korea.

Cold-induced norepinephrine activates β3-adrenergic receptors (β3-AR) to stimulate the kinase cascade and cAMP-response element-binding protein, leading to the induction of thermogenic gene expression including uncoupling protein 1 (Ucp1). Here, we showed that stimulation of the β3-AR by its agonists isoproterenol and CL316,243 in adipocytes increased the expression of Ucp1 and Heme Oxygenase 1 (Hmox1), the principal Nrf2 target gene, suggesting the functional interaction of Nrf2 with β3-AR signaling. The activation of Nrf2 by tert-butylhydroquinone and reactive oxygen species (ROS) production by glucose oxidase induced both Ucp1 and Hmox1 expression. The increased expression of Ucp1 and Hmox1 was significantly reduced in the presence of a Nrf2 chemical inhibitor or in Nrf2-deleted (knockout) adipocytes. Furthermore, Nrf2 directly activated the Ucp1 promoter, and this required DNA regions located at -3.7 and -2.0 kb of the transcription start site. The CL316,243-induced Ucp1 expression in adipocytes and oxygen consumption in obese mice were partly compromised in the absence of Nrf2 expression. These data provide additional insight into the role of Nrf2 in β3-AR-mediated Ucp1 expression and energy expenditure, further highlighting the utility of Nrf2-mediated thermogenic stimulation as a therapeutic approach to diet-induced obesity.
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March 2021

Bilateral cervical chondrocutaneous branchial remnants: A case report and a review of the literature.

Medicine (Baltimore) 2020 Jul;99(28):e21114

Department of Surgery.

Rationale: Cervical chondrocutaneous branchial remnants are rare, benign, congenital anomalies, frequently seen bilaterally.

Patient Concerns: Here, we report the case of a 4-month-old female infant who presented with bilateral lower neck skin tag since birth.

Diagnosis And Interventions: The patient underwent mass excision. The final pathological diagnosis was bilateral cervical chondrocutaneous branchial remnants with hyaline cartilage.

Outcomes: No complications were observed after excision. One-year follow-up revealed no recurrence.

Lessons: Bilateral chondrocutaneous branchial remnants are rare anomalies. They are often associated with cardiac or genitourinary abnormalities. Therefore, additional preoperative imaging of the abdomen and heart are recommended.
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http://dx.doi.org/10.1097/MD.0000000000021114DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360197PMC
July 2020

Clinical implication of tumor site in terms of node metastasis for intrahepatic cholangiocarcinoma.

Eur J Surg Oncol 2020 05 28;46(5):832-838. Epub 2019 Nov 28.

Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University, College of Medicine, Jinju, Republic of Korea. Electronic address:

Background: The clinical implication of lymph node (LN) dissection of intrahepatic cholangiocarcinoma (ICCA) is still controversial, and LN metastasis (LNM) based on tumor site has not been confirmed yet.

Methods: Patients who underwent curative-intent surgery at 10 tertiary referral centers were identified and divided into peripheral (PP) and near second confluence level tumor (NC) groups on the basis of the distance from the second confluence and oncological outcomes were compared.

Results: Of 179 patients, 121 patients with LND were divided into the NC (n = 89) and PP groups (n = 32) on the basis of 4.5 cm from the second confluence. NC group showed higher LNM rate than PP group (46.1 vs 21.9%, p = 0.016) and NC was a risk factor for LNM (odds ratio: 4.367; 95% confidence interval: 1.234-15.453, p = 0.022). The 5-year overall survival (OS) rate (38.0% vs. 27.8%, p = 0.777) and recurrence-free survival (RFS) rates (22.8% vs. 25.8%, p = 0.742) showed no differences between the PP and NC groups. In the NC group, N1 patients showed worse 5-year OS (12.7% vs 39.0%, p = 0.004) and RFS (8.8% vs 28.6%, p = 0.004) than the N0 patients. In the PP group, discordant results in 5-year OS (48.9% vs. 50.0%, p = 0.462) and RFS (41.3% vs. 0%, p = 0.056) were found between the N0 and N1 patients.

Conclusion: The NC group was an independent risk factor for LNM and LNM worsened prognosis in NC group for ICCA. In the PP group, LND should not be omitted because of high LNM rate and insufficient oncologic evidence.
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http://dx.doi.org/10.1016/j.ejso.2019.11.511DOI Listing
May 2020

Does surgical difficulty relate to severity of acute cholecystitis? Validation of the parkland grading scale based on intraoperative findings.

Am J Surg 2020 04 8;219(4):637-641. Epub 2018 Dec 8.

Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University Postgraduate School of Medicine, Republic of Korea. Electronic address:

Background: The Parkland grading scale (PGS) was assessed to validate its correlation to severity of acute cholecystitis (AC).

Methods: This study investigated the correlation between the PGS and Tokyo guidelines (TG) using multinomial logistic regression analysis in 177 patients with AC.

Results: High PGS grades were related to higher C-reactive protein (p < 0.001) and frequent gangrenous cholecystitis (p < 0.001). The PGS and TG grades correlated with statistical significance (p < 0.001). Patients with PGS Grade 4 had a higher risk of moderate AC than those with Grade 3 (odds ratio: 4.4; 95% confidence interval [CI]: 1.2-15.6; p = 0.019). The PGS showed good predictive power for moderate or severe AC (area under the curve: 0.771; 95% CI: 0.700-0.842; p = 0.031).

Conclusion: The PGS is helpful to discriminate severity of AC. Patients with PGS Grade 4 or 5 have a high risk of moderate or severe AC.
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http://dx.doi.org/10.1016/j.amjsurg.2018.12.005DOI Listing
April 2020

Comparing the surgical outcomes of stapled anastomosis versus hand-sewn anastomosis of duodenojejunostomy in pylorus-preserving pancreaticoduodenectomy.

Ann Hepatobiliary Pancreat Surg 2019 Aug 30;23(3):245-251. Epub 2019 Aug 30.

Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Korea.

Backgrounds/aims: This study is to evaluate the perioperative outcomes of the duodenojejunostomy (DJ) procedure in pylorus preserving pancreaticoduodenectomy (PPPD).

Methods: In this study, as noted between 2010 and 2018, there were 77 PPPDs which were performed at our hospital by one surgeon. We began the circular stapled method from 2014, and continue with this procedure for the aforementioned surgeries including and up to today. The clinical data for the study were collected retrospectively to compare clinical outcomes of the two methods, the circular stapled anastomosis and the hand - sewn anastomosis.

Results: There were 34 patients in a circular stapled group, and 43 in a hand-sewn group as identified for this study. The delayed gastric emptying (DGE) occurred in 6 (17.64%) patients in the circular stapled group, and 10 (23.3%) in the hand-sewn group (=0.547). It is noted that there was a serum albumin level measured on the 14th day after the operation, which was significantly high in the circular stapled group (3.41±0.47 (g/dl) vs 2.92±0.39 (g/dl), <0.001). There were no significant differences in terms of the incidence of postoperative complications (58.8% vs 58.1%, =0.952) and mortality rates (5.9% vs 0, =0.192) among the patient participants in this study.

Conclusions: We conclude that using a circular stapler for the DJ procedure in PPPDs do not increase the development of a DGE, and is also helpful for the benefit of the patient's nutritional status going forward during recovery from the operation.
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http://dx.doi.org/10.14701/ahbps.2019.23.3.245DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6728254PMC
August 2019

Laparoscopic segmentectomy using ultrasound probe compression of hepatic vessel.

Asian J Endosc Surg 2020 Jul 5;13(3):423-425. Epub 2019 Sep 5.

Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University Postgraduate School of Medicine, Jinju, South Korea.

Although open liver resection using ultrasound (US) probe compression of the hepatic vessel has been reported, laparoscopic liver resection using the same method has not yet been reported. Magnetic resonance imaging of a 55-year-old man with hepatitis B-related liver cirrhosis revealed a 2.5 cm liver mass in segment VI. He underwent laparoscopic segmentectomy. After right liver mobilization, the subglissonean pedicle of segment VI was identified and it was compressed with laparoscopic US probe with confirmation using Doppler US. The liver parenchyma was transected with a Cavitron ultrasonic surgical aspirator and advanced bipolar system along the ischemic line. The patient was discharged 9 days after surgery without complications. Laparoscopic segmentectomy using laparoscopic US probe compression has advantages including preservation of the hepatic parenchyma and prevention of injury to the adjacent Glissonean pedicle.
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http://dx.doi.org/10.1111/ases.12738DOI Listing
July 2020

Retrospective comparison of outcomes of laparoscopic and open surgery for T2 gallbladder cancer - Thirteen-year experience.

Surg Oncol 2019 Jun 13;29:142-147. Epub 2019 May 13.

Department of Surgery, Seoul National University College of Medicine, Department of Surgery, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea.

Background: The objective of this retrospective study is to compare the outcomes of laparoscopic and open surgery for T2 gallbladder cancer (GBC) performed at our hospital for last 13 years.

Methods: Of 247 GBC patients who were treated at our hospital between Apr 2004 and Apr 2017, 151 patients with pathologic stage T2 were reviewed. Patients were divided into laparoscopic surgery group (LS group) and open (OS group). Medical recordings were reviewed to check perioperative outcomes, overall survival rates, and disease free survival rates.

Results: Fifty-five patients in LS group and 44 in OS met the inclusion criteria. Incidences of postoperative complication were similar between two groups (12.7% vs 13.6%, p = 1.000). Average postoperative hospital stay was significantly shorter in LS group (5.8 vs 9.5 days, p < 0.001). LS group showed significantly higher disease free survival rate (p = 0.0171). There was no significant difference in terms of disease free survival between T2N0 (p = 0.107) and T2N1 patients (p = 0.969) of LS group and OS group. In terms of overall survival rate there was no significant difference (p = 0.116). Overall survival rate was also not significantly different between T2N0 (p = 0.0941) and T2N1 (p = 0.579) patients of LS group and OS group.

Conclusions: Laparoscopic approach for treatment of T2 GBC was comparable to open approach in terms of disease free survival, overall survival and complication rate. Further prospective study with higher number of patients should be done to confirm this result in the future.
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http://dx.doi.org/10.1016/j.suronc.2019.05.007DOI Listing
June 2019

Validation of the oncologic effect of hepatic resection for T2 gallbladder cancer: a retrospective study.

World J Surg Oncol 2019 Jan 7;17(1). Epub 2019 Jan 7.

Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University Postgraduate School of Medicine, 79, Gangnam-ro, Jinju, 660-702, South Korea.

Background: While extended cholecystectomy is recommended for T2 gallbladder cancer (GBC), the role of hepatic resection for T2 GBC is unclear. This study aimed to identify the necessity of hepatic resection in patients with T2 GBC.

Methods: Data of 81 patients with histopathologically proven T2 GBC who underwent surgical resection between January 1999 and December 2017 were enrolled from a retrospective database. Of these, 36 patients had peritoneal-side (T2a) tumors and 45 had hepatic-side (T2b) tumors. To identify the optimal surgical management method, T2 GBC patients were classified into the hepatic resection group (n = 44, T2a/T2b = 20/24) and non-hepatic resection group (n = 37, T2a/T2b = 16/21). The recurrence pattern and role of hepatic resection for T2 GBC were then investigated.

Results: Mean age of the patients was 69 (range 36-88) years, and the male-to-female ratio was 42:39 (male, 51.9%; female, 48.1%). Hepatic-side GBC had a higher rate of recurrence than peritoneal-side GBC (44.4% vs. 8.3%, p = 0.006). The most common type of recurrence in T2a GBC was para-aortic lymph node recurrence (n = 2, 5.6%); the most common types of recurrence in T2b GBC were para-aortic lymph node recurrence (n = 7, 15.6%) and intrahepatic metastasis (n = 6, 13.3%). Hepatic-side GBC patients had worse survival outcomes than peritoneal-side GBC patients (76.0% vs. 96.6%, p = 0.041). Hepatic resection had no significant treatment effect in T2 GBC patients (p = 0.272). Multivariate analysis showed that lymph node metastasis was the only significant prognostic factor (p = 0.002).

Conclusions: Hepatic resection is not essential for curative treatment in T2 GBC, and more systemic treatments are needed for GBC patients, particularly for those with T2b GBC.
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http://dx.doi.org/10.1186/s12957-018-1556-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6323785PMC
January 2019

Simultaneous osteosarcoma and adenocarcinoma of the gallbladder: A rare case report and literature review.

Turk J Gastroenterol 2019 Jun;30(6):569-572

Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Republic of Korea.

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http://dx.doi.org/10.5152/tjg.2018.18203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6565350PMC
June 2019

Three-Port Laparoscopic Right Colectomy Versus Conventional Five-Port Laparoscopy for Right-Sided Colon Cancer.

J Laparoendosc Adv Surg Tech A 2019 Apr 8;29(4):465-470. Epub 2018 Nov 8.

1 Department of General Surgery, Gyeongsang National University Hospital, Gyeongsang National University School of Medicine, Jinju, Republic of Korea.

Background: The purpose of the study was to evaluate the safety and effectiveness of three-port laparoscopic right colectomy (3-LRC) for right-sided colon cancer compared with conventional five-port laparoscopic right colectomy (5-LRC).

Materials And Methods: One hundred sixty-three patients diagnosed with right-sided colon adenocarcinoma underwent laparoscopic right colectomy (LRC) between April 2011 and December 2017. Seventy-four of these patients underwent 3-LRC procedure and 89 patients underwent 5-LRC. Clinical characteristics, perioperative short-term outcomes, and pathologic data were analyzed.

Results: There were no differences in TNM stage, tumor location, estimated blood loss, complications, and open conversion rates. The operation time was shorter in the 3-LRC group than in 5-LRC group (140.9 ± 27.5 minutes versus 178.2 ± 38.2 minutes; P = .001). The number of harvested lymph nodes (28.5 ± 13.9 versus 22.6 ± 11.7; P = .004) was also higher in the 3-LRC group. The first passage of flatus and first oral diet were significantly faster in the 3-LRC group than in the 5-LRC group (2.8 ± 1.0 days versus 4.0 ± 1.2 days; P = .001, 3.6 ± 2.9 days versus 5.0 ± 1.5 days; P = .001). The number of patients who required analgesics is less in the 3-LRC group (32.4% versus 43.8%; P = .583).

Conclusion: 3-LRC for right-sided colon cancer is technically feasible and is associated with a short operation time. We believe that 3-LRC effectively reduces the costs associated with equipment and manpower and represents a standard procedure.
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http://dx.doi.org/10.1089/lap.2018.0498DOI Listing
April 2019

Feasibility of a novel laparoscopic technique with unidirectional knotless barbed sutures for the primary closure of duodenal ulcer perforation.

Surg Endosc 2018 08 22;32(8):3667-3674. Epub 2018 Feb 22.

Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University Postgraduate School of Medicine, 79 Gangnam-ro, Jinju, 52727, Republic of Korea.

Background: Laparoscopic primary repair is one of the main procedures used for perforated gastric ulcers, and this technique requires reproducible and secure suturing. The aim of this study was to investigate the safety and efficacy of a novel continuous suture method with barbed sutures during laparoscopic repair for perforated peptic ulcers.

Patients And Methods: Clinical data from 116 consecutive patients undergoing laparoscopic repair for perforated peptic ulcers were collected between November 2009 and October 2015. Continuous suturing with 15-cm-long unidirectional absorbable barbed sutures was used for laparoscopic repair in the study group, termed group V (n = 51). Patients who underwent laparoscopic repair with conventional interrupted sutures were defined as group C (n = 65). The complication and operative data were compared between groups.

Results: Although there was no difference between group V and group C in the overall complication rate (15.7% vs. 24.6%; p = 0.259), the complication rate related to suturing was lower (3.9% vs. 15.4%; p = 0.04) in group V. Group V showed rates of 0% for leakage, 2% for intra-abdominal fluid collection, and 2% for stricture; the corresponding rates in group C were 3.1, 7.7, and 4.6%, respectively. Regarding operative data, the total operation time (V vs. C, 87.7 min vs. 131.2 min), total suture time (7.1 min vs. 25.3 min), and suture time per stitch (1.2 min vs. 6.2 min) were significantly shorter in group V than in group C (p < 0.001).

Conclusion: The use of a continuous suture technique with unidirectional barbed sutures is as safe as the conventional suture technique and allows easier and faster suturing in the repair of perforated peptic ulcers.
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http://dx.doi.org/10.1007/s00464-018-6099-yDOI Listing
August 2018

Do hepatic-sided tumors require more extensive resection than peritoneal-sided tumors in patients with T2 gallbladder cancer? Results of a retrospective multicenter study.

Surgery 2017 09 16;162(3):515-524. Epub 2017 Jun 16.

Department of Surgery, Gyeongsang National University Hospital, Gyeongsang National University, College of Medicine, Jinju, Republic of Korea. Electronic address:

Background: Tumor location is a prognostic factor for survival in patients with T2 gallbladder cancer. However, the optimal extent of resection according to tumor location remains unclear.

Methods: We reviewed the records of 192 patients with T2 gallbladder cancer who underwent R0 or R1 resection at 6 institutions. Perioperative and oncologic outcomes were compared according to the extent of resection between hepatic-sided (n = 93) and peritoneal-sided (n = 99) tumors.

Results: After a median follow-up of 30 months, the 5-year overall survival (84.9% vs 71.8%, P = .048) and recurrence-free survival (74.6% vs 62.2%, P = .060) were greater in peritoneal-sided T2 patients than in hepatic-sided T2 patients. Among hepatic-sided T2 patients, the 5-year overall survival was greater in patients who underwent radical cholecystectomy including lymph node dissection with liver resection than in patients who underwent lymph node dissection without liver resection (80.3% vs 30.0%, P = .032), and the extent of liver resection was not associated with overall survival (P = .526). Lymph node dissection without liver resection was an independent prognostic factor for overall survival in hepatic-sided T2 gallbladder cancer (hazard ratio 5.009, 95% confidence interval 1.512-16.596, P = .008). In peritoneal-sided T2 patients, the 5-year overall survival was not significantly different between the lymph node dissection with liver resection and the lymph node dissection without liver resection subgroups (70.5% vs 54.8%, P = .111) and the extent of lymph node dissection was not associated with overall survival (P = .395).

Conclusion: In peritoneal-sided T2 gallbladder cancer, radical cholecystectomy including lymph node dissection without liver resection is a reasonable operative option. Radical cholecystectomy including lymph node dissection with liver resection is suitable for hepatic-sided T2 gallbladder cancer.
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http://dx.doi.org/10.1016/j.surg.2017.05.004DOI Listing
September 2017

Laparoscopic Anatomic Segment 6 Liver Resection Using the Glissonian Approach.

Surg Laparosc Endosc Percutan Tech 2017 Jun;27(3):e22-e25

*Department of Surgery, Chungbuk National University Hospita, Cheongju-sil †Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine Seongnam-si ‡Department of Surgery, Gyeongsang National University Hospital, Jinju-si, Korea.

Introduction: Laparoscopic liver resection has become important procedure for malignant liver disease. In this report, we describe the relevant technical maneuvers and perioperative outcomes in laparoscopic anatomic segment 6 liver resection using the Glissonian approach.

Patients And Methods: From March 2003 and October 2015, 7 patients who diagnosed hepatocellular carcinoma had undergone laparoscopic anatomic segment 6 liver resection at the single institution. We performed retrospective analysis of the clinical and perioperative outcomes of these patients.

Results: All patients were men with mean age of 62.3 years (range, 49 to 73 y). The mean operation time was 352.8 minutes (range, 180 to 435 min) and there was no case of open conversion. The mean estimated blood loss was 521.4 mL (range, 200 to 800 mL) and intraoperative transfusion needed in 1 patient. There was no postoperative morbidity and mortality. The mean postoperative hospital stay was 7.5 days (range, 5 to 12 d). All patients obtained negative resection margins. There was no patient had developed tumor recurrence during a median follow-up period of 43 months (range, 7 to 60.7 mo).

Conclusions: Laparoscopic anatomic segment 6 liver resection is a feasible operative procedure, being possible even in patients with limited liver function.
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http://dx.doi.org/10.1097/SLE.0000000000000391DOI Listing
June 2017

Three-Dimensional Laparoscopic Anatomical Segment 8 Liver Resection with Glissonian Approach.

Ann Surg Oncol 2017 Jun 24;24(6):1606-1609. Epub 2017 Jan 24.

Department of Surgery, Chungbuk National University Hospital, Cheongju, Korea.

Background: Anatomical liver resection has been reported to have oncologic benefit over nonanatomical resection in surgery for hepatocellular carcinoma (HCC). Basic concept of anatomical resection is preventing tumor spread through the portal or venous flow. Few cases have been reported for laparoscopic anatomical segment 8 resection because of its technical difficulties. This video shows operative techniques for laparoscopic anatomical resection of segment 8, exposing middle and right hepatic vein and inferior vena cava using three-dimensional video.

Methods: A 61-year-old male was diagnosed to be a hepatitis B virus carrier 6 years ago. A 6.6-cm-sized HCC lesion was detected at segment 8 by computed tomography scan. We have used a high-definition, three-dimensional laparoscope with a deflectable tip (Olympus Medical Systems Corp., Japan), a trocar inserted in the right seventh intercostal space to obtain the optimal field of view on the superior-posterior portion of the liver. Using the Glissonian pedicle approach, we isolated and clamped the branch to the segment 8 to confirm the anatomical border of the segment 8. Segmentectomy was completed exposing the middle and right hepatic vein and inferior vena cava.

Results: Operation took 420 min. Estimated blood loss was 600 mL, and no red blood cell was transfused. Final pathology was an HCC with 0.3-cm safety margin. The patient discharged on the sixth day after operation with normal liver function test results. There was no operation-related complication from the operation day to the first outpatient visit day.

Conclusions: Laparoscopic anatomical resection of segment 8 is feasible.
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http://dx.doi.org/10.1245/s10434-017-5778-6DOI Listing
June 2017

Comparison of laparoscopic liver resection for hepatocellular carcinoma located in the posterosuperior segments or anterolateral segments: A case-matched analysis.

Surgery 2016 11 25;160(5):1219-1226. Epub 2016 Jun 25.

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University, College of Medicine, Seongnam, Republic of Korea.

Background: Laparoscopic liver resection is an attractive option for treating liver tumors. Laparoscopic liver resection is more difficult for hepatocellular carcinomas located in the posterosuperior segments than for hepatocellular carcinomas in the anterolateral segments. We compared perioperative and long-term outcomes between laparoscopic liver resection for hepatocellular carcinomas located in the posterosuperior and anterolateral segments.

Methods: We retrospectively reviewed the clinical data for 230 patients who underwent laparoscopic liver resection for hepatocellular carcinomas between September 2003 and July 2014. Of these, 116 patients were selected by case-matched analysis using age, sex, tumor number and size, Child-Pugh class, and extent of liver resection. Patients were classified into 2 groups according to tumor location: the anterolateral group (n = 58) and the posterosuperior group (n = 58).

Results: Operation time (355 minutes vs 212 minutes, P < .005), intraoperative blood loss (600 mL vs 410 mL, P < .001), and hospital stay (8.5 days vs 7 days, P = .040) were significantly greater in the posterosuperior group than in the anterolateral group. The open conversion (13.8% vs 10.3%, P = .777), postoperative complication (17.2% vs 10.3%, P = .420), 5-year overall survival (88.5% vs 85.7%, P = .370), and 5-year, recurrence-free survival (47.6% vs 40.9%, P = .678) rates were not significantly different between the posterosuperior and anterolateral groups.

Conclusion: Although laparoscopic liver resection is more difficult for hepatocellular carcinomas located in the posterosuperior segment, there were no differences in the short- and long-term outcomes between the posterosuperior and anterolateral groups. The perceived impact of tumor location on patient outcomes could be overcome by experience and technical improvements.
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http://dx.doi.org/10.1016/j.surg.2016.05.009DOI Listing
November 2016

Laparoscopic left lateral sectionectomy in patients with histologically confirmed cirrhosis.

Surg Oncol 2016 Sep 7;25(3):132-8. Epub 2016 May 7.

Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea.

Background: Laparoscopic left lateral sectionectomy (LLS) is now considered as a standard practice. However, the safety of laparoscopic LLS in cirrhotic patients is unclear. This is the retrospective study of comparing the outcomes of laparoscopic LLS between cirrhotic and non-cirrhotic patients.

Methods: We reviewed the clinical data for 107 patients who underwent laparoscopic LLS between July 2003 and July 2013. The patients were divided into cirrhotic group (n = 31) and non-cirrhotic group (n = 76) with histologically confirmed F4 or F3 fibrosis.

Results: There were no differences between the two groups in terms of the operation time (P = 0.807), blood loss (P = 0.115), transfusion rate (P = 0.716), postoperative complication rate (P = 0.601) and duration of hospital stay (P = 0.261). Open conversion occurred in one non-cirrhotic patient (P = 1.000). The postoperative peak total bilirubin level was higher in cirrhotic patients than in non-cirrhotic patients (P < 0.001). Among patients with hepatocellular carcinoma, the disease-free survival (P = 0.249) and overall survival (P = 0.768) rates were not significantly different between cirrhotic patients (n = 28) and non-cirrhotic patients (n = 12). There were no significant differences in the complication rate (P = 0.085), operation time (P = 0.159), blood loss (P = 0.306), transfusion rate (P = 1.00), and hospital day (P = 0.408) between laparoscopic LLS and cases of open LLS performed in the same study period (n = 10).

Conclusions: Laparoscopic LLS is safe and reproducible, even in cirrhotic patients.
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http://dx.doi.org/10.1016/j.suronc.2016.05.001DOI Listing
September 2016

Failure of transplantation tolerance induction by autologous regulatory T cells in the pig-to-non-human primate islet xenotransplantation model.

Xenotransplantation 2016 07 7;23(4):300-9. Epub 2016 Jul 7.

Xenotransplantation Research Center, Seoul National University College of Medicine, Seoul, Korea.

Background: Islet allotransplantation is a promising way to treat some type 1 diabetic (T1D) patients with frequent hypoglycemic unawareness, and islet xenotransplantation is emerging to overcome the problem of donor organ shortage. Our recent study showing reproducible long-term survival of porcine islets in non-human primates (NHPs) allows us to examine whether autologous regulatory T-cell (Treg) infusion at peri-transplantation period would induce transplantation tolerance in xenotransplantation setting.

Methods: Two diabetic rhesus monkeys were transplanted with porcine islets from wild-type adult Seoul National University (SNU) miniature pigs with immunosuppression by anti-thymoglobulin (ATG), cobra venom factor, anti-CD154 monoclonal antibody (mAb), and sirolimus. CD4(+) CD25(high) CD127(low) autologous regulatory T cells from the recipients were isolated, ex vivo expanded, and infused at the peri-transplantation period. Blood glucose and porcine C-peptide from the recipients were measured up to 1000 days. Maintenance immunosuppressants including a CD40-CD154 blockade were deliberately discontinued to confirm whether transplantation tolerance was induced by adoptively transferred Tregs.

Results: After pig islet transplantation via portal vein, blood glucose levels of diabetic recipients became normalized and maintained over 6 months while in immunosuppressive maintenance with a CD40-CD154 blockade and sirolimus. However, the engrafted pig islets in the long-term period were fully rejected by activated immune cells, particularly T cells, when immunosuppressants were stopped, showing a failure of transplantation tolerance induction by autologous Tregs.

Conclusions: Taken together, autologous Tregs infused at the peri-transplantation period failed to induce transplantation tolerance in pig-to-NHP islet xenotransplantation setting.
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http://dx.doi.org/10.1111/xen.12246DOI Listing
July 2016

Validation of difficulty scoring system for laparoscopic liver resection in patients who underwent laparoscopic left lateral sectionectomy.

Surg Endosc 2017 01 10;31(1):430-436. Epub 2016 Jun 10.

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Korea.

Background: A difficulty scoring system (DSS) based on the extent of liver resection, tumor location, liver function, tumor size, and tumor proximity to major vessels was recently developed to assess the difficulty of various laparoscopic liver resection procedures. We validated DSS in patients who underwent laparoscopic left lateral sectionectomy (LLS).

Methods: We reviewed the clinical data of 124 patients who underwent laparoscopic LLS between July 2003 and November 2015 and validated the DSS in 90 patients who underwent laparoscopic LLS for tumor according to their surgical outcomes. We also developed and evaluated the modified DSS in 34 patients who underwent LLS for intrahepatic duct (IHD) stones.

Results: The DSS score ranged from 3 to 6 in laparoscopic LLS for tumors. The median blood loss (P = 0.002) was significantly different among patients divided into subgroups by DSS score. We made modified DSS for IHD stones using factors influencing longer operation time, including stone location (P = 0.002), atrophy of liver parenchyma (P = 0.012), ductal stricture <1 cm from the bifurcation (P = 0.047), and combined choledochoscopic examination for remnant IHD (P < 0.001). The modified DSS score for IHD stones ranged from 3 to 7. Blood loss (P = 0.02) and operation time (P < 0.001) were significantly different among subgroups of patients divided by their difficulty scores. The median hospital stay (P = 0.004) and operation time (P = 0.039) were significantly longer and the complication rate (P = 0.025) and complication grade (P = 0.021) were significantly greater in patients with IHD stones than in patients with tumors.

Conclusions: The surgical difficulty varies among patients undergoing the same laparoscopic LLS procedure. The modified DSS developed here can also be applied to patients with IHD stones.
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http://dx.doi.org/10.1007/s00464-016-4994-7DOI Listing
January 2017

Prognostic relevance of preoperative diabetes mellitus and the degree of hyperglycemia on the outcomes of resected pancreatic ductal adenocarcinoma.

J Surg Oncol 2016 Feb;113(2):203-8

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Republic of Korea.

Introduction: The prognostic relevance of preoperative diabetes mellitus (DM) on the outcomes of resected pancreatic ductal adenocarcinoma (PDAC) is controversial. Most previous studies evaluated the prognostic role of DM based on a single blood test.

Methods: The participants included 147 patients with PDAC who underwent pancreatectomy between September 2003 and June 2012. They were divided into following groups according to the preoperative DM and degree of hyperglycemia defined by glycosylated hemoglobin (HbA1c): non-DM (n = 70), DM with HbA1c < 9.0% (n = 52), and DM with HbA1c ≥ 9.0% (n = 25).

Results: There were no significant differences in cancer stage or postoperative complications among the three groups. The survival rate was significantly lower in the DM with HbA1c ≥ 9.0% group (22.3%) than in the non-DM group (33.6%) and the DM with HbA1c < 9.0% group (33.8%) (P = 0.044). Multivariate analysis revealed that DM with HbA1c ≥ 9.0% (hazard ratio [HR] 2.495, 95% confidence interval [CI] 1.274-4.886, P = 0.008) and the presence of venous invasion (HR 1.836, 95%CI 1.072-3.146, P = 0.027) were independent prognostic factors for survival.

Conclusion: Uncontrolled severe hyperglycemia rather than preoperative DM negatively affects the survival outcomes following PDAC resection.
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http://dx.doi.org/10.1002/jso.24133DOI Listing
February 2016

Defining Surgical Difficulty According to the Perceived Complexity of Liver Resection: Validation of a Complexity Classification in Patients with Hepatocellular Carcinoma.

Ann Surg Oncol 2016 08 4;23(8):2602-9. Epub 2016 Jan 4.

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, Republic of Korea.

Background: A classification system for defining the complexity of hepatectomy according to its technical difficulty was recently proposed as a consensus of a panel of experts. We validated this classification system for a prospective liver resection cohort in patients with hepatocellular carcinoma (HCC).

Method: The complexity classification separated liver resections into three categories of complexity (low, medium, or high). We retrospectively reviewed 150 open hepatectomies between 1 March 2004 and 30 November 2013 in patients with HCC, and compared the perioperative outcomes according to the complexity classification.

Results: No differences in patient demographics or pathologic findings were observed among the three groups according to the complexity classification, which effectively differentiated the three groups in terms of intraoperative findings and short-term outcomes. The mean estimated blood loss (p = 0.001), rate of blood transfusion (p < 0.001), and mean operation time (p < 0.001) were significantly different among the three groups. The rates of overall and major complications (p = 0.026 and 0.005, respectively) were significantly greater in the high-complexity group. Multivariate analysis showed that the complexity classification was independently associated with major complications (odds ratio 4.73; p = 0.040); however, overall patient survival (p = 0.139) and disease-free survival (p = 0.076) were not significantly different among the three groups.

Conclusion: The complexity classification effectively differentiated intraoperative and short-term outcomes, and was independently associated with major complications after hepatectomy in patients with HCC.
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http://dx.doi.org/10.1245/s10434-015-5058-2DOI Listing
August 2016

Outcomes of Simultaneous Major Liver Resection and Colorectal Surgery for Colorectal Liver Metastases.

J Gastrointest Surg 2016 Mar 15;20(3):554-63. Epub 2015 Oct 15.

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, Republic of Korea.

Background: The optimal surgical strategy for treating colorectal cancer liver metastases (CRLM) in patients requiring major liver resection (MLR) is controversial, especially in rectal cancer patients.

Method: Between March 2004 and January 2015, 103 patients underwent MLR for CRLM and underwent MLR simultaneously with colorectal surgery (simultaneous group; n = 55) or MLR after colorectal surgery (liver-only group; n = 48).

Results: There were no significant differences in sex, age, ASA score, BMI, size and number of liver metastases, liver resection margin, surgical outcomes, and estimated blood loss. The rates of postoperative complications (simultaneous group vs. liver-only group; 76.4 % vs. 62.5 %; P = 0.126) and major complications (29.0 % vs. 25.0 %; P = 0.513) were also similar in both groups. The time to starting a soft diet was longer in the simultaneous group (6.0 days vs. 3.4 days; P < 0.001), but the length of hospital stay was similar (14.9 days vs. 13.3 days; P = 0.345). There were no perioperative deaths, anastomotic leakage, or septic complications. Among patients who underwent rectal surgery, the frequency of complications was greater in the simultaneous group (87.0 % vs. 56.2 %; P = 0.031), but there was no difference in major complications (34.7 % vs. 25.0 %; P = 0.822). The postoperative morbidity index was 0.204 and 0.180 in the simultaneous and liver-only groups, respectively, in all patients, and was 0.227 and 0.136, respectively, in the rectal surgery subgroup.

Conclusion: Simultaneous MLR is feasible and safe in synchronous CRLM patients, including rectal cancer patients.
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http://dx.doi.org/10.1007/s11605-015-2979-9DOI Listing
March 2016

Laparoscopic resection of hilar cholangiocarcinoma.

Ann Surg Treat Res 2015 Oct 25;89(4):228-32. Epub 2015 Sep 25.

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

Laparoscopic resection of hilar cholangiocarcinoma is technically challenging because it involves complicated laparoscopic procedures that include laparoscopic hepatoduodenal lymphadenectomy, hemihepatectomy with caudate lobectomy, and hepaticojejunostomy. There are currently very few reports describing this type of surgery. Between August 2014 and December 2014, 5 patients underwent total laparoscopic or laparoscopic-assisted surgery for hilar cholangiocarcinoma. Two patients with type I or II hilar cholangiocarcinoma underwent radical hilar resection. Three patients with type IIIa or IIIb cholangiocarcinoma underwent extended hemihepatectomy together with caudate lobectomy. The median (range) age, operation time, blood loss, and length of hospital stay were 63 years (43-76 years), 610 minutes (410-665 minutes), 650 mL (450-1,300 mL), and 12 days (9-21 days), respectively. Four patients had a negative margin, but 1 patient was diagnosed with high-grade dysplasia on the proximal resection margin. The median tumor size was 3.0 cm. One patient experienced postoperative biliary leakage, which resolved spontaneously. Laparoscopic resection is a feasible surgical approach in selected patients with hilar cholangiocarcinoma.
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http://dx.doi.org/10.4174/astr.2015.89.4.228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4595825PMC
October 2015

Is Laparoscopy Contraindicated for Gallbladder Cancer? A 10-Year Prospective Cohort Study.

J Am Coll Surg 2015 Oct 20;221(4):847-53. Epub 2015 Jul 20.

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gyeonggi-do, Korea.

Background: Laparoscopic treatment for gallbladder cancer (GBC) has long been contraindicated, but few studies have demonstrated the oncologic outcomes of this treatment. The purpose of this study was to evaluate long-term survival after intended laparoscopic surgery for early-stage GBC based on our 10 years of experience.

Study Design: Between May 2004 and April 2014, eighty-three patients suspected of having early-stage GBC with no evidence of liver invasion were enrolled in the prospective protocol for laparoscopic surgery. Data for 45 of these patients with pathologically proven GBC were analyzed to determine the safety and oncologic outcomes of a laparoscopic approach to GBC. Twenty-six patients whose postoperative follow-up exceeded 5 years were investigated to determine the 5-year actual survival outcomes.

Results: Extended cholecystectomy, including laparoscopic lymphadenectomy, was performed in 32 patients and simple cholecystectomy in 13 patients. The T stages based on final pathologic results were Tis (n = 2), T1a (n = 10), T1b (n = 8), and T2 (n = 25). After a median follow-up of 60 months after surgery, recurrence was detected in 4 patients as distant metastases. There was no local recurrence around the gallbladder bed or lymphadenectomy. Disease-specific 5-year survival rate of the 45 patients was 94.2%. Disease-specific actual survival rate of 26 patients whose postoperative follow-up period exceeded 5 years was 92.3% at 5 years.

Conclusions: The favorable long-term oncologic results shown in this study confirm the oncologic safety of laparoscopic cholecystectomy, including laparoscopic lymphadenectomy in selected patients with GBC.
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http://dx.doi.org/10.1016/j.jamcollsurg.2015.07.010DOI Listing
October 2015

Comparison of porcine c-peptide measurement using ELISA and radioimmunoassay kits.

Xenotransplantation 2014 Sep-Oct;21(5):480-1. Epub 2014 Jul 2.

Translational Xenotransplantation Research Center, Seoul National University College of Medicine, Seoul, Korea; Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Korea; Medical Research Institute for Infectious Diseases, Seoul National University College of Medicine, Seoul, Korea.

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http://dx.doi.org/10.1111/xen.12113DOI Listing
June 2015

Minimizing immunosuppression in islet xenotransplantation.

Immunotherapy 2014 ;6(4):419-30

Translational Xenotransplantation Research Center, Seoul National University College of Medicine, 103 Daehak-ro Jongno-gu, Seoul 110-799, Korea.

Pancreatic islet transplantation is a promising treatment option for Type 1 diabetes, but organ supply shortage limits its wide adoption. Pig islets are the most promising alternative source and many important measures such as donor animal selection, pig islet production release criteria, preclinical data and zoonosis surveillance prior to human clinical trials have been put forward as a consensus through the efforts of the International Xenotransplantation Association. To bring pig islet transplantation to clinical reality, the development of clinically applicable immunosuppression regimens and methods to minimize immunosuppression to reduce side effects should be established. This review encompasses immune rejection mechanisms in islet xenotransplantation, immunosuppression regimens that have enabled long-term graft survival in pig-to-nonhuman primate experiments and strategies for minimizing immunosuppression in islet xenotransplantation. By thoroughly examining the drugs that are currently available and in development and their individual targets within the immune response, the best strategy for enabling clinical trials of pig islets for Type 1 diabetes will be proposed.
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http://dx.doi.org/10.2217/imt.14.14DOI Listing
December 2014

The effect of propofol on intravenous glucose tolerance test in rhesus monkey.

J Med Primatol 2014 Aug 12;43(4):242-6. Epub 2014 May 12.

Translational Xenotransplantation Research Center, Seoul, Korea; Department of Microbiology and Immunology, Seoul National University College of Medicine, Seoul, Korea; Medical Research Institute for Infectious Diseases, Seoul National University College of Medicine, Seoul, Korea.

Background: Many anesthetics have been shown to impair glucose metabolism and cause hyperglycemia. The aim of this study was to evaluate the effects of propofol on glucose metabolism and insulin secretion during intravenous glucose tolerance test (IVGTT) in rhesus monkey.

Methods: Serum cortisol, blood glucose, insulin, and C-peptide concentrations during IVGTT were measured in four rhesus monkeys under either conscious state or propofol anesthesia.

Results And Conclusions: The levels of serum cortisol significantly increased under conscious condition, whereas these levels remained constant under propofol anesthesia. In propofol group, the levels of serum insulin and C-peptide significantly increased compared with those in conscious group. Accordingly, glucose disposal capacity was significantly improved, and the time to return to basal glucose levels was shortened in propofol group. This study showed that propofol significantly increased insulin and C-peptide, and the corresponding improvement in glucose disposal may be related to reduction of serum cortisol in monkey.
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http://dx.doi.org/10.1111/jmp.12128DOI Listing
August 2014
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