Publications by authors named "Seon-Hahn Kim"

99 Publications

Laparoscopic en bloc lateral pelvic exenteration for locally advanced and recurrent rectal cancer.

ANZ J Surg 2021 Sep 23. Epub 2021 Sep 23.

Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea.

This study describes minimally invasive lateral pelvic compartment en bloc excision for rectal cancer.
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http://dx.doi.org/10.1111/ans.17205DOI Listing
September 2021

Meta-analysis of transanal versus laparoscopic total mesorectal excision for rectal cancer: a 'New Health Technology' assessment in South Korea.

Ann Surg Treat Res 2021 Sep 31;101(3):167-180. Epub 2021 Aug 31.

TaTME Assessment Committee, National Evidence-based Healthcare Collaborating Agency, Seoul, Korea.

Purpose: Under the South Korea's unique health insurance structure, any new surgical technology must be evaluated first by the government in order to consider whether that particular technology can be applied to patients for further clinical trials as categorized as 'New Health Technology,' then potentially covered by the insurance sometime later. The aim of this meta-analysis was to assess the safety and efficacy of transanal total mesorectal excision (TaTME) for rectal cancer, activated by the National Evidence-based Healthcare Collaborating Agency (NECA) TaTME committee.

Methods: We systematically searched Ovid-MEDLINE, Ovid-Embase, Cochrane, and Korean databases (from their inception until August 31, 2019) for studies published that compare TaTME with laparoscopic total mesorectal excision (LaTME). End-points included perioperative and pathological outcomes.

Results: Sixteen cohort studies (7 for case-matched studies) were identified, comprising 1,923 patients (938 TaTMEs and 985 LaTMEs). Regarding perioperative outcomes, the conversion rate was significantly lower in TaTME (risk ratio, 0.19; 95% confidence interval, 0.11-0.34; P < 0.001); whereas other perioperative outcomes were similar to LaTME. There were no statistically significant differences in pathological results between the 2 procedures.

Conclusion: Our meta-analysis showed comparable results in preoperative and pathologic outcomes between TaTME and LaTME, and indicated the benefit of TaTME with low conversion. Extensive evaluations of well-designed, multicenter randomized controlled trials are required to come to unequivocal conclusions, but the results showed that TaTME is a potentially beneficial technique in some specific cases. This meta-analysis suggests that TaTME can be performed for rectal cancer patients as a 'New Health Technology' endorsed by NECA in South Korea.
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http://dx.doi.org/10.4174/astr.2021.101.3.167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8424436PMC
September 2021

Clinical characteristics of patients in their forties who underwent surgical resection for colorectal cancer in Korea.

World J Gastroenterol 2021 Jul;27(25):3901-3912

Department of Surgery, Korea University College of Medicine, Seoul 02841, South Korea.

Background: The proportion of young patients with colorectal cancer (CRC), especially in their 40s, is increasing worldwide.

Aim: To confirm the clinical characteristics of such patients, we planned a study comparing them to patients in their 30s and 50s.

Methods: Patients undergoing primary resection for CRC, patients in their 30s, 40s and 50s were included in the study. Patient and tumor characteristics, and perioperative and oncologic outcomes were compared.

Results: Most clinical characteristics of 451 (10.5%) patients in their 40s were more similar to those of patients in their 30s than those in their 50s. On pathology data, there were more metastatic lesions (30s 40s 50s; 17.5% 21.1% 14.9%, = 0.012) in patients in their 40s. There was a trend toward less frequent K-ras mutations among patients in their 40s (48.5% 33.3% 44.5%, = 0.064). The proportion of patients receiving postoperative chemotherapy was also significantly greater among patients in their 40s (58.3% 63.9% 56.3%, = 0.032). Five-year overall survival (OS) and disease-free survival (DFS) did not differ between the three groups (5-year OS, 92.2% 89.8% 92.2%, = 0.804; 5-year total DFS, 98.6% 95.7% 96.1%, = 0.754; 5-year local DFS, 98.6% 94.3% 94.9%, = 0.579; 5-year systemic DFS, 86.4% 87.9 % 86.4%, = 0.908).

Conclusion: Patients with CRC in their 40s showed significantly more numerous metastatic lesions. The oncologic outcome of stage 1-3 patients in their 40s was not inferior compared to that of those in their 30s and 50s.
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http://dx.doi.org/10.3748/wjg.v27.i25.3901DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8291016PMC
July 2021

Novel technique in atraumatic retraction for minimally invasive low anterior resection.

ANZ J Surg 2021 Jul 26. Epub 2021 Jul 26.

Department of Colorectal Surgery, Korea University Anam Hospital, Seoul, South Korea.

This study describes an atraumatic minimally invasive retraction system for rectal cancer surgery.
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http://dx.doi.org/10.1111/ans.17087DOI Listing
July 2021

How to do robotic low anterior resection using Da Vinci-Xi system: Addressing the ergonomics dilemma.

ANZ J Surg 2021 Jun 7. Epub 2021 Jun 7.

Department of Colorectal Surgery, Korea University Anam Hospital, Seoul, South Korea.

We describe six-arm, double-targeting, arm repositioning technique of performing robotic low anterior resection. This technique addresses the dilemma faced during traditional technique.
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http://dx.doi.org/10.1111/ans.16983DOI Listing
June 2021

Clinical Implication of Liquid Biopsy in Colorectal Cancer Patients Treated with Metastasectomy.

Cancers (Basel) 2021 May 6;13(9). Epub 2021 May 6.

Division of Medical Oncology and Hematology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, Korea.

Background & Aims: The application of circulating tumor DNA (ctDNA) has been studied for predicting recurrent disease after surgery and treatment response during systemic treatment. Metastasectomy can be curative for well-selected patients with metastatic colorectal cancer (mCRC). This prospective study investigated the ctDNA level before and after metastasectomy in patients with mCRC to explore its potential as a predictive biomarker.

Methods: We collected data on 98 metastasectomies for mCRC performed from March 2017 to February 2020. Somatic mutations in the primary and metastatic tumors were identified and tumor-informed ctDNAs were selected by ultra-deep targeted sequencing. Plasma samples were mandatorily collected before and 3-4 weeks after metastasectomy and serially, if patients agreed.

Results: Data on 67 of 98 metastasectomies (58 patients) meeting the criteria were collected. ctDNA was detected in 9 (29%) of 31 cases treated with upfront metastasectomy and in 7 (19.4%) of 36 cases treated with metastasectomy after upfront chemotherapy. The detection rate of ctDNA was higher in liver metastasis ( = 0.0045) and tumors measuring ≥1 cm ( = 0.0183). ctDNA was less likely to be detected if the response to chemotherapy was good. After metastasectomy, ctDNA was found in 4 (6%) cases with rapid progressive disease.

Conclusion: The biological factors affecting the ctDNA shedding from the tumor should be considered when applying ctDNA assays in a clinical setting. After metastasectomy for oligometastatic lesions in good responders of chemotherapy, most ctDNA was cleared or existed below the detection level. To assist clinical decision making after metastasectomy for mCRC using ctDNA, further studies for improving specific outcomes are needed.
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http://dx.doi.org/10.3390/cancers13092231DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8125778PMC
May 2021

Optimizing outcomes of colorectal cancer surgery with robotic platforms.

Surg Oncol 2021 Jun 31;37:101559. Epub 2021 Mar 31.

Division of Colon and Rectal Surgery, Department of Surgery, Korea University College of Medicine, Seoul, South Korea. Electronic address:

Advanced robotic technology makes it easier to perform total mesorectal excision procedures in the narrow pelvis for rectal cancer while maintaining the advantages of minimally invasive surgery. Robotic surgery for rectal cancer leads to lower conversion rates and faster recovery of urogenital function than conventional laparoscopic surgery. However, longer operative time and high cost are major weaknesses of robotic surgery. To date, most other short-term surgical outcomes, pathologic outcomes, and long-term oncologic outcomes of robotic surgery have not shown significant advantages over laparoscopic surgery. However, robotic surgery is still a valid and highly anticipated surgical approach for rectal cancer because it greatly reduces the surgeon's workload and learning curve. There are also advantages when robotic techniques are applied to technically demanding procedures such as lateral pelvic lymph node dissection or intersphincteric resection. The introduction of new surgical robot systems, including the da Vinci® SP system, is expected to expand the applications of robotic surgery and provide new advantages.
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http://dx.doi.org/10.1016/j.suronc.2021.101559DOI Listing
June 2021

Impact of D3 lymph node dissection on upstaging and short-term survival in clinical stage I right-sided colon cancer.

Asian J Surg 2021 Mar 20. Epub 2021 Mar 20.

Division of Colon and Rectal Surgery, Korea University Guro Hospital, Seoul, South Korea.

Background: D3 lymph node dissection is becoming the standard procedure for the treatment of advanced right colon cancer and has shown increasing evidence of its oncologic benefit. However, a clear indication for its application is lacking and data on this topic is unsatisfactory. Thus, the necessity for D3 lymph node dissection in clinical stage I right colon cancer remains controversial.

Methods: We retrospectively analyzed data from clinical stage I right colon cancer patients who underwent radical surgery at three hospitals of Korea university medical center between January 2015 and June 2018. We compared surgical complications and short-term oncologic outcomes between D2 and D3 lymph node dissections in these patients.

Results: Among 512 patients, 122 (23.8%) were clinical stage I. Of these, 88 and 34 patients received D2 and D3 lymph node dissection, respectively. There were no statistically significant differences in clinicopathologic variables and surgical outcomes between the two groups. Upstaging occurred in 16 patients (47.1%) in the D3 group and 23 patients (26.1%) in the D2 group. There were four recurrences in the D2 group but no recurrence in the D3 group. Log-rank tests showed no statistically significant difference in disease-free survival rates between the two groups (p = 0.210).

Conclusion: There was no significant difference in disease-free survival rates between D2 and D3 lymph node dissection in clinical stage I right colon cancer patients. However, recurrence occurred in the D2 group. Efforts to improve the accuracy of clinical staging are required and more studies with better quality are needed.
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http://dx.doi.org/10.1016/j.asjsur.2021.02.011DOI Listing
March 2021

Midline incision vs. transverse incision for specimen extraction is not a significant risk factor for developing incisional hernia after minimally invasive colorectal surgery: multivariable analysis of a large cohort from a single tertiary center in Korea.

Surg Endosc 2021 Mar 3. Epub 2021 Mar 3.

Division of Colon and Rectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 73 Goryodae-ro, Seongbuk-gu, Seoul, 02841, South Korea.

Background: Incisional hernia (IH) is a commonly encountered problem even in the era of minimally invasive surgery (MIS). Numerous studies on IH are available in English literature, but there are lack of data from the Eastern part of the world. This study aimed to evaluate the risk factors as well as incidence of IH by analyzing a large cohort collected from a single tertiary center in Korea.

Methods: Among a total number of 4276 colorectal cancer patients who underwent a surgical resection from 2006 to 2019 in Korea University Anam Hospital, 2704 patients (2200 laparoscopic and 504 robotic) who met the inclusion criteria were analyzed. IH was confirmed by each patient's diagnosis code registered in the hospital databank based on physical examination and/or computed tomography findings. Clinical data including specimen extraction incision (transverse or vertical midline) were compared between IH group and no IH group. Risk factors of developing IH were assessed by utilizing univariable and multivariable analyses.

Results: During the median follow-up of 41 months, 73 patients (2.7%) developed IH. Midline incision group (n = 1472) had a higher incidence of IH than that of transverse incision group (n = 1232) (3.5% vs. 1.7%, p = 0.003). The univariable analysis revealed that the risk factors of developing IH were old age, female gender, obesity, co-morbid cardiovascular disease, transverse incision for specimen extraction, and perioperative bleeding requiring transfusion. However, on multivariable analysis, specimen extraction site was not significant in developing IH and transfusion requirement was the strongest risk factor.

Conclusions: IH development after MIS is uncommon in Korean patients. Multivariable analysis suggests that specimen extraction site can be flexibly chosen between midline and transverse incisions, with little concern about risk of developing IH. Careful efforts are required to minimize operative bleeding because blood transfusion is a strong risk factor for developing IH.
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http://dx.doi.org/10.1007/s00464-021-08388-zDOI Listing
March 2021

Anatomic Landmarks for Transabdominal Robotic-Assisted Intersphincteric Dissection for Ultralow Anterior Resection.

Dis Colon Rectum 2021 05;64(5):e87-e88

1 Colorectal Surgery Unit, Department of Surgery, Fondazione Instituto di Ricerca a Carattere Scientifico, Istituto Nazionale dei Tumori, Milan, Italy 2 Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea.

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http://dx.doi.org/10.1097/DCR.0000000000001988DOI Listing
May 2021

Arc of Riolan-Dominant Colonic Perfusion Identified by Indocyanine Green After High Ligation of Inferior Mesenteric Artery: Critical in Preventing Anastomotic Ischemia.

Dis Colon Rectum 2021 04;64(4):e64

Colorectal Division, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea.

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http://dx.doi.org/10.1097/DCR.0000000000001864DOI Listing
April 2021

Does the learning curve in robotic rectal cancer surgery impact circumferential resection margin involvement and reoperation rates? A risk-adjusted cumulative sum analysis.

Minerva Surg 2021 Apr 9;76(2):124-128. Epub 2020 Nov 9.

Section of Colorectal Surgery, Department of Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA -

Background: The aim of this study was to evaluate the impact of surgeons' learning curve in robotic surgery for rectal cancer on circumferential resection margin (CRM) involvement and reoperation rates.

Methods: Learning curve data were prospectively collected from four centers. Patients undergoing robotic proctectomy for resectable rectal cancer were included. CRM was involved when ≥1 mm. TME quality was classified as complete, nearly complete, or incomplete. T-test and χ tests were used to compare continuous and categorical variables, respectively. Risk-adjusted cumulative sum (RA-CUSUM) analysis was utilized to evaluate the effect of the learning curve on primary endpoints. Univariate analysis of potential risk factors for CRM involvement and reoperation was performed. Factors with the P value ≤0.2 were included in the multivariate logistic regression model for further RA-CUSUM analysis.

Results: A total of 221 patients (80, 36, 62, and 43 patients operated on by surgeons 1, 2, 3, and 4, respectively) who underwent robotic surgery for rectal cancer during the surgeons' learning curves were included. CRM involvement rate was 0%, 11%, 3%, and 5% in surgeons 1, 2, 3, and 4, respectively. Reoperation rate was 3.7%, 8.3%, 4.8%, and 11.6%, respectively. RA-CUSUM analysis of CRM involvement (R=0.9886) and reoperation (R=0.9891) found a statistically significant decreasing trend in aggregate CUSUM values throughout the learning curve.

Conclusions: This study found a continued significant decrease in CRM involvement and reoperation rates throughout the learning curve in robotic rectal cancer surgery.
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http://dx.doi.org/10.23736/S0026-4733.20.08491-6DOI Listing
April 2021

Bowel function and quality of life after minimally invasive colectomy with D3 lymphadenectomy for right-sided colon adenocarcinoma.

World J Gastroenterol 2020 Sep;26(33):4972-4982

Department of Surgery, Korea University College of Medicine, Seoul 02841, South Korea.

Background: Changes in bowel function after right-sided colectomy are not well understood compared to those associated with left-sided colectomy or rectal resection. In particular, there are concerns about bowel function after right-sided colectomy with complete mesocolic excision, which has become popular in the West.

Aim: To evaluate the functional outcomes of patients who underwent right-sided colectomy with D3 lymphadenectomy for colon cancer.

Methods: Functional data from patients who underwent minimally invasive right-sided colectomy for colon cancer from October 2017 to September 2018 were prospectively collected. Functional outcomes were evaluated preoperatively and at 3, 6, 12, and 18 mo postoperatively.

Results: Prior to surgery, 57 patients answered the questionnaire, and 47 responded at three months, 52 at 6 mo, 52 at 12 mo, and 25 at 18 mo postoperatively. Most scales of quality of life and bowel function improved significantly over time. Urgency persisted to a high degree throughout the period without a significant change over time. The use of medications for defecation was about 10% over the entire period. Gas ( = 0.023) and fecal frequency ( < 0.001) increased, and bowel dysfunction group ( = 0.028) was more common among patients taking medication. At six months, resected bowel and colon lengths were significantly different as a risk factor between the dysfunction group and the no dysfunction group [odd ratio (OR): 1.095, = 0.026; OR: 1.147, = 0.031, respectively] in univariate analysis, but not in multivariate analysis.

Conclusion: Despite D3 lymphadenectomy, most bowel symptoms improved over time after right-sided colectomy using a minimally invasive approach, and continuous medication was needed in only approximately 10% of patients.
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http://dx.doi.org/10.3748/wjg.v26.i33.4972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7476173PMC
September 2020

Impact of robotic learning curve on histopathology in rectal cancer: A pooled analysis.

Surg Oncol 2020 Sep 13;34:121-125. Epub 2020 Apr 13.

Section of Colorectal Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA; Department of Surgery, Clinic of Colorectal and Minimally Invasive Surgery, Sechenov Medical University, Moscow, Russia. Electronic address:

Background: A beneficial impact of robotic proctectomy on circumferential resection margin (CRM) is expected due to the robot's articulating instruments in the pelvis. There are however concerns about a negative impact on the quality of total mesorectal excision (TME) due to the lack of tactile feedback. The aim of this study was to assess whether surgeons' learning curve impacted CRM and TME quality.

Methods: In a multicenter study, individual patient data of robotic proctectomy for resectable rectal cancer were pooled. Patients were stratified into two phases of surgeons' learning curve. Cumulative sum (CUSUM) analysis was used to determine the transition from learning phase (LP) to plateau phase (PP), which were compared. CRM was microscopically measured in mm by pathologists. TME quality was classified by pathologists as complete, nearly complete or incomplete. T-test and Chi-squared tests were used to compare continuous and categorical variables, respectively.

Results: 235 patients underwent robotic proctectomy by five surgeons. 83 LP patients were comparable to 152 PP patients for age (p = 0.20), gender (67.5% vs. 65.1% males; p = 0.72), BMI (p = 0.82), cancer stage (p = 0.36), neoadjuvant chemoradiation (p = 0.13), distance of tumor from anal verge (5.8 ± 4.4 vs. 5.5 ± 3.3; p = 0.56). CRM did not differ (7.7 ± 11.4 mm vs. 8.4 ± 10.3 mm; p = 0.62). The rate of complete TME quality was significantly improved in PP patients as compared to LP patients (73.5% vs. 92.1%; p < 0.001).

Conclusion: While learning had no impact on circumferential resection margins, the quality of TME significantly improved during surgeons' plateau phase as compared to their learning phase.
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http://dx.doi.org/10.1016/j.suronc.2020.04.011DOI Listing
September 2020

How to accurately measure the distance from the anal verge to rectal cancer on MRI: a prospective study using anal verge markers.

Abdom Radiol (NY) 2021 02 20;46(2):449-458. Epub 2020 Jul 20.

Department of Biostatistics, Korea University College of Medicine, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, Republic of Korea.

Purpose: To determine an accurate method for localizing rectal cancer using the distance from the anal verge on preoperative MRI.

Methods: This prospective study included 50 patients scheduled for MRI evaluation of rectal cancer. After rectal filling with gel, MRI was performed with two markers attached at the anal verge. The distance between the tumor and the anal verge on a sagittal T2-weighted image (T2WI) was measured independently by two radiologists using six methods divided into three groups of similar measurement approaches, and compared to those obtained on rigid sigmoidoscopy. The anal verge location relative to the external anal sphincter was assessed on oblique coronal T2WI in reference to the markers. Correlation analysis was performed using the intraclass correlation coefficient (ICC) for verification, and a paired t test was used to evaluate the mean differences.

Results: The highest correlation (ICC 0.797-0.815) and the least mean difference (0.74-0.85 cm) with rigid sigmoidoscopy, and the least standard deviation (3.12-3.17 cm) were obtained in the direct methods group using a straight line from the anal verge to the tumor. The anal verge was localized within a range of - 1.4 to 1.5 cm (mean - 0.31 cm and - 0.22 cm) from the lower end of the external anal sphincter.

Conclusion: The direct methods group provided the most accurate tumor distance among the groups. Among the direct methods, we recommend the direct mass method for its simplicity. Despite minor differences in location, the lower end of the external anal sphincter was a reliable anatomical landmark for the anal verge.
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http://dx.doi.org/10.1007/s00261-020-02654-9DOI Listing
February 2021

Clinical characteristics and oncologic outcomes in patients with preoperative clinical T3 and T4 colon cancer who were staged as pathologic T3.

Ann Surg Treat Res 2020 Jul 29;99(1):37-43. Epub 2020 Jun 29.

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

Purpose: Clinically suspected T4 stage colon cancer from a preoperative exam is often diagnosed as T3 stage colon cancer pathologically after surgery, raising concerns about understaging. The aims of this study were to compare the survival of clinical T3 and T4 colon cancer patients who had received a pathologic T3 stage diagnosis postoperatively.

Methods: Patients who were diagnosed with pathologic T3 stage colon cancer postoperatively were reviewed. Patients with clinically suspected T3 or T4 stage cancer on preoperative exam were enrolled in the study. We compared patient demographics and survival of the cT3 and cT4 groups.

Results: Out of the 536 patients with pT3 colon cancer, 503 patients were cT3 (93.8%) and 33 patients were cT4 (6.2%) preoperatively. The most common reason for suspected clinical T4 stage cancer was free perforation (78.8%). There were no statistically significant differences between the 5-year overall survival and the total 5-year disease-free survival (DFS) between the cT3 and cT4 groups; however, local recurrence was significantly higher in the cT4 group (local 5-year DFS: 98.6% vs. 84.0%, P < 0.001). Multivariate analysis showed cT stage was associated with local recurrence, but the association was not statistically significant (P = 0.056).

Conclusion: Preoperative clinically suspected T4 stage colon cancer showed inferior local recurrence despite a postoperative pathologic diagnosis of T3 stage cancer. It is necessary to address the shortcomings of pathologic exams in the matter of the understaging of T4 colon cancer, and to reinforce the treatment for local control in patients with cT4 colon cancer.
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http://dx.doi.org/10.4174/astr.2020.99.1.37DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332321PMC
July 2020

Trends of robotic-assisted surgery for thyroid, colorectal, stomach and hepatopancreaticobiliary cancer: 10 year Korea trend investigation.

Asian J Surg 2021 Jan 19;44(1):199-205. Epub 2020 Jun 19.

Department of Surgery, Korea University Medical Center, Korea University College of Medicine, Inchon-ro 73, Seongbuk-gu, Seoul, 136-705, Republic of Korea.

Background: The current position of robotic surgery in the field of minimally invasive surgery remains ambiguous. We evaluated long-term trends of robotic general surgery and the future direction of its development.

Methods: Data on robotic cancer surgeries between 2005 and 2014 were retrospectively collected by volunteer institutions in the Republic of Korea. Spearman's correlation and logistic regression analyses were used to compare robotic and laparoscopic surgery trends in general surgery.

Results: The odds that robotic surgery was performed instead of laparoscopic surgery significantly decreased in the fields of colorectal, stomach, and hepato-biliary-pancreatic surgery (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.93-0.97; OR: 0.90, 95% CI: 0.88-0.92; and OR: 0.71, 95% CI: 0.65-0.78, respectively), except for thyroid surgery (OR: 1.28, 95% CI: 1.25-1.30). Of the total numbers of each procedure, proportions of robotic intersphincteric resections, abdominoperineal resections, and pylorus-preserving surgery performed significantly increased (r = 0.98, P < .001; r = 0.78, P = .01; and r = 0.86, P = .007, respectively).

Conclusions: The use of robotic surgery failed to preponderate that of laparoscopic surgery, except for thyroid surgery. Robotic surgery is increasingly preferred for limited fields or complex surgeries, but the use of robotics in simple surgeries has decreased.
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http://dx.doi.org/10.1016/j.asjsur.2020.05.029DOI Listing
January 2021

Minimally invasive complete mesocolic excision for right colon cancer.

Ann Gastroenterol Surg 2020 May 7;4(3):234-242. Epub 2020 Apr 7.

Department of Surgery Korea University Anam Hospital Seoul South Korea.

Complete mesocolic excision (CME) with central vascular ligation (CVL) follows the same principles as the total mesorectal excision (TME) in the rectum of following the embryological planes for right-sided cancers. The number of lymph nodes yielded increased with a resultant improvement in the oncological outcomes and by reducing local recurrence rates. Hohenberger's radical CME and CVL and the East's modified CME with D3 lymphadenectomy, which traditionally followed the embryological plane dissection for most of its intraabdominal cancer resection, have both shown to harvest significantly higher number of lymph nodes leading to a higher overall survival rate than the traditional right hemicolectomies of the West. To achieve the oncologically superior excision of the CME, awareness of the significant vascular anatomical variation will enhance the precision of the oncosurgery as well as minimize the risk of vascular complications. There has been an increasing body of evidence emerging on the safety of minimally invasive surgery (MIS); both its oncological safety as well as complication rates in the hands of expert and trained surgeons. The surgical technique of a CME right hemicolectomy is described step by step to aid standardization. There is mounting evidence that CME + CVL/ D3 improves survival in patients with colon cancer. Whilst the technical aspect of MIS is more challenging than the left, with a standardized technique and systematic teaching method, safety and benefits for patients can be achieved.
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http://dx.doi.org/10.1002/ags3.12331DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240146PMC
May 2020

Association between Abdominal Obesity and Incident Colorectal Cancer: A Nationwide Cohort Study in Korea.

Cancers (Basel) 2020 May 26;12(6). Epub 2020 May 26.

Department of Surgery, College of Medicine, Korea University, Seoul 02841, Korea.

Background: We investigated the association of waist circumference (WC) and abdominal obesity with the incident colorectal cancer risk in Korean adults.

Methods: This nationwide population-based cohort study was based on health insurance claims data. We analyzed data from 9,959,605 participants acquired through health check-ups of the Korean National Health Insurance Service in 2009 who were followed up until the end of 2017. We performed multivariable Cox proportional hazards regression analysis.

Results: During 8.3 years of follow up, 101,197 cases (1.0%) of colorectal cancer were recorded. After adjusting for potential confounders, there was a positive association between WC and colorectal cancer risk ( for trend <0.001). Abdominal obesity was associated with an increased risk of colorectal (hazard ratio: 1.10, (95% confidence interval: 1.08-1.12)), colon (1.11, 1.09-1.13), and rectal cancer (1.08, 1.05-1.10). These associations were independent of body mass index and were more pronounced in men and elderly individuals.

Conclusion: We revealed that higher WC is related to colorectal cancer risk, thus suggesting that abdominal obesity may be a risk factor for colorectal cancer in this East Asian population.
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http://dx.doi.org/10.3390/cancers12061368DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352920PMC
May 2020

Upfront radical surgery with total mesorectal excision followed by adjuvant FOLFOX chemotherapy for locally advanced rectal cancer (TME-FOLFOX): an open-label, multicenter, phase II randomized controlled trial.

Trials 2020 Apr 7;21(1):320. Epub 2020 Apr 7.

Division of Medical Oncology, Department of Internal Medicine, Yonsei Cancer Center, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.

Background: Preoperative chemoradiotherapy (PCRT) followed by surgery and adjuvant chemotherapy is the current standard treatment for stage II/III rectal cancer. However, radiotherapy in the pelvic area is commonly associated with complications such as anastomotic leakage, sexual dysfunction, and fecal incontinence. Recently, the MERCURY study showed that preoperative high-resolution magnetic resonance imaging (MRI) helped to selectively avoid PCRT. It remains unclear whether PCRT is necessary in patients who can achieve a negative circumferential resection margin (CRM) with surgery alone and in patients with cTN or cTN without CRM involvement and lateral lymph node metastasis. This study aims to evaluate the efficacy of upfront radical surgery with total mesorectal excision (TME) followed by adjuvant chemotherapy with folinic acid (or leucovorin), fluorouracil, and oxaliplatin (FOLFOX) versus the current standard treatment in patients with surgically resectable, locally advanced rectal cancer.

Methods: This study, named TME-FOLFOX, is a prospective, open-label, multicenter, phase II randomized trial. Patients with locally advanced rectal cancer will be randomized to receive PCRT followed by TME and adjuvant chemotherapy (arm A) or upfront radical surgery with TME followed by adjuvant FOLFOX chemotherapy (arm B). Clinical stage II/III rectal cancer without CRM involvement and lateral lymph node metastasis will be defined using preoperative MRI. The primary endpoint is 3-year disease-free survival (DFS). Secondary endpoints include 5-year DFS, local recurrence rate, systemic recurrence rate, cost-effectiveness, and overall survival. We hypothesized that our experimental group (arm B) will have a 3-year DFS of 75% and a non-inferiority margin of 15%.

Discussion: Identifying whether patients require PCRT is one of the critical issues in locally advanced rectal cancer. This study aims to elucidate whether PCRT may not be required for all patients with stage II/III rectal cancer, especially for the MRI-based intermediate-risk group (with cTN or cTN) without CRM involvement and lateral lymph node metastasis. If the findings indicate that our proposed treatment, which omits PCRT, is non-inferior to the standard treatment, then patients may avoid unnecessary radiation-related toxicity, have a shorter treatment duration, and save on medical costs.

Trial Registration: ClinicalTrials.gov, NCT02167321. Registered on 19 June 2014.
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http://dx.doi.org/10.1186/s13063-020-04266-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7140505PMC
April 2020

Clinical Implication of Concordant or Discordant Genomic Profiling between Primary and Matched Metastatic Tissues in Patients with Colorectal Cancer.

Cancer Res Treat 2020 Jul 16;52(3):764-778. Epub 2020 Feb 16.

Division of Oncology, Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea.

Purpose: The purpose of this study was to identify the concordant or discordant genomic profiling between primary and matched metastatic tumors in patients with colorectal cancer (CRC) and to explore the clinical implication.

Materials And Methods: Surgical samples of primary and matched metastatic tissues from 158 patients (335 samples) with CRC at Korea University Anam Hospital were evaluated using the Ion AmpliSeq Cancer Hotspot Panel. We compared genetic variants and classified them as concordant, primary-specific, and metastasis-specific variants. We used a combination of principal components analysis and clustering to find genomic groups. Kaplan-Meier curves were used to appraise survival between genomic groups. We used machine learning to confirm the correlation between genetic variants and metastatic sites.

Results: A total of 282 types of deleterious non-synonymous variants were selected for analysis. Of a total of 897 variants, an average of 40% was discordant. Three genomic groups were yielded based on the genomic discrepancy patterns. Overall survival differed significantly between the genomic groups. The poorest group had the highest proportion of concordant KRAS G12V and additional metastasis-specific SMAD4. Correlation analysis between genetic variants and metastatic sites suggested that concordant KRAS mutations would have more disseminated metastases.

Conclusion: Driver gene mutations were mostly concordant; however, discordant or metastasis-specific mutations were present. Clinically, the concordant driver genetic changes with additional metastasis-specific variants can predict poor prognosis for patients with CRC.
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http://dx.doi.org/10.4143/crt.2020.044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7373863PMC
July 2020

Robotic surgery in colorectal cancer: the way forward or a passing fad.

J Gastrointest Oncol 2019 Dec;10(6):1222-1228

Colorectal Division, Department of Surgery, Korea University Anam Hospital, Seoul, South Korea.

Introduced mainly to overcome the technical limitations of laparoscopy, robotic colorectal surgery (CRS) has been touted to provide superior optics, ergonomics, and surgeon autonomy. This technological advancement is nonetheless associated with certain drawbacks, mainly involving its cost and the lack of unequivocal benefit over conventional laparoscopy. In this era of evidence-based medicine, robotic CRS remains predominantly a subject of individual institution case series, retrospective studies, matched comparisons at best, and repeated reviews of the above literature. This article provides a critique of the more contemporary data regarding the use of robotics in colorectal cancer surgery and the controversies surrounding the literature.
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http://dx.doi.org/10.21037/jgo.2019.04.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6955008PMC
December 2019

Clinical Outcomes of Ileostomy Closure According to Timing During Adjuvant Chemotherapy After Rectal Cancer Surgery.

Ann Coloproctol 2019 Aug 31;35(4):187-193. Epub 2019 Aug 31.

Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea.

Purpose: No guidelines exist detailing when to implement a temporary ileostomy closure in the setting of adjuvant chemotherapy following sphincter-saving surgery for rectal cancer. The aim of this study was to evaluate the clinical and oncological outcomes of ileostomy closure during adjuvant chemotherapy in patients with curative resection of rectal cancer.

Methods: This retrospective study investigated 220 patients with rectal cancer undergoing sphincter-saving surgery with protective loop ileostomy from January 2007 to August 2016. Patients were divided into 2 groups: group 1 (n = 161) who underwent stoma closure during adjuvant chemotherapy and group 2 (n = 59) who underwent stoma closure after adjuvant chemotherapy.

Results: No significant differences were observed in operative time, blood loss, postoperative hospital stay, or postoperative complications in ileostomy closure between the 2 groups. No difference in overall survival (P = 0.959) or disease-free survival (P = 0.114) was observed between the 2 groups.

Conclusion: Ileostomy closure during adjuvant chemotherapy was clinically safe, and interruption of chemotherapy due to ileostomy closure did not change oncologic outcomes.
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http://dx.doi.org/10.3393/ac.2018.10.18.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732323PMC
August 2019

Early Systemic Failure After Preoperative Chemoradiotherapy for the Treatment of Patients With Rectal Cancer.

Ann Coloproctol 2019 Apr 30;35(2):94-99. Epub 2019 Apr 30.

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

Purpose: Distant metastasis can occur early after neoadjuvant chemoradiotherapy (CRT) in patients with rectal cancer. This study was conducted to evaluate the clinical characteristics of patients who developed early systemic failure.

Methods: The patients who underwent neoadjuvant CRT for a rectal adenocarcinoma between June 2007 and July 2015 were included in this study. Patients who developed distant metastasis within 6 months after CRT were identified. We compared short- and long-term clinicopathologic outcomes of patients in the early failure (EF) group with those of patients in the control group.

Results: Of 107 patients who underwent neoadjuvant CRT for rectal cancer, 7 developed early systemic failure. The lung was the most common metastatic site. In the EF group, preoperative carcinoembryonic antigen was higher (5 mg/mL vs. 2 mg/mL, P = 0.010), and capecitabine as a sensitizer of CRT was used more frequently (28.6% vs. 3%, P = 0.002). Of the 7 patients in the EF group, only 4 underwent a primary tumor resection (57.1%), in contrast to the 100% resection rate in the control group (P < 0.001). In terms of pathologic outcomes, ypN and TNM stages were more advanced in the EF group (P < 0.001 and P = 0.047, respectively), and numbers of positive and retrieved lymph nodes were much higher (P < 0.001 and P = 0.027, respectively).

Conclusion: Although early distant metastasis after CRT for rectal cancer is very rare, patients who developed early metastasis showed a poor nodal response with a low primary tumor resection rate and poor oncologic outcomes.
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http://dx.doi.org/10.3393/ac.2018.08.28DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6529755PMC
April 2019

Meta-Analysis of the Impact of the Learning Curve in Robotic Rectal Cancer Surgery on Histopathologic Outcomes.

Surg Technol Int 2019 May;34:139-155

Section of Colorectal Surgery, New York Medical College, Westchester Medical Center Valhalla, NY.

Introduction: Although the process of learning robotic surgery for rectal cancer is associated with a prolonged operating time and higher complication rates, its impact on histopathologic outcomes is unknown. The aim of this meta-analysis was to evaluate the impact of the learning curve in robotic surgery for rectal cancer on histopathologic outcomes.

Methods: The PubMed, EMBASE, Cochrane Library, MEDLINE via Ovid, CINAHL, and Web of Science databases were systematically searched. The inclusion criterion was any clinical study comparing the outcomes of robotic surgery for rectal cancer between different phases of the learning curve (LC) including competence (C). The primary endpoint was the circumferential resection margin (CRM) involvement rate defined as CRM ≤1 mm. The Mantel-Haenszel method with odds ratios with 95% confidence intervals (OR (95%CI)) was used for dichotomous variables.

Results: Ten studies including a total of 907 patients (521 LC and 386 C) were selected. Nine studies were found to have a low risk of bias, and one had a moderate risk of bias. The CRM involvement rate was 2.9% (13/441) for learning curve vs. 4.6% (13/284) for competence. This difference was not significant (OR (95%CI) = 0.70 (0.30, 1.60); p=0.39; I2=0%).

Conclusion: A surgeon's learning curve seems to have no impact on CRM involvement rates compared to surgeon competence in robotic surgery for rectal cancer.
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May 2019

International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer.

Gastroenterol Rep (Oxf) 2019 Feb 23;7(1):24-31. Epub 2019 Jan 23.

Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China.

In recent years, natural orifice specimen extraction surgery (NOSES) in the treatment of colorectal cancer has attracted widespread attention. The potential benefits of NOSES including reduction in postoperative pain and wound complications, less use of postoperative analgesic, faster recovery of bowel function, shorter length of hospital stay, better cosmetic and psychological effect have been described in colorectal surgery. Despite significant decrease in surgical trauma of NOSES have been observed, the potential pitfalls of this technique have been demonstrated. Particularly, several issues including bacteriological concerns, oncological outcomes and patient selection are raised with this new technique. Therefore, it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery. After three rounds of discussion by all members of the International Alliance of NOSES, the consensus is finally completed, which is also of great significance to the long-term progress of NOSES worldwide.
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http://dx.doi.org/10.1093/gastro/goy055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6375350PMC
February 2019

Anastomotic Sinus That Developed From Leakage After a Rectal Cancer Resection: Should We Wait for Closure of the Stoma Until the Complete Resolution of the Sinus?

Ann Coloproctol 2019 Feb 25;35(1):30-35. Epub 2019 Jan 25.

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

Purpose: The aims of this study were to identify the clinical characteristics of an anastomotic sinus and to assess the validity of delaying stoma closure in patients until the complete resolution of an anastomotic sinus.

Methods: The subject patients are those who had undergone a resection of rectal cancer from 2011 to 2017, who had a diversion ileostomy protectively or therapeutically and who developed a sinus as a sequelae of anastomotic leakage. The primary outcomes that were measured were the incidence, management and outcomes of an anastomotic sinus.

Results: Of the 876 patients who had undergone a low anterior resection, 14 (1.6%) were found to have had an anastomotic sinus on sigmoidoscopy or a gastrografin enema before their ileostomy closure. In the 14 patients with a sinus, 7 underwent ileostomy closure as scheduled, with a mean closure time of 4.1 months. The remaining 7 patients underwent ileostomy repair, but it was delayed until after the follow-up for the widening of the sinus opening by using digital dilation, with a mean closure time of 6.9 months. Four of those remaining seven patients underwent stoma closure even though their sinus condition had not yet been completely resolved. No pelvic septic complications occurred after closure in any of the 14 patients with an anastomotic sinus, but 2 of the 14 needed a rediversion due to a severe anastomotic stricture.

Conclusion: Patients with an anastomotic sinus who had been carefully selected underwent successful ileostomy closure without delay.
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http://dx.doi.org/10.3393/ac.2018.08.13DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6425247PMC
February 2019

A Multicenter Matched Comparison of Transanal and Robotic Total Mesorectal Excision for Mid and Low-rectal Adenocarcinoma.

Ann Surg 2019 12;270(6):1110-1116

Department of Colorectal Surgery, Florida Hospital, Orlando, FL.

Objective: To compare the quality of surgical resection of transanal total mesorectal excision (TA-TME) and robotic total mesorectal excision (R-TME).

Background: Both TA-TME and R-TME have been advocated to improve the quality of surgery for rectal cancer below 10 cm from the anal verge, but there are little data comparing TA-TME and R-TME.

Methods: Data of patients undergoing TA-TME or R-TME for rectal cancer below 10 cm from the anal verge and a sphincter-saving procedure from 5 high-volume rectal cancer referral centers between 2011 and 2017 were obtained. Coarsened exact matching was used to create balanced cohorts of TA-TME and R-TME. The main outcome was the incidence of poor-quality surgical resection, defined as a composite measure including incomplete quality of TME, or positive circumferential resection margin (CRM) or distal resection margin (DRM).

Results: Out of a total of 730 patients (277 TA-TME, 453 R-TME), matched groups of 226 TA-TME and 370 R-TME patients were created. These groups were well-balanced. The mean tumor height from the anal verge was 5.6 cm (SD 2.5), and 70% received preoperative radiotherapy. The incidence of poor-quality resection was similar in both groups (TA-TME 6.9% vs R-TME 6.8%; P = 0.954). There were no differences in TME specimen quality (complete or near-complete TA-TME 99.1% vs R-TME 99.2%; P = 0.923) and CRM (5.6% vs 6.0%; P = 0.839). DRM involvement may be higher after TA-TME (1.8% vs 0.3%; P = 0.051).

Conclusions: High-quality TME for patients with rectal adenocarcinoma of the mid and low rectum can be equally achieved by transanal or robotic approaches in skilled hands, but attention should be paid to the distal margin.
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http://dx.doi.org/10.1097/SLA.0000000000002862DOI Listing
December 2019

Analysis of reduced-dose administration of oxaliplatin as adjuvant FOLFOX chemotherapy for colorectal cancer.

Ann Surg Treat Res 2018 Apr 26;94(4):196-202. Epub 2018 Mar 26.

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

Purpose: An oxaliplatin-based regimen is the most common adjuvant chemotherapy for patients with stage II/III colorectal cancer, but many patients experience dose reduction or early termination of chemotherapy due to side effects. We conducted this study to verify the range of reduction with oncologic safety.

Methods: Patients with stage II/III colorectal cancer who received adjuvant FOLFOX chemotherapy were enrolled in this study. The total amount of oxaliplatin administered per patient was calculated as a percentile based on 12 cycles of full-dose FOLFOX as a standard dose. The cutoff values showing significant differences in survival were calculated, and the clinicopathologic outcomes of patient groups classified by the value were compared.

Results: Among a total of 611 patients, there were 107 stage II patients, and 504 stage III patients. At 60% of the standard dose of oxaliplatin, the patients in the dose reduction group were older (62 years . 58 years, P = 0.003), had lower body mass index (BMI) (23.1 kg/m. 24.0 kg/m, P = 0.005), and were more exposed to neoadjuvant treatment (18.0% . 9.1%, P = 0.003) in comparison to the standard group. At 60% of the standard dose, there were no significant differences in 5-year disease-free survival (DFS) and overall survival (OS) between the 2 groups (5-year DFS: 73.5% . 74.2%, P = 0.519; 5-year OS: 71.9% . 81.5%, P = 0.256, respectively).

Conclusion: Patients with old age, low BMI, and more frequent exposure to neoadjuvant treatment tended to show lower compliance with chemotherapy. More than 60% dose should be administered to patients with stage II/III colorectal cancer as adjuvant chemotherapy to achieve acceptable oncologic outcomes.
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http://dx.doi.org/10.4174/astr.2018.94.4.196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880977PMC
April 2018

Robotic colorectal surgery: more than a fantastic toy?

Innov Surg Sci 2018 Mar 21;3(1):65-68. Epub 2018 Mar 21.

Division of Colorectal Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, 02841, Inchon-ro 73, Seongbuk-gu,Seoul, Korea.

There has been a rapid rise in the number of robotic colorectal procedures worldwide since the da Vinci Surgical System robotic technology was approved for surgical procedures in the year 2000. Several recent meta-analyses and systematic reviews have shown a significant difference in outcomes between robotic and laparoscopic rectal cancer surgery. However, these results from pooled data have not been supported by the initial results reported from the Robotic assisted versus laparoscopic assisted resection for rectal cancer trial. In this article, we examine the current evidence for robotic colorectal surgery, assess its features and functionality, evaluate its learning curve and provide our perspective on its future.
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http://dx.doi.org/10.1515/iss-2017-0046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6754041PMC
March 2018
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