Publications by authors named "Yoo Seok Yoon"

202 Publications

Management of indeterminate hepatic nodules and evaluation of factors predicting their malignant potential in patients with colorectal cancer.

Sci Rep 2021 Jul 2;11(1):13744. Epub 2021 Jul 2.

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gumi-ro 173, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.

Some liver nodules remain indeterminate despite hepatocyte-specific contrast MRI in patients with colorectal liver metastasis (CRLM). Our objective was to study the natural course and evaluate possible treatment strategies for indeterminate nodules. We retrospectively evaluated patients in whom MRI revealed 'indeterminate' or 'equivocal' nodules between January 2008 and October 2018. Patients were followed up until October 2019 or until death (median, 18 months; (1-130 months)). The incidence of patients with indeterminate nodules on MRI was 15.4% (60 of 389). The sensitivity and specificity of intraoperative ultrasound for detecting indeterminate nodules were 73.68% and 93.75%, respectively, with a positive predictive value of 96.6%. Over half of the patients followed up had benign nodules (58.8%). By comparing characteristics of patients with benign or malignant nodules in the follow up group, the ratio of positive lymph nodes to total number of lymph nodes resected (pLNR) was significantly greater in patients with malignant nodules (P = 0.006). Intraoperative ultrasound could be considered as an adjunct to MRI in patients with indeterminate nodules owing to its high positive predictive value. The pLNR could be used to help select which patients can undergo conservative therapy, at least in metachronous CRLM.
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http://dx.doi.org/10.1038/s41598-021-93339-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8253834PMC
July 2021

Minimally Invasive Versus Open Pancreatectomy for Right-Sided and Left-Sided G1/G2 Nonfunctioning Pancreatic Neuroendocrine Tumors: A Multicenter Matched Analysis with an Inverse Probability of Treatment-Weighting Method.

Ann Surg Oncol 2021 May 9. Epub 2021 May 9.

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

Background: Limited evidence exists for the safety and oncologic efficacy of minimally invasive surgery (MIS) for nonfunctioning pancreatic neuroendocrine tumors (NF-PNETs) according to tumor location. This study aimed to compare the surgical outcomes of MIS and open surgery (OS) for right- or left-sided NF-PNETs.

Methods: The study collected data on patients who underwent surgical resection (pancreatoduodenectomy, distal/total/central pancreatectomy, duodenum-preserving pancreas head resection, or enucleation) of a localized NF-PNET between January 2000 and July 2017 at 14 institutions. The inverse probability of treatment-weighting method with propensity scores was used for analysis.

Results: The study enrolled 859 patients: 478 OS and 381 MIS patients. A matched analysis by tumor location showed no differences in resection margin, intraoperative blood loss, or complications between MIS and OS. However, MIS was associated with a longer operation time for right-sided tumors (393.3 vs 316.7 min; P < 0.001) and a shorter postoperative hospital stay for left-sided tumors (8.9 vs 12.9 days; P < 0.01). The MIS group was associated with significantly higher survival rates than the OS group for right- and left-sided tumors, but survival did not differ for the patients divided by tumor grade and location. Multivariable analysis showed that MIS did not affect survival for any tumor location.

Conclusion: The short-term outcomes offered by MIS were comparable with those of OS except for a longer operation time for right-sided NF-PNETs. The oncologic outcomes were not compromised by MIS regardless of tumor location or grade. These findings suggest that MIS can be performed safely for selected patients with localized NF-PNETs.
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http://dx.doi.org/10.1245/s10434-021-10092-0DOI Listing
May 2021

Development and External Validation of Survival Prediction Model for Pancreatic Cancer Using Two Nationwide Database: Surveillance, Epidemiology and End Results (SEER) and Korea Tumor Registry System-Biliary Pancreas (KOTUS-BP).

Gut Liver 2021 May 7. Epub 2021 May 7.

Department of Statistics and Interdisciplinary Program in Bioinformatics, Seoul National University, Seoul, Korea.

Background/aims: Several prediction models for evaluating the prognosis of nonmetastatic resected pancreatic ductal adenocarcinoma (PDAC) have been developed, and their performances were reported to be superior to that of the 8th edition of the American Joint Committee on Cancer (AJCC) staging system. We developed a prediction model to evaluate the prognosis of resected PDAC and externally validated it with data from a nationwide Korean database.

Methods: Data from the Surveillance, Epidemiology and End Results (SEER) database were utilized for model development, and data from the Korea Tumor Registry System-Biliary Pancreas (KOTUS-BP) database were used for external validation. Potential candidate variables for model development were age, sex, histologic differentiation, tumor location, adjuvant chemotherapy, and the AJCC 8th staging system T and N stages. For external validation, the concordance index (C-index) and time-dependent area under the receiver operating characteristic curve (AUC) were evaluated.

Results: Between 2004 and 2016, data from 9,624 patients were utilized for model development, and data from 3,282 patients were used for external validation. In the multivariate Cox proportional hazard model, age, sex, tumor location, T and N stages, histologic differentiation, and adjuvant chemotherapy were independent prognostic factors for resected PDAC. After an exhaustive search and 10-fold cross validation, the best model was finally developed, which included all prognostic variables. The C-index, 1-year, 2-year, 3-year, and 5-year time-dependent AUCs were 0.628, 0.650, 0.665, 0.675, and 0.686, respectively.

Conclusions: The survival prediction model for resected PDAC could provide quantitative survival probabilities with reliable performance. External validation studies with other nationwide databases are needed to evaluate the performance of this model.
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http://dx.doi.org/10.5009/gnl20306DOI Listing
May 2021

Four-Tier Pathologic Tumor Regression Grading System Predicts the Clinical Outcome in Patients Who Undergo Surgical Resection for Locally Advanced Pancreatic Cancer after Neoadjuvant Chemotherapy.

Gut Liver 2021 Apr 23. Epub 2021 Apr 23.

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

Background/aims: Neoadjuvant chemotherapy is increasingly utilized in patients with borderline or locally advanced pancreatic cancer (LAPC). However, the pathologic evaluation of tumor regression is not routinely performed or well established. We aimed to evaluate the prognostic value of three tumor regression grading systems frequently used in LAPC and to determine the correlation between pathologic and clinical response.

Methods: We included a total of 38 patients with LAPC who were treated with neoadjuvant chemotherapy and subsequent resection. Pathologic tumor regression was graded based on the College of American Pathologists (CAP), Evans, and MD Anderson grading systems.

Results: One out of 38 patients (2.6%) achieved a pathologic complete response. Unlike other grading systems (Evans, p=0.063; MD Anderson, p=0.110), the CAP grading system was a significant prognostic factor for overall survival (p=0.043). Pathologic N stage (p=0.023), margin status (p=0.044), and radiologic response (p=0.016) correlated with overall survival. In the multivariate analysis, CAP 3 was an independent predictor of shorter overall survival (p=0.026). The CAP grading system correlated with the radiologic response (p=0.007) but not the carbohydrate antigen 19-9 level (p=0.333).

Conclusions: The four-tier CAP pathologic tumor regression grading system predicted the clinical outcome in LAPC patients who underwent resection after neoadjuvant chemotherapy. Therefore, a more comprehensive pathologic evaluation is warranted in these patients.
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http://dx.doi.org/10.5009/gnl20312DOI Listing
April 2021

Development, validation, and comparison of a nomogram based on radiologic findings for predicting malignancy in intraductal papillary mucinous neoplasms of the pancreas: An international multicenter study.

J Hepatobiliary Pancreat Sci 2021 Apr 2. Epub 2021 Apr 2.

Department of Surgery, Sungkyunkwan University School of Medicine, Seoul, South Korea.

Background: Although we previously proposed a nomogram to predict malignancy in intraductal papillary mucinous neoplasms (IPMN) and validated it in an external cohort, its application is challenging without data on tumor markers. Moreover, existing nomograms have not been compared. This study aimed to develop a nomogram based on radiologic findings and to compare its performance with previously proposed American and Korean/Japanese nomograms.

Methods: We recruited 3708 patients who underwent surgical resection at 31 tertiary institutions in eight countries, and patients with main pancreatic duct >10 mm were excluded. To construct the nomogram, 2606 patients were randomly allocated 1:1 into training and internal validation sets, and area under the receiver operating characteristics curve (AUC) was calculated using 10-fold cross validation by exhaustive search. This nomogram was then validated and compared to the American and Korean/Japanese nomograms using 1102 patients.

Results: Among the 2606 patients, 90 had main-duct type, 900 had branch-duct type, and 1616 had mixed-type IPMN. Pathologic results revealed 1628 low-grade dysplasia, 476 high-grade dysplasia, and 502 invasive carcinoma. Location, cyst size, duct dilatation, and mural nodule were selected to construct the nomogram. AUC of this nomogram was higher than the American nomogram (0.691 vs 0.664, P = .014) and comparable with the Korean/Japanese nomogram (0.659 vs 0.653, P = .255).

Conclusions: A novel nomogram based on radiologic findings of IPMN is competitive for predicting risk of malignancy. This nomogram would be clinically helpful in circumstances where tumor markers are not available. The nomogram is freely available at http://statgen.snu.ac.kr/software/nomogramIPMN.
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http://dx.doi.org/10.1002/jhbp.962DOI Listing
April 2021

Tailored adjuvant gemcitabine versus 5-fluorouracil/folinic acid based on hENT1 immunohistochemical staining in resected pancreatic ductal adenocarcinoma: A biomarker stratified prospective trial.

Pancreatology 2021 Jun 4;21(4):796-804. Epub 2021 Mar 4.

Division of Gastroenterology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea. Electronic address:

Background: The study aimed to evaluate the clinical outcomes of tailored adjuvant chemotherapy according to human equilibrative nucleoside transporter 1 (hENT1) expression in resected pancreatic ductal adenocarcinoma (PDA).

Methods: Patients who underwent pancreatectomy for PDA were enrolled prospectively. According to intra-tumoral hENT1 expression, the high hENT1 (≥50%) group received gemcitabine and the low hENT1 (<50%) group received 5-fluorouracil plus folinic acid (5-FU/FA). The propensity score-matched control consisted of patients who received hENT1-independent adjuvant chemotherapy. The primary outcome was recurrence free survival (RFS) and the secondary outcomes were overall survival (OS) and toxicities.

Results: Between May 2015 and June 2017, we enrolled 44 patients with resected PDA. During a median follow-up period of 28.5 months, the intention-to-treat population showed much longer median RFS [22.9 (95% CI, 11.3-34.5) vs. 10.9 (95% CI, 6.9-14.9) months, P = 0.043] and median OS [36.2 (95% CI, 26.5-45.9) vs. 22.1 (95% CI, 17.7-26.6) months, P = 0.001] compared to the controls. Among 5 patients in the low hENT1 group who discontinued treatment, 2 patients receiving 5-FU/FA discontinued treatment due to drug toxicities (febrile neutropenia and toxic epidermal necrolysis).

Conclusion: Tailored adjuvant chemotherapy based on hENT1 staining provides excellent clinical outcomes among patients with resected PDA.

Clinical Trial Registration: clinicaltrials.gov identifier: NCT02486497.
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http://dx.doi.org/10.1016/j.pan.2021.02.022DOI Listing
June 2021

Hepatic Artery Embolization for Postoperative Hemorrhage: Importance of Arterial Collateral Vessels and Portal Venous Impairment.

J Vasc Interv Radiol 2021 06 10;32(6):826-834. Epub 2021 Mar 10.

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

Purpose: To investigate the association between hepatic ischemic complications and hepatic artery (HA) collateral vessels and portal venous (PV) impairment after HA embolization for postoperative hemorrhage.

Materials And Methods: From October 2003 to November 2019, 42 patients underwent HA embolization for postoperative hemorrhage. HA collateral vessels were classified according to visualization after embolization (grade 1, none; grade 2, 1-4 segmental HA; and grade 3, ≥4 segmental HA). Transhepatic portal vein stent placements were performed in the same session for 5 patients (11.9%) with poor HA collateral vessels (grade 1 or 2) and compromised PV flow (>70% stenosis). Hepatic ischemic complications were analyzed for relevance to HA collateral vessels and PV compromise.

Results: After HA embolization, HA flow was found to be preserved (grade 3) through intra- and/or extrahepatic collateral vessels in 23 patients (54.8%), and hepatic complications did not occur regardless of PV flow status (0%). Of the 19 patients (45.2%) with poor HA collateral vessels (grade 1 or 2), segmental hepatic infarction occurred in 2 of 15 patients (13.3%) with preserved PV flow (10 naïve and 5 stented). The remaining 4 patients with poor HA collateral vessels and untreated compromised PV flow experienced multisegmental hepatic infarction (n = 3) or hepatic failure (n = 1) (100%) (P < .005).

Conclusions: After HA embolization, preserved HA flow (≥4 segmental HA) lowered the risk of hepatic complications regardless of the PV flow. Based on these findings, transhepatic PV stent placement seems to be an effective intervention for the prevention of hepatic complications in cases of poor HA collateral vessels and compromised PV flow.
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http://dx.doi.org/10.1016/j.jvir.2021.03.412DOI Listing
June 2021

Effect of Enhanced Recovery After Surgery program on hospital stay and 90-day readmission after pancreaticoduodenectomy: a single, tertiary center experience in Korea.

Ann Surg Treat Res 2021 Feb 1;100(2):76-85. Epub 2021 Feb 1.

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

Purpose: Despite increasing number of reports on Enhanced Recovery After Surgery program (ERAS) and readmission after pancreaticoduodenectomy (PD) from Western countries, there are very few reports on this topic from Asian countries. This study aimed to evaluate the effects of ERAS on hospital stay and readmission and to identify reasons and risk factors for readmission after PD.

Methods: This retrospective cohort study included 670 patients who underwent open PD from January 2003 to December 2017. The patients were classified into ERAS (n = 352) and non-ERAS (n = 318) groups. Patients' characteristics, perioperative outcomes, and readmission rates were compared.

Results: There were no significant differences in the postoperative complication rates between the groups. The mean postoperative hospital stay was significantly shorter in the ERAS group (24.5 18.0 days, P < 0.001), but the 90-day readmission rate was similar in the 2 groups (9.1% 8.5%, P = 0.785). Complications associated with pancreatic fistula (42.4%) were the most common cause for readmission. In the multivariate analysis, diabetes mellitus (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.05-3.24; P = 0.034), preoperative non-jaundice (OR, 0.45; 95% CI, 0.25-0.82; P = 0.009) and severe postoperative complications (OR, 4.12; 95% CI, 2.34-7.26; P < 0.001) were identified as risk factors for readmission.

Conclusion: The results confirmed that the ERAS program for PD was beneficial in reducing postoperative stay without increasing readmission risks. To decrease readmission rates, prudent discharge planning and medical support should be considered in patients who experience severe complications.
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http://dx.doi.org/10.4174/astr.2021.100.2.76DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870429PMC
February 2021

Precision vascular anatomy for minimally invasive distal pancreatectomy: A systematic review.

J Hepatobiliary Pancreat Sci 2021 Feb 1. Epub 2021 Feb 1.

Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.

Background: Minimally invasive distal pancreatectomy (MIDP) is increasingly performed worldwide; however, the surgical anatomy required to safely perform MIDP has not yet been fully considered. This review evaluated the literature concerning peripancreatic vascular anatomy, which is considered important to conduct safe MIDP.

Methods: A database search of PubMed and Ichushi (Japanese) was conducted. Qualified studies investigating the anatomical variations of peripancreatic vessels related to MIDP were evaluated using SIGN methodology.

Results: Of 701 articles yielded by our search strategy, 76 articles were assessed in this systematic review. The important vascular anatomy required to recognize MIDP included the pancreatic parenchymal coverage on the root and the running course of the splenic artery, branching patterns of the splenic artery, confluence positions of the left gastric vein and the inferior mesenteric vein, forms of pancreatic veins including the centro-inferior pancreatic vein, characteristics of the left renal vein, and collateral routes perfusing the spleen following Warshaw's technique. Very few articles evaluating the relationship between the anatomical variations and surgical outcomes of MIDP were found.

Conclusions: The precise knowledge of peripancreatic vessels is important to adequately complete MIDP. More detailed anatomic analyses and descriptions will benefit surgeons and their patients who are facing these operations.
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http://dx.doi.org/10.1002/jhbp.903DOI Listing
February 2021

Improved Outcomes of Laparoscopic Liver Resection for Hepatocellular Carcinoma Located in Posterosuperior Segments of the Liver.

World J Surg 2021 Apr 13;45(4):1178-1185. Epub 2021 Jan 13.

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Gumi-ro 173, Gyeonggi-do, Bundang-gu, 13620, Seongnam-si, Republic of Korea.

Background: LLR is widely adapted for HCC, while LLR in PS segments is still challenging. With recent improvement of techniques and accumulation of experiences, LLR in PS segments is feasible, but studies investigating the result after the modifications are lacking.

Methods: In this single-center, retrospective study, 149 patients who underwent LLR for HCC located in PS segments from September 2003 to December 2016 were analyzed. The patients were divided into Group 1 (n=43) and Group 2 (n=106) who underwent LLR before and after 2012, respectively, when advanced techniques including use of intercostal trocars, Pringle maneuver, and semi-lateral position of patient were introduced. Also, these patients were compared with those who underwent open liver resection (OLR; n=124) for HCC in PS segments during the same period.

Results: Mean operative time (394.7 minutes vs 331.2 minutes; P=0.013), intraoperative blood loss (1545.8 ml vs 1208.2 ml; P=0.020), and hospital stay (11.6 days vs 9.2, P<0.001) were significantly less in Group 2. Postoperative complication rate (18.6% vs 18.9%; P=0.970), open conversion rate (23% vs 17%; P=0.374), 5-year overall (79% vs 89%; P=0.607) and 5-year disease-free (52% vs 53%; P=0.657) survival rates were not significantly different between the groups. Compared to the OLR group, complication rate (40.3% vs 18.8%; P< 0.001) and hospital stay (17.6 days vs 9.7 days; P< 0.001) were significantly lower in the LLR group.

Conclusion: The complexity of LLR for HCC in PS segments is being gradually overcome by the introduction of advanced techniques.
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http://dx.doi.org/10.1007/s00268-020-05912-5DOI Listing
April 2021

The clinical significance of preoperative C-reactive protein/albumin ratio in patients with resected extrahepatic bile duct cancer.

Surg Today 2021 Jun 2;51(6):978-985. Epub 2021 Jan 2.

Division of Gastroenterology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea.

Purpose: The C-reactive protein (CRP)/albumin ratio has been identified as a potential prognostic factor for several malignancies. We, therefore, assessed the prognostic role of the CRP/albumin ratio in resected extrahepatic cholangiocarcinoma (EC).

Materials And Methods: A total of 235 patients were retrospectively analyzed between March 2005 and December 2017. The correlations among the preoperative CRP/albumin ratio, clinicopathological factors, and clinical outcomes were investigated.

Results: There were 143 males (60.8%), and the median age at the diagnosis was 70.1 (range 41.0-85.5) years. Patients were diagnosed with perihilar bile duct cancer (n = 61) and distal bile duct cancer (n = 174). The median recurrence-free survival and overall survival were 32.7 and 38.7 months, respectively. The optimal prognostic cut-off point of the CRP/albumin ratio for the survival was 0.18 (× 10). According to the Kaplan-Meier analysis with a log-rank test, the high CRP/albumin ratio group (≥ 0.18) had a significantly shorter overall survival than the low CRP/albumin ratio group (< 0.18) (29.8 vs. 54.6 months, p = 0.002). A multivariate logistic regression analysis for the overall survival showed that CA19-9 ≥ 37 and a high CRP/albumin ratio were associated with a shorter overall survival.

Conclusion: A high CRP/albumin ratio appears to be significantly associated with clinically worse outcomes in patients with resected EC.
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http://dx.doi.org/10.1007/s00595-020-02188-zDOI Listing
June 2021

Neutrophil-to-lymphocyte ratio predicts early acute cellular rejection in living donor liver transplantation.

Ann Surg Treat Res 2020 Dec 26;99(6):337-343. Epub 2020 Nov 26.

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

Purpose: The aim of this study was to evaluate the predictive value of neutrophil-to-lymphocyte ratio (NLR) in acute cellular rejection (ACR) after living donor liver transplantation (LDLT).

Methods: All consecutive patients who underwent ABO-compatible (ABOc) LDLT from September 2014 to December 2017 were retrospectively reviewed. NLR was calculated on 3 occasions; (1) 4 weeks prior to liver transplantation (LT), (2) the day of LT, and (3) the day before liver biopsy.

Results: Among 66 patients who underwent ABOc LDLT, ACR was identified in 15 patients (22.7%) on protocol liver biopsy performed routinely on the postoperative day 7. There was no significant difference in NLR at 4 weeks prior to LT and the day of LT between no-ACR and ACR group (2.98 ± 1.92 2.54 ± 1.15, P = 0.433; 17.9 ± 8.31 20.5 ± 13.4, P = 0.393). However, NLR was significantly lower in ACR group compared to non-ACR group just prior to liver biopsy (5.82 ± 3.42 18.4 ± 17.2, P = 0.035). NLR tends to decrease 3.5 days before the onset of ACR. The area under the receiver operating characteristic curve for optimal cut-off value of NLR was 6.49, with sensitivity and specificity of 80.4% and 73.3% respectively.

Conclusion: NLR has a potential as a noninvasive predictor of early ACR in ABOc LDLT.
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http://dx.doi.org/10.4174/astr.2020.99.6.337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7704271PMC
December 2020

Risk prediction for malignant intraductal papillary mucinous neoplasm of the pancreas: logistic regression versus machine learning.

Sci Rep 2020 11 18;10(1):20140. Epub 2020 Nov 18.

Pancreatic Surgery Unit, Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute At Center for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.

Most models for predicting malignant pancreatic intraductal papillary mucinous neoplasms were developed based on logistic regression (LR) analysis. Our study aimed to develop risk prediction models using machine learning (ML) and LR techniques and compare their performances. This was a multinational, multi-institutional, retrospective study. Clinical variables including age, sex, main duct diameter, cyst size, mural nodule, and tumour location were factors considered for model development (MD). After the division into a MD set and a test set (2:1), the best ML and LR models were developed by training with the MD set using a tenfold cross validation. The test area under the receiver operating curves (AUCs) of the two models were calculated using an independent test set. A total of 3,708 patients were included. The stacked ensemble algorithm in the ML model and variable combinations containing all variables in the LR model were the most chosen during 200 repetitions. After 200 repetitions, the mean AUCs of the ML and LR models were comparable (0.725 vs. 0.725). The performances of the ML and LR models were comparable. The LR model was more practical than ML counterpart, because of its convenience in clinical use and simple interpretability.
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http://dx.doi.org/10.1038/s41598-020-76974-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676251PMC
November 2020

Clinical practice guidelines for the management of liver metastases from extrahepatic primary cancers 2021.

J Hepatobiliary Pancreat Sci 2021 Jan 12;28(1):1-25. Epub 2020 Dec 12.

Division of Public Health, Osaka Institute of Public Health, Higashinari, Japan.

Background: Hepatectomy is standard treatment for colorectal liver metastases; however, it is unclear whether liver metastases from other primary cancers should be resected or not. The Japanese Society of Hepato-Biliary-Pancreatic Surgery therefore created clinical practice guidelines for the management of metastatic liver tumors.

Methods: Eight primary diseases were selected based on the number of hepatectomies performed for each malignancy per year. Clinical questions were structured in the population, intervention, comparison, and outcomes (PICO) format. Systematic reviews were performed, and the strength of recommendations and the level of quality of evidence for each clinical question were discussed and determined. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations.

Results: The eight primary sites were grouped into five categories based on suggested indications for hepatectomy and consensus of the guidelines committee. Fourteen clinical questions were devised, covering five topics: (1) diagnosis, (2) operative treatment, (3) ablation therapy, (4) the eight primary diseases, and (5) systemic therapies. The grade of recommendation was strong for one clinical question and weak for the other 13 clinical questions. The quality of the evidence was moderate for two questions, low for 10, and very low for two. A flowchart was made to summarize the outcomes of the guidelines for the indications of hepatectomy and systemic therapy.

Conclusions: These guidelines were developed to provide useful information based on evidence in the published literature for the clinical management of liver metastases, and they could be helpful for conducting future clinical trials to provide higher-quality evidence.
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http://dx.doi.org/10.1002/jhbp.868DOI Listing
January 2021

Fistula risk score-adjusted comparison of postoperative pancreatic fistula following laparoscopic vs open pancreatoduodenectomy.

J Hepatobiliary Pancreat Sci 2020 Nov 10. Epub 2020 Nov 10.

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

Background: To evaluate a risk-adjusted comparison of clinically relevant postoperative pancreatic fistula POPF (CR-POPF) following laparoscopic pancreatoduodenectomy (LPD) vs open pancreatoduodenectomy (OPD) using the fistula risk score (FRS).

Methods: We retrospectively analyzed 579 patients who underwent LPD (n = 274) or OPD (n = 305) between 2012 and 2019 at two tertiary hospitals. Using the FRS, the risk was stratified into four categories; negligible, low, intermediate and high risk.

Results: The median FRS was significantly higher in the LPD than in the OPD group (5.4 ± 1.2 vs 3.9 ± 1.8, P < .001). The overall incidence of CR-POPF in the LPD vs OPD groups were 16.4% vs 17.7% (P = .187). When POPF risks were stratified by FRS, CR-POPF following LPD vs OPD in patients with low risk (0% vs 6.3%, P = .294), intermediate risk (16.1% vs 22.9%, P = .053) and high risk (33.3% vs 27.3%, P = .577) were not significantly different.

Conclusion: Despite a higher risk score in the LPD group, the CR-POPF was similar following both procedures in the unadjusted and FRS-risk-adjusted comparisons. The CR-POPF was more significantly affected by patient risk factors such as the soft pancreas and small pancreatic duct.
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http://dx.doi.org/10.1002/jhbp.866DOI Listing
November 2020

Impact of preoperative malnutrition, based on albumin level and body mass index, on operative outcomes in patients with pancreatic head cancer.

J Hepatobiliary Pancreat Sci 2020 Oct 31. Epub 2020 Oct 31.

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

Background: To investigate whether preoperative malnutrition in patients who underwent curative pancreaticoduodenectomy (PD) in pancreatic head cancer correlated with short-term outcomes.

Methods: This study was a retrospective review of medical records from January 2004 to December 2018. Preoperative malnutrition was defined as body mass index (BMI) <18.5 kg/m , or hypoalbuminemia with serum albumin level < 3.5 g/dL within 30 days before surgery.

Results: Of the 289 eligible patients, 60 patients (20.7%) were classified as the malnutrition group. The estimated blood loss (EBL, mL) (964.1 ± 879.7 vs 597.7 ± 501.7, P = .044) and transfusion rate (51.7% vs 18.8%, P < .001) was significantly higher in the malnutrition group than no-malnutrition group. The hospital stay (days) (20.5 ± 12.2 vs 18.1 ± 13.6, P = .05) was significantly longer in the malnutrition group. The open conversion rate (45.4% vs 6.67%, P < .001) and major complication rate (36.7% vs 21.8%, P = .032) was significantly higher in the malnutrition group. In multivariate analysis, preoperative malnutrition was found to be the predictor of postoperative complication (HR 1.971 95% confidence interval 1.071-3.624, P = .029).

Conclusion: Preoperative malnutrition in patients who underwent curative PD for pancreatic head cancer is associated with adverse short-term outcomes.
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http://dx.doi.org/10.1002/jhbp.858DOI Listing
October 2020

Laparoscopic bile duct resection with lymph node dissection for gallbladder cancer diagnosed after laparoscopic cholecystectomy.

Surg Oncol 2020 Dec 16;35:475. Epub 2020 Oct 16.

Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, 13620, Republic of Korea. Electronic address:

Introduction: Laparoscopic reoperation of postoperatively diagnosed gallbladder cancer is a technically challenging procedure due to inflammatory adhesion or fibrosis around the hepatoduodenal ligament and gallbladder bed [1,2]. Here we describe a technique for laparoscopic bile duct resection with lymph node dissection in a patient with cystic duct cancer diagnosed after laparoscopic cholecystectomy.

Video: A 73-year-old woman presented with postoperatively diagnosed gallbladder cancer. She underwent laparoscopic cholecystectomy to treat symptomatic gallbladder stones at another hospital, 2 months earlier. Postoperative pathology revealed a 0.9 × 0.7 cm, T2 lesion of adenosquamous carcinoma located at the cystic duct. The cystic duct margin showed high-grade dysplasia. We planned to perform laparoscopic bile duct resection with lymph node dissection. After adhesiolysis to expose the hepatoduodenal ligament, the lymph nodes were dissected around the retropancreatic area, hepatoduodenal ligament, and common hepatic artery in an en bloc fashion. Combined segmental resection of the bile duct, including the fibrotic scar around the cystic duct stump, was completed with negative resection margins. Retrocolic choledochojejunostomy and side-to-side jejunojejunostomy were then performed intracorporeally.

Results: The operation time was 195 minutes and the estimated intraoperative blood loss was minimal. The postoperative pathologic report revealed no residual tumor tissue and negative resection margins. Lymph node metastasis was found in one of eight retrieved lymph nodes. The patient was discharged on postoperative day 4 with no postoperative complications.

Conclusion: Laparoscopic radical surgery involving bile duct resection and lymph node dissection can be safely performed in patients with postoperatively diagnosed gallbladder cancer.
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http://dx.doi.org/10.1016/j.suronc.2020.10.006DOI Listing
December 2020

Improved outcomes of major laparoscopic liver resection for hepatocellular carcinoma.

Surg Oncol 2020 Dec 18;35:470-474. Epub 2020 Oct 18.

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

Background: Minor laparoscopic liver resection (LLR) is currently becoming standard treatment option for hepatocellular carcinoma (HCC) while major LLR is still challenging. Recent advancement of surgical techniques has enabled surgeons to perform major LLR. This study compared the outcomes of major LLR for HCC before and after the adaptation of technological improvements.

Methods: We retrospectively analyzed 141 patients who underwent major LLR for HCC from January 2004 to July 2018.32 open conversion cases were excluded. We divided the patients into two groups according to the date of operation: Group 1 (n = 38) and Group 2 (n = 71) who underwent major LLR before and after 2012, when advanced techniques including the use of intercostal trocars, Pringle maneuver, and semi-lateral position of patient were introduced. We also compared these patients including open conversion cases (n = 141) with those who underwent major open liver resection (OLR; n = 131) during the same period.

Results: Mean operative time (413.0 min vs 331.0 min; P = 0.009), transfusion rate (31.6% vs 11.3%, P = 0.009) and hospital stay (9.8 days vs 8.5 days; P = 0.001) were significantly less in Group 2. Intraoperative blood loss (1269.7 ml vs 844.5 ml; P = 0.341) and postoperative complication (15.8% vs 23.9%; P = 0.320) were not significantly different between the groups. Although tumor size in OLR group and type of resection was different, transfusion rate (36.6% vs 24.1%; P = 0.026), postoperative complication (41.2% vs 25.5%; P = 0.007), and hospital stay (17.2 days vs 10.0 days; P < 0.001) were significantly lower in LLR group.

Conclusion: Development of surgical techniques have gradually improved the surgical outcomes of the laparoscopic major liver resection.
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http://dx.doi.org/10.1016/j.suronc.2020.10.007DOI Listing
December 2020

Prognostic Significance of Tumor Location in T2 Gallbladder Cancer: A Korea Tumor Registry System Biliary Pancreas (KOTUS-BP) Database Analysis.

J Clin Med 2020 Oct 12;9(10). Epub 2020 Oct 12.

Department of Surgery and Cancer Research Institute, Seoul National University College of Medicine, Seoul 03080, Korea.

Background: T2 gallbladder cancer (GBC) is subdivided into T2a and T2b by the American Joint Committee on Cancer (AJCC) 8th edition. However; there is a lack of evidence for the prognostic significance of tumor location and validation with large-scale studies is needed. The aims of this study were to investigate the clinical features and clinical outcomes of T2 GBC according to tumor location and determine the prognostic significance of tumor location and an appropriate surgical strategy.

Methods: Between 2000 and 2014 the Korea Tumor Registry System Biliary Pancreas (KOTUS-BP) database was used to identify and enroll a total 707 patients with pathologically diagnosed T2 GBC who underwent curative resection. Clinicopathological findings and long-term follow-up results were analyzed.

Results: The incidence of lymph node metastasis in T2b was significantly higher than that of T2a tumors (37.9% vs. 29.5%, = 0.032). The 5-year disease-specific survival of T2a was better than that of T2b tumors (74.8% vs. 65.4%, 0.019). There was no significant survival difference in T2a between extended cholecystectomy and simple cholecystectomy with lymph node dissection (81.8% vs. 73.7%, 0.361). However; there was a better survival trend for T2b tumor after extended cholecystectomy (71.7% vs. 59.3%, 0.057). Adjuvant chemotherapy was associated with improved survival for patients with lymph node metastasis in T2a (72.1% vs. 56.9; p = 0.022) and in T2b (68.2 vs. 48.5; p < 0.001). Multivariate analysis revealed that lymph node metastasis was the only significant poor prognostic factor (Hazard ratio 3.222; 95% confidential interval 1.960-4.489; < 0.001).

Conclusions: For T2 GBC; tumor location was not an independent prognostic factor. Lymph node metastasis was a significant poor prognostic factor and adjuvant chemotherapy should be considered for the patients with lymph node metastasis.
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http://dx.doi.org/10.3390/jcm9103268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7600653PMC
October 2020

Laparoscopic versus Open Hepatectomy for Hepatocellular Carcinoma in Elderly Patients: A Single-Institutional Propensity Score Matching Comparison.

Dig Surg 2020 8;37(6):495-504. Epub 2020 Oct 8.

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

Background: The incidence of hepatocellular carcinoma (HCC) in elderly patients is increasing worldwide. Although open hepatectomy (OH) yields acceptable outcomes, high morbidity rate is concerned. Laparoscopic hepatectomy (LH) has evolved to improve perioperative outcomes. However, comparative study between both techniques for elderly patients with HCC is scarce.

Objective: This study aimed to compare outcomes between LH and OH specifically.

Methods: HCC patients aged ≥70 years after hepatectomy (2003-2018) were included. The propensity score matching (PSM) and comparative analyses between groups were performed.

Results: After PSM, there were 41 patients in each group with similar demographics, radiographic tumor characteristics, cirrhotic status, and extent of resection. The LH group had a shorter hospital stay (7 vs. 11 days, p = 0.002) compared with the OH group. The completeness of resection and complication rates were not statistically different between groups. The 5-year overall survival and recurrence-free survival rates were 86.7 and 43.4% in the LH group and 62.2 and 30.8% in the OH group (p = 0.221 and 0.500).

Conclusion: Our study confirmed the operative and oncological safety of LH in elderly HCC patients with improved perioperative outcomes compared with OH.
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http://dx.doi.org/10.1159/000510960DOI Listing
October 2020

Risk Factors for Recurrence in Pancreatic Neuroendocrine Tumor and Size as a Surrogate in Determining the Treatment Strategy: A Korean Nationwide Study.

Neuroendocrinology 2021 1;111(8):794-804. Epub 2020 Oct 1.

Department of Surgery, Chonnam National University Hospital, Gwangju, Republic of Korea.

Introduction: The prognostic factors of pancreatic neuroendocrine tumor (PNET) are unclear, and the treatment guidelines are insufficient. This study aimed to suggest a treatment algorithm for PNET based on risk factors for recurrence in a large cohort.

Methods: Data of 918 patients who underwent curative intent surgery for PNET were collected from 14 tertiary centers. Risk factors for recurrence and survival analyses were performed.

Results: The 5-year disease-free survival (DFS) rate was 86.5%. Risk factors for recurrence included margin status (R1, hazard ratio [HR] 2.438; R2, HR 3.721), 2010 WHO grade (G2, HR 3.864; G3, HR 7.352), and N category (N1, HR 2.273). A size of 2 cm was significant in the univariate analysis (HR 8.511) but not in the multivariate analysis (p = 0.407). Tumor size was not a risk factor for recurrence, but strongly reflected 2010 WHO grade and lymph node (LN) status. Tumors ≤2 cm had lower 2010 WHO grade, less LN metastasis (p < 0.001), and significantly longer 5-year DFS (77.9 vs. 98.2%, p < 0.001) than tumors >2 cm. The clinicopathologic features of tumors <1 and 1-2 cm were similar. However, the LN metastasis rate was 10.3% in 1-2-cm sized tumors and recurrence occurred in 3.0%. Tumors <1 cm in size did not have any LN metastasis or recurrence.

Discussion/conclusion: Radical surgery is needed in suspected LN metastasis or G3 PNET or tumors >2 cm. Surveillance for <1-cm PNETs should be sufficient. Tumors sized 1-2 cm require limited surgery with LN resection, but should be converted to radical surgery in cases of doubtful margins or LN metastasis.
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http://dx.doi.org/10.1159/000511875DOI Listing
October 2020

Prognosis prediction of pancreatic cancer after curative intent surgery using imaging parameters derived from F-18 fluorodeoxyglucose positron emission tomography/computed tomography.

Medicine (Baltimore) 2020 Aug;99(35):e21829

Department of Nuclear Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam.

Imaging parameters including metabolic or textural parameters during F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) are being used for evaluation of malignancy. However, their utility for prognosis prediction has not been thoroughly investigated. Here, we evaluated the prognosis prediction ability of imaging parameters from preoperative FDGPET/CT in operable pancreatic cancer patients.Sixty pancreatic cancer patients (male:female = 36:24, age = 67.2 ± 10.5 years) who had undergone FDGPET/CT before the curative intent surgery were enrolled. Clinico-pathologic parameters, metabolic parameters from FDGPET/CT; maximal standard uptake value (SUVmax), glucose-incorporated SUVmax (GI-SUVmax), metabolic tumor volume, total-lesion glycolysis, and 53 textural parameters derived from imaging analysis software (MaZda version 4.6) were compared with overall survival.All the patients underwent curative resection. Mean and standard deviation of overall follow-up duration was 16.12 ± 9.81months. Among them, 39 patients had died at 13.46 ± 8.82 months after operation, whereas 21 patients survived with the follow-up duration of 18.56 ± 9.97 months. In the univariate analysis, Tumor diameter ≥4 cm (P = .003), Preoperative Carbohydrate antigen 19-9 ≥37 U/mL (P = .034), number of metastatic lymph node (P = .048) and GI-SUVmax (P = .004) were significant parameters for decreased overall survival. Among the textural parameters, kurtosis3D (P = .052), and skewness3D (P = .064) were potentially significant predictors in the univariate analysis. However, in multivariate analysis only GI-SUVmax (P = .026) and combined operation (P = .001) were significant independent predictors of overall survival.The current research result indicates that metabolic parameter (GI-SUVmax) from FDGPET/CT, and combined operation could predict the overall survival of surgically resected pancreatic cancer patients. Other metabolic or textural imaging parameters were not significant predictors for overall survival of localized pancreatic cancer.
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http://dx.doi.org/10.1097/MD.0000000000021829DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7458160PMC
August 2020

Role of cholangitis in predicting survival in patients with carcinoma of the ampulla of vater.

Surg Oncol 2020 Dec 11;35:34-38. Epub 2020 Aug 11.

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

Background: There have been strong suggestions that acute inflammation promotes tumour growth, and has a tendency for increased invasiveness, leading to poor survival after surgery. When cholangitis coexists with ampulla of vater cancer, the patient's prognosis may be influenced by the acute inflammatory status of the bile duct. We evaluated the relationship between the severity of acute cholangitis, preoperative CRP levels and survival.

Methods: We retrospectively analysed 154 patients who underwent surgical resection for AOV cancer between January 2003 and November 2018. Cholangitis was graded according to Tokyo Guidelines 2018. Patients were categorised into two groups based on their CRP levels: CRP > 1 mg/L and CRP ≤ 1 mg/L. Relationship of cholangitis grade and CRP >1 mg/L with survival was assessed.

Results: The mean age of the patients was 65.8 years. Preoperative cholangitis was present in 40 (25.9%) patients, of which 28 (18.2%) had mild cholangitis, 11 (7.1%) had moderate cholangitis, and one (0.6%) had severe cholangitis. CRP was elevated preoperatively in 56 (36.4%) patients. The median follow-up period was 33.5 months. Severity of cholangitis significantly affected the overall survival (P < 0.001) and disease-free survival (P < 0.001). Patients with mild cholangitis had a median overall survival of 43 months compared to 14 months in those with moderate cholangitis. A preoperative CRP level of >1 mg/L was significantly associated with poor overall survival (P = 0.023) but not with disease-free survival (P = 0.128), although it was associated with a trend towards poorer survival. The survival rate of patients with CRP ≤1 mg/L was 77.4%, whereas that of patients with CRP >1 mg/L was 56.7%. In multivariable analysis, age >65 years (P = 0.015), cholangitis grade (P = 0.050), CRP > 1 mg/L (P = 0.045), venous invasion (P = 0.005), and perineural invasion (P = 0.034) were independent prognostic factors for overall survival while cholangitis grade (P = 0.049) and perineural invasion (P = 0.004) were independent prognostic factors for disease-free survival.

Conclusion: Acute inflammation when associated with cancer can have a negative effect on patient's survival. Patients with higher grades of cholangitis should be adequately treated to improve the inflammatory status.
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http://dx.doi.org/10.1016/j.suronc.2020.08.003DOI Listing
December 2020

A multicenter prospective randomized controlled trial for preoperative biliary drainage with uncovered metal versus plastic stents for resectable periampullary cancer.

J Hepatobiliary Pancreat Sci 2020 Oct 16;27(10):690-699. Epub 2020 Aug 16.

Department of Internal Medicine, Seoul National University Bundang Hosptial, Seoul National University College of Medicine, Seongnam, Korea.

Background/purpose: Although routine preoperative biliary drainage (PBD) in patients with distal malignant biliary obstruction is generally not recommended, there are still various situations where it may be necessary. The current study aims to compare the uncovered self-expandable metal stent (uSEMS) and plastic stent (PS), where PBD may be necessary.

Patients And Methods: In this multicenter prospective randomized study, patients with resectable periampullary cancer with cholangitis, deep jaundice, or expected long waiting time for surgery were included. PBD was performed endoscopically, but percutaneous drainage was allowed if the initial endoscopic drainage was not feasible. The primary outcome was the reintervention rate; the secondary outcomes were the complication rates, rate of decrease of total bilirubin, waiting time for surgery, and postoperative hospital stay.

Results: Of the 60 enrolled patients, 53 were included for analysis (26 PS and 27 uSEMS). Common bile duct cancer was the most common (27, 50.9%), followed by pancreatic head cancer (20, 37.7%). Regarding PBD indication, 36 (67.9%) had cholangitis and 21 (39.6%) had a total bilirubin level of more than 10 mg/dL at randomization; 10 (18.9%) were included due to delayed surgery by more than 7 days. Fifty (94.3%) patients received pancreaticoduodenectomy, and one (1.9%) patient received palliative hepaticojejunostomy. The median waiting time for surgery was 11.0 days. There was no difference in the reintervention rate (3.8% and 3.8% in PS and uSEMS, P > .999), PBD-related complication rate (23.1% and 22.2%, P > .999), PBD- or surgery-related complication rate (57.7% and 48.1%, P = .674), and the rate of decrease of total bilirubin (P = .541). The median hospital stay after surgery was 13.0 days without significant difference.

Conclusion: For patients who received surgery within the first 2 weeks from receiving PBD, there was no superiority of uSEMS to PS. According to the expected waiting time for surgery, selective approach for stent choice should be considered.
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http://dx.doi.org/10.1002/jhbp.811DOI Listing
October 2020

Laparoscopic excision of type II choledochal cyst arising from the intrapancreatic common bile duct in an adult.

J Hepatobiliary Pancreat Sci 2020 Oct 15;27(10):789-790. Epub 2020 Aug 15.

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

Highlight In this video article, Lee and colleagues present the first report of laparoscopic excision of a type II choledochal cyst located in the intrapancreatic bile duct, which remains technically demanding. The authors recommend sharp dissection of the cyst from the pancreas using a bipolar energy device to control small vessels.
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http://dx.doi.org/10.1002/jhbp.808DOI Listing
October 2020

Does adjuvant treatment improve prognosis after curative resection of ampulla of Vater carcinoma? A multicenter retrospective study.

J Hepatobiliary Pancreat Sci 2020 Oct 15;27(10):721-730. Epub 2020 Aug 15.

Department of Surgery, Pancreatobiliary Cancer Clinic, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.

Background/purpose: Ampulla of Vater (AoV) carcinoma is a rare tumor that accounts for approximately 0.2% of gastrointestinal malignancies. There are no clinical guidelines concerning the treatment of AoV carcinoma. This study aimed to investigate the effectiveness of adjuvant treatment in AoV carcinoma following curative resection and define the "high-risk" group.

Methods: Clinical data of patients who underwent curative resection for AoV carcinoma in four hospitals, namely Yonsei Gangnam Severance Hospital, Seoul National University Hospital, Seoul National University Bundang Hospital, and National Cancer Center (n = 651; 2002-2015), were reviewed. Overall survival (OS) and recurrence-free survival (RFS) rates were compared using Kaplan-Meier estimates.

Results: Data of 651 patients who had undergone curative resection were retrospectively reviewed. Age, T stage, N stage, and differentiation type remained strong and independent risk factors for RFS and OS. In early-stage AoV carcinoma (T1N0, T2N0), the non-adjuvant group had better prognosis based on the RFS and OS than the adjuvant group (P < .001, P = .007). In advanced T stage (T3N0, T4N0), the adjuvant group had better prognosis than the non-adjuvant group, but the difference was not statistically significant (P > .05). In node-positive patients (any T, N1/2), adjuvant treatment did not affect RFS and OS (P > .05).

Conclusions: Adjuvant treatment after curative resection of AoV carcinoma is not associated with improved survival. The high-risk group (node-positive or advanced T stage (T3, T4)) treated with adjuvant treatment was not statistically associated with improved survival; however, our study showed that the adjuvant treatment for the high-risk group might help achieve better patient outcome.
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http://dx.doi.org/10.1002/jhbp.801DOI Listing
October 2020

Laparoscopic liver resection versus open liver resection for intrahepatic cholangiocarcinoma: 3-year outcomes of a cohort study with propensity score matching.

Surg Oncol 2020 Jun 14;33:63-69. Epub 2020 Jan 14.

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

Introduction: Laparoscopic liver resection(LLR) for intrahepatic cholangiocarcinoma is debatable due to technical challenges associated with major hepatectomy and lymph node dissection. This study aims to analyze the long-term outcomes with propensity score matching.

Methods: Patients who underwent liver resection for intrahepatic cholangiocarcinoma from August 2004 to October 2015 were enrolled. Those who had combined hepatocellular-cholangiocarcinoma and palliative surgery were excluded. Medical records were reviewed for postoperative outcome, recurrence, and survival. The 3-year disease-free survival(DFS) and 3-year overall survival(OS) were set as the primary endpoint, and 3-year disease-specific survival, 1-year OS, 1-year DFS, operative outcome, and postoperative complications were secondary endpoints.

Results: A total of 91 patients were enrolled with 61 in the open group and 30 in the laparoscopic group. Propensity score matching included 24 patients in both groups. In total, the 3-year OS was 81.2% in the open group and 76.7% in the laparoscopic group(p = 0.621). For 3-year DFS, open was 42.5% and laparoscopic was 65.6%(p = 0.122). Mean operation time for the open group was 343.2 ± 106.0 min and laparoscopic group was 375.2 ± 204.0 min(p = 0.426). Hospital stay was significantly shorter in the laparoscopic group(9.8 ± 5.1 days) than the open group(18.3 ± 14.7, p=<0.001). There was no difference in complication rate and 30-day readmission rate. Tumor size, nodularity, and presence of perineural invasion showed an independent association with the 3-year DFS in multivariate analysis.

Conclusion: Laparoscopic liver resection for intrahepatic cholangiocarcinoma is technically feasible and safe, providing short-term benefits without increasing complications or affecting long-term survival.
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http://dx.doi.org/10.1016/j.suronc.2020.01.001DOI Listing
June 2020

Evaluation of a single surgeon's learning curve of laparoscopic pancreaticoduodenectomy: risk-adjusted cumulative summation analysis.

Surg Endosc 2021 Jun 16;35(6):2870-2878. Epub 2020 Jun 16.

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

Background: Laparoscopic pancreaticoduodenectomy (LPD) is technically demanding and there is much controversy about its safety. We evaluated the learning curve for pure LPD based on the clinical outcomes of consecutive patients treated by a single surgeon.

Methods: We reviewed the medical records of 119 consecutive patients who underwent LPD by a single surgeon between June 2013 and August 2018. The learning curve was evaluated using the cumulative summation (CUSUM) and risk-adjusted CUSUM (RA-CUSUM) methods. Perioperative outcomes were compared among the learning curve phases.

Results: CUSUM analysis of the operation time showed that the operation time improved after the 47th case. RA-CUSUM analysis showed the learning curve for surgical failure, defined as severe complications (Clavien-Dindo grade ≥ 3) or open conversion, comprised three phases (phase 1: cases 1-60; phase 2: cases 61-83; phase 3: cases 84-119). There were no significant differences in operation time among the three phases. Intraoperative blood loss decreased significantly over the three phases (P = 0.032). There were no postoperative deaths. The rates of postoperative complications, pancreatic fistula (grade B/C), and post-pancreatic hemorrhage were significantly lower in phase 3 than in phase 2 (2.8% vs. 21.7%, P = 0.019; 2.8% vs. 17.4%, P = 0.049; 0% vs. 13.0%, P = 0.026), but not between phases 1 and 2. Postoperative hospital stay decreased progressively, and was significantly shorter in phase 3 than in phase 1 (9.1 vs. 16.7 days, P = 0.001).

Conclusions: The LPD failure rate decreased after the first 60 cases and stabilized after 84 cases. For safe dissemination of LPD, it is important to shorten the long learning curve and decrease the unfavorable outcomes in the early phase of the learning curve.
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http://dx.doi.org/10.1007/s00464-020-07724-zDOI Listing
June 2021

Timing for Introduction of Total Laparoscopic Living Donor Right Hepatectomy; Initial Experience Based on the Data of Laparoscopic Major Hepatectomy.

Transplantation 2021 06;105(6):1273-1279

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

Background: This study evaluated the timing of safe introduction of total laparoscopic donor right hepatectomy (TLDRH) based on outcomes of laparoscopic major hepatectomy (LMH).

Methods: The data of 1013 consecutive patients who underwent laparoscopic liver resection from 2003 to 2017 were reviewed; the cumulative sum method was used to evaluate the learning curve of LMH. Patients were divided into 3 groups according to the timing of introduction of TLDRH (since 2010) and learning curve of LMH. Surgical outcomes of LMH and TLDRH were evaluated.

Results: Cumulative sum analysis demonstrated a learning curve of approximately 73 cases of LMH. In phase I (before the introduction of TLDRH, 2003-2009), 38 cases of LMH were performed. Phase II (after the introduction of TLDRH until learning curve of LMH, 2010-2014), 35 and 15 cases of LMH and TLDRH were performed, respectively. Phase III (after learning curve of LMH until 2017, 2014-2017), 59 and 20 cases of LMH and TLDRH were performed, respectively. In cases of LMH, there was significant improvement in the operation time 398.9 ± 140.9 versus 403.7 ± 165.2 versus 265.5 ± 91.7; P < 0.001), estimated blood loss (1122.9 ± 1460.2 versus 1209.3 ± 1409.1 versus 359.8 ± 268.8; P < 0.001), and open conversion rate (26.3% versus 22.9% versus 13.6%; P = 0.026) between phases I versus II versus III. In cases of TLDRH, the operation time (567.8 ± 117.9 versus 344.2 ± 71.8; P < 0.001), estimated blood loss (800.7 ± 514.8 versus 439.4 ± 347.0; P = 0.004), and hospital stay (12.5 ± 4.36 versus 9.15 ± 4.84; P = 0.025) significantly improved in phase III.

Conclusions: Overcoming the learning curve of LMH before starting TLDRH is advisable to ensure donor's surgical outcomes.
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http://dx.doi.org/10.1097/TP.0000000000003344DOI Listing
June 2021

Advanced laparoscopic HPB surgery: Experience in Seoul National University Bundang Hospital.

Ann Gastroenterol Surg 2020 May 25;4(3):224-228. Epub 2020 Mar 25.

Seoul National University Bundang Hospital Gyeonggi-do Korea.

The worldwide trend in surgery has moved from open surgery to minimally invasive surgery. Likewise, the application of minimally invasive surgery in the hepato-pancreato-biliary (HBP) field is also rapidly expanding. The field of HBP surgery can be divided into liver, pancreas and biliary fields. Minimally invasive liver surgery is recently developed. However, laparoscopic liver resection in difficult areas is challenging. However, with the accumulation of experiences, laparoscopic liver resection for difficult areas is performed more than before. With more propagation, more and more liver resection will be performed by laparoscopic approach. In minimally surgery for the pancreas, distal pancreatectomy has become a well-recommended procedure in benign and borderline malignancy. There have been several systemic reviews that show advantages of laparoscopic distal pancreatectomy. The reports on laparoscopic pancreaticoduodenectomy (PD) are slowly increasing in spite of technical difficulty, with several systemic reviews showing advantages of the procedure. However, more PD will be performed as robotic-assisted procedures in the future. The laparoscopic surgery for biliary tract malignancy is still in early stages. The laparoscopic surgery for gallbladder cancer has been contraindicated, although there have been encouraging reports from expert centers. The laparoscopic surgery for Klatskin tumor is still an experimental procedure. Robotic-assisted procedures for the surgery of cholangiocarcinoma will be the future. Robotic-assisted surgery for the HBP field is still not well-developed. However, with the necessity of more precise manipulation like intracorporeal suturing, robotic-assisted surgery will be used more often in the field of HBP surgery.
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http://dx.doi.org/10.1002/ags3.12323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7240149PMC
May 2020
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