Prognostic value of preoperative protein-induced vitamin K absence or antagonist II after liver resection for hepatitis B-related hepatocellular carcinoma: a nationwide multicenter study.

Purpose: Although protein-induced vitamin K absence or antagonist II (PIVKA-II) has been used as a diagnostic tool for hepatocellular carcinoma (HCC), its prognostic value remains unclear. Methods: This was a nationwide multicenter study using the database of the Korean Liver Cancer Association. Patients with hepatitis B-related HCC who underwent liver resection as the first treatment after initial diagnosis (2008-2014) were selected randomly. Propensity score matching (1:1) was performed for comparative analysis between those with low and high preoperative PIVKA-II. Univariable and multivariable Cox proportional-hazards regression were used to identify prognostic factors for HCC-specific survival. Results: Among 6,770 patients, 956 patients were included in this study. After propensity score matching, the 2 groups (n = 245, each) were well balanced. The HCC-specific 5-year survival rate was 80.9% in the low PIVKA-II group and 78.7% in the high PIVKA-II group (P = 0.605). In univariable analysis, high PIVKA-II (>106.0 mAU/mL) was not a significant predictor for worse HCC-specific survival (hazard ratio [HR], 1.183; 95% confidence interval [CI], 0.76-1.85; P = 0.461). In multivariable analysis, hyponatremia of <135 mEq/L (HR, 4.855; 95% CI, 1.67-14.12; P = 0.004), preoperative ascites (HR, 4.072; 95% CI, 1.59-10.43; P = 0.003), microvascular invasion (HR, 3.112; 95% CI, 1.69-5.74; P < 0.001), and largest tumor size of ≥5.0 cm (HR, 2.665; 95% CI, 1.65-4.31; P < 0.001), but not preoperative high PIVKA-II, were independent predictors for worse HCC-specific survival. Conclusion: Preoperative PIVKA-II is not an independent prognostic factor for HCC-specific survival after liver resection for hepatitis B-related HCC.

Effect of Radiocephalic Anastomotic Length on the Maturation of Arteriovenous Fistula.

BACKGROUND: A radiocephalic arteriovenous fistula (RCAVF) is associated with better long-term patency and fewer complications. However, RCAVF have lower maturation rate for hemodialysis compared with upper AVF or arteriovenous graft. We performed this study to determine the effect of the radiocephalic (RC) anastomotic length on the AVF maturation. METHODS: We reviewed the patients who underwent RCAVF creation with a side-to-end manner from March 2015 to December 2018. AVF maturation was defined as successful hemodialysis (HD) in at least two consecutive sessions. We compared the possible factors including the RC anastomotic length between the initial HD success group and initial HD failure group. RESULTS: A total of 114 patients underwent RCAVF creation: 72 males and 42 females (63.2% and 36.8%, respectively). The mean preoperative arteriotomy length of the AVF was 14.1 mm (range 11.0-16.0 mm). Out of 114 patients, initial HD was executed successfully in 83 patients (72.8%). Among the 31 patients with initial HD failure (27.2%) balloon angioplasty was successfully performed in 17 patients, failed in 4 patients, and not performed in 10 patients. The secondary success rate after balloon angioplasty was 87.7%. After factor analysis, pre-emptive AVF (P = 0.01), vein diameter (P < 0.001), and flow rate (P < 0.001) were revealed significant factors for initial HD success, but not RC anastomotic length of AVF (P = 0.55). CONCLUSION: The length of the radiocephalic anastomosis does not affect the RCAVF maturation rate statistically. However, lengthening of arteriotomy on the radial artery may increase the initial success rate of HD.

Pure Laparoscopic Hepatectomy for Tumors Close to the Major Hepatic Veins: Intraparenchymal Identification of the Major Hepatic Veins using the Ventral Approach.

BACKGROUND: Laparoscopic hepatectomy for tumors close to the major hepatic veins (HVs) is a technically demanding procedure that is relatively contraindicated. We investigated this surgical technique and the outcomes of intraparenchymal identification of the major HVs using the ventral approach in pure laparoscopic hepatectomy for tumors close to the major HVs. METHODS: In the present study, tumors < 10 mm from the major HVs were defined as lesions in proximity to the major HVs. The cranio-ventral part of the liver parenchyma along the targeted major hepatic veins was opened to facilitate an open cutting plane. After a wide exposure of the surgical plane, the targeted major HVs were identified. RESULTS: Thirteen patients with tumors close to the major HVs underwent laparoscopic hepatectomy. The median operative time was 260 min (range, 160-410 min), while the intraoperative blood loss was 100 mL (range, 30-310 mL). The median Pringle maneuver time was 45 min (range, 40-75 min). The median tumor size was 50 mm (range, 17-140 mm), and the median tumor margin was 4 mm (range, 0-10 mm). Three patients (23.1%) experienced minor postoperative complications. The median postoperative hospital stay was 7 days (range, 4-25 days). CONCLUSIONS: Pure laparoscopic hepatectomy for tumors close to the major HVs is technically feasible in selected patients. Intraparenchymal identification of the major HVs using the ventral approach achieves transection plane accuracy and avoids inadvertent injury to the major HVs.

Optimal Treatment Strategy and Natural History of Isolated Superior Mesenteric Artery Dissection Based on Long-Term Follow-up CT Findings.

BACKGROUND: Isolated superior mesenteric artery dissection (ISMAD) was previously considered a rare disorder; however, this condition has been increasingly diagnosed as time progressed. Although treatment regimen and treatment outcomes have become clearer, the optimal treatment strategy has not yet been well established. MATERIALS AND METHODS: This study included 54 patients diagnosed with ISMAD by computed tomography (CT) between November 2004 and December 2017. Thirteen patients were excluded from the analysis of natural course as 6 were lost to follow-up, and 7 underwent endovascular therapy. RESULTS: Of the 54 patients included in the study, 50 were male, and 4 were female. The mean age of the patients was 52.3 years (range 40-74). The mean follow-up duration was 18.5 months (range 1.0-131.0). Thirty-eight patients were symptomatic, and 16 were asymptomatic. All aneurysmal changes observed on follow-up CT scans were initially classified as type III or IV. Of these patients, 7 underwent endovascular therapy. The failure rate of conservative treatment was 13%. CONCLUSIONS: Conservative treatment is safe and effective if bowel necrosis or arterial rupture is not present. Symptomatic patients classified as type III or IV on the initial CT scan should be followed up. If there is recurrent pain or aneurysmal progression, endovascular therapy should be performed.

Pure laparoscopic anatomical segment VI resection using the Glissonian approach, Rouviere's sulcus as a landmark, and a modified liver hanging maneuver (with video).

BACKGROUND: Pure laparoscopic anatomical segmental resection has rarely been reported because this technique frequently presents technical difficulties. We describe the laparoscopic resection of anatomical segment VI using the Glissonian approach and a modified liver hanging maneuver. METHODS: Rouviere's sulcus is identified after retracting superiorly the gallbladder. The Glissonian approach for anatomical resection of segment VI can be performed with minimal dissection of the liver parenchyma around the sulcus. After clamping the Glissonian pedicle in the sulcus, the ischemic area fed by the portal pedicle was confirmed. The right triangular ligament was divided to create a small opening for placement of the hanging tape along the ischemic line. The liver parenchymal transection was performed along the hanging tape. RESULTS: Four patients underwent pure laparoscopic anatomical segment VI resection using the Glissonian approach and a modified liver hanging maneuver. The median operation time was 205 min (range, 110-250 min), and median estimated blood loss was 110 mL (range, 100-350 mL). The median postoperative hospital stay was 5 days (range, 4-8 days). There was no postoperative morbidity or mortality. CONCLUSION: The Glissonian approach at Rouviere's sulcus as a landmark combined with the modified liver hanging maneuver may be safe and useful for laparoscopic anatomical segment VI resection.

Gastrointestinal Stromal Tumor of the Stomach Presenting as Multilobular with Diffuse Calcifications.

Gastrointestinal stromal tumors (GISTs) are the most common primary mesenchymal neoplasms of the gastrointestinal tract and usually appear as a well-circumscribed mass. However, it may be difficult to confirm the extent of the disease for some GISTs. A 70-year-old asymptomatic female presented for a regular physical exam. An esophagogastroduodenoscopy showed a 2.0 cm protruding mass on the gastric fundus. Endoscopic ultrasound revealed an ill-defined heterogenous hypoechoic lesion (3.0×1.5 cm). A computed tomography (CT) scan demonstrated a 4.5 cm multifocal calcified mass at the gastric body as well as at the gastric fundus. Laparoscopic gastric wedge resection was performed according to the extent of multifocal calcifications that are shown on the CT. Intraoperative specimen mammography and intraoperative biopsy might be helpful to obtain a tumor-free margin. Final pathologic diagnosis was an intermediate risk GIST in multilobular form. In patients with diffuse multifocal calcifications in the stomach, the possibility of GIST should be considered.

Clinical and oncologic outcomes of totally robotic total mesorectal excision for rectal cancer: initial results in a center for minimally invasive surgery.

PURPOSE: A robotic system was mainly designed to allow precise dissection in deep and narrow spaces. We report the clinical and oncologic outcomes of totally robotic total mesorectal excision for rectal cancer. METHODS: Between July 2009 and January 2012, 60 consecutive patients undergoing robotic surgery for rectal cancer at the Eulji University Hospital were included. RESULTS: The mean total operation time, docking time, and surgeon console time were 466.8 ± 115.6, 7.5 ± 6.7, and 261 ± 87.5 min, respectively. Oral intake of diet was started at 3.3 ± 0.9 days and the mean hospital stay was 8.6 ± 2.4 days. All 60 procedures were technically successful without the need for conversion to open or laparoscopic surgery. Complications included anastomotic leakage, anastomotic stricture, postoperative bleeding, ileus, and perineal wound infection in 3 (5 %), 1 (1.7 %), 2 (3.3 %), 2 (3.3 %), and 1 (1.7 %) patient, respectively. The mean distal resection margin and total number of lymph nodes harvested was 3.1 ± 1.7 cm and 20.1 ± 11.5, respectively. During the mean follow-up period of 48.5 months (range, 7-75), the 4-year overall and disease-free survival rates were 87.7 and 72.8 %, respectively. CONCLUSIONS: A totally robotic approach for rectal cancer operations was a time-consuming procedure, although we already had a lot experience in laparoscopic colorectal surgery. However, the dexterity of the robotic surgery could enable the surgeon to expand the choice of surgical methods according to the condition of the rectal cancer without the need for conversion.

Treatment results for spontaneous isolated superior mesenteric artery dissection according to our previous guidelines and collective literature review.

BACKGROUND: Isolated superior mesenteric artery dissection (ISMAD) is not a rare disease. However, its optimal treatment strategy has not yet been established. METHODS: This study included 13 consecutive patients with ISMAD who were treated between April 2010 and July 2013 according to published treatment guidelines. Through a literature search, 10 studies on treatments and outcomes for ISMAD that were published from 2007 to the present were analyzed. RESULTS: In the present study, 11 patients had acute onset abdominal pain and 2 patients were asymptomatic. Twelve patients were treated with conservative treatment, whereas 1 patient underwent coil embolization. In the literature review, initial conservative treatment, endovascular procedure, and surgical repair were done in 172, 25, and 14 patients, respectively. Bowel resection was done in 8 patients (3.7%) due to bowel necrosis. Conservative treatment failed in 15 patients (6.8%) during follow-up. CONCLUSIONS: If bowel necrosis or arterial rupture was not present, conservative treatment of ISMAD was a safe and effective treatment. Aneurysmal type IV patients on computed tomography scan should be carefully followed up, and if there is a recurrence of pain or aneurysmal progression, an endovascular procedure could be safely performed.

The role of hand-assisted laparoscopic surgery in a right hemicolectomy for right-sided colon cancer.

PURPOSE: The purpose of this study is to evaluate the perioperative and long-term oncologic outcomes of hand-assisted laparoscopic surgery (HALS) and standard laparoscopic surgery (SLS) and assess the role of HALS in the management of right-sided colon cancer. METHODS: The study group included 53 patients who underwent HALS and 45 patients who underwent SLS for right-sided colon cancer between April 2002 and December 2008. RESULTS: The patients in each group were similar in age, American Society of Anesthesiologist (ASA) score, body mass index, and history of previous abdominal surgeries. Eight patients in the HALS group and no patient in the SLS group exhibited signs of tumor invasion into adjacent structures. No differences were noted in the time to return of normal bowel function, time to toleration of diet, lengths of hospital stay and narcotic usage, and rate of postoperative complications. The median incision length was longer in the HALS group (HALS: 7.0 cm vs. SLS: 4.8 cm, P < 0.001). The HALS group had a significantly higher pathologic TNM stage and significantly larger tumor size (HALS: 6.0 cm vs. SLS: 3.3 cm, P < 0.001). The 5-year overall, disease-free, and cancer-specific survival rates of the HALS and the SLS groups were 87.3%, 75.2%, and 93.9% and 86.4%, 78.0%, and 90.7%, respectively (P = 0.826, P = 0.574, and P = 0.826). CONCLUSION: Although patients in the HALS group had more advanced disease and underwent more complex procedures than those in the SLS group, the short-term benefits and the oncologic outcomes between the two groups were comparable. HALS can, therefore, be considered an alternative to SLS for bulky and fixed right-sided colon cancer.

The endovascular treatment of a ruptured aneurysm of the middle colic artery combined with an isolated dissection of superior mesenteric artery: report of a case.

BACKGROUND: Ruptured aneurysm of the middle colic artery is very rare. Its concomitance with isolated dissection of the superior mesenteric artery (SMAD) has not yet been reported in the literature. CASE REPORT: A previously well 56-year-old man was referred to our hospital with acute-onset pain throughout the entire abdomen. A ruptured aneurysm of the middle colic artery and isolated SMAD were revealed using a computed tomography (CT) scan. Coil embolization was successfully performed for a ruptured aneurysm of the middle colic artery. During the immediate postprocedural period, the patient had ischemic colitis, but he recovered in a few days with conservative treatment. Close observation was elected to address the SMAD because the condition was not thought to be responsible for any symptoms. The CT scan followed after 2 years showed no change in SMAD. CONCLUSIONS: We successfully performed endovascular treatment for a ruptured aneurysm of the middle colic artery. For the incidentally detected SMAD, close observational management was chosen.

Premalignant lesion of heterotopic pancreas combined with gastritis cystica profunda in gastric fundus.

Heterotopic pancreas, also known as ectopic pancreas, is found mainly in the stomach, duodenum, or jejunum. Pancreatic intraepithelial neoplasia (PanIN) is the non-invasive precursor of pancreatic cancer and gastritis cystica profunda (GCP) is considered a precursor of gastric cancer. As with most putative cancer precursor lesions, the diagnosis and treatment of these lesions has been controversial. A patient with no history of gastric surgery visited our institution for a regular evaluation. Endoscopy showed a 2 x 2 cm sized, protruding mass lesion with overlying normal mucosa on the fundus of stomach. Endoscopic ultrasound (EUS) and computed tomography (CT) led to the possible diagnosis of a gastrointestinal stromal tumor with cystic change. Laparoscopic gastric wedge resection was performed with intra-operative endoscopic guidance. Microscopic examination identified the mass as pancreatic tissue. Furthermore, it demonstrated PanIN, grade 3 (PanIN-3) mixed pancreatobiliary and intestinal type, arising in the heterotopic pancreas and associated with GCP. This report describes a rare case of a PanIN lesion combined with GCP as precursors of precancerous lesions in heterotopic pancreas and stomach.

The Effects of Preoperative (18)F-FDG PET/CT in Breast Cancer Patients in Comparison to the Conventional Imaging Study.

PURPOSE: There have been recent studies of the (18)F-fluorodeoxyglucose positron emission tomography and computed tomography ((18)F-FDG PET/CT) in the staging, detection, and follow-up of the breast cancer occurrence and recurrence. There was controversy concerning the use of (18)F-FDG PET/CT for staging primary breast cancer. In this study, we investigated the potential effects of (18)F-FDG PET/CT in the initial assessment of patients with primary breast cancer. METHODS: From January 2008 to December 2009, 154 consecutive biopsy-proven invasive breast cancer patients were enrolled in this study. Patients underwent conventional imaging studies including mammography, breast ultrasonography (USG), and magnetic resonance imaging for local assessment, and plain chest X-ray, liver USG, and bone scan to rule out distant metastasis. All 154 patients underwent (18)F-FDG PET/CT in the initial assessment. RESULTS: (18)F-FDG PET/CT did not detect primary breast lesions in 16 patients with a sensitivity of 89.6% and detected only 5 multiple lesions (12.5%) out of 40 cases. Histologically confirmed axillary lymph node (LN) metastases were in 51 patients, and the sensitivity and specificity of (18)F-FDG PET/CT to detect metastatic axilla were 37.3% and 95.8%, respectively; whereas the corresponding estimates of USG were 41.2% and 93.7%, respectively. Eleven extra-axillary LN metastases were found in eight patients, and seven lesions were detected by (18)F-FDG PET/CT only. The sensitivity and specificity of (18)F-FDG PET/CT in detecting distant metastasis were 100% and 96.4%, respectively; whereas the sensitivity and specificity of the conventional imaging were 61.5% and 99.2%, respectively. CONCLUSION: (18)F-FDG PET/CT cannot be recommended as a primary diagnostic procedure in breast cancer, but it has the potential to be used as an additional imaging tool for the detection of axillary metastasis, distant metastasis, and extra-axillary LN metastasis. (18)F-FDG PET/CT cannot solely replace the conventional diagnostic procedure in primary breast cancer. The best approach may be the combination of different imaging modalities.

A giant retroperitoneal lymphangioma in a patient with neurofibromatosis type 1.

Neurofibromatosis type 1 (NF-1) is a genetically inherited disorder that may cause skin abnormalities and tumors that form on nerve tissues. These tumors can be small or large and can occur anywhere in the body, including the brain, spinal cord, or other peripheral nerves. Retroperitoneal lymphangiomas are very rare benign malformations of the lymphatic system. About 95% lymphangiomas occur in the skin and the subcutaneous tissues of the head, neck and axillary region and the remaining 5% appear in other parts of the body such as lungs, pleura, pericardium, liver, gallbladder, kidney, and the mesentery. Herein, we report the case of a giant retroperitoneal lymphangioma in a patient with NF-1 with a review of the literature.

Laparoscopic treatment of early retroperitoneal abdominal pregnancy implanted on inferior vena cava.

The case of an early retroperitoneal abdominal pregnancy implanted on inferior vena cava successfully resected through laparoscopic surgery is reported here. A 28-year-old woman presented with vaginal spotting and amenorrhrea for 7(+5) weeks. Although a diagnosis of right cornual ectopic pregnancy by transvaginal ultrasound was made and a laparoscopic wedge resection of the left uterine cornus was performed, the beta-human chorionic gonadotropin level remained high. Abdominal ultrasonography and computerized tomography of the abdomen demonstrated a 3.4x2.6 cm sized hypervascular cystic mass along the anterior aspect of the Inferior vena cava. A diagnosis of retroperitoneal abdominal pregnancy was made and a laparoscopic resection was performed. This is the first retroperitoneal abdominal pregnancy that has been treated through laparoscopy.