15-Year Experience of Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer-A Korean Nationwide Investigation.

BACKGROUND: As systemic treatment for pancreatic cancer advances, distal pancreatectomy with celiac axis resection (DP-CAR) has been considered a curative-intent surgical option for advanced pancreatic cancer. This study aimed to review the surgical and oncologic outcomes of patients undergoing DP-CAR based on Korean nationwide data. METHODS: We collected the data of patients who underwent DP-CAR for pancreatic cancer between 2007 and 2021 at seven major hospitals in Korea. The clinicopathological characteristics, postoperative complications, and data on the survival of the patients were retrospectively reviewed. Logistic regression analysis was performed to identify risk factors for postoperative complications and survival. RESULTS: A total of 75 patients, consisting mainly of borderline resectable (n = 32) or locally advanced (n = 30) pancreatic cancer, were included in the analysis. Forty-two (56.0%) patients underwent neoadjuvant treatment (NAT). Twenty (26.7%) patients experienced Clavien-Dindo grade ≥ 3 complications, including four patients with ischemic gastropathy, two with hepatic ischemia, and two procedure-related mortalities. Neoadjuvant chemotherapy increased the risk of postoperative complications (p = 0.028). The median recurrence-free and overall survival were 7 and 19 months, with a 5-year survival rate of 13% and 24%, respectively. In the NAT group, a decrease in CA 19-9 and the post-NAT maximum standardized uptake value (SUVmax) in positron emission tomography were associated with survival after surgical resection. CONCLUSIONS: Despite the possibility of major complications, DP-CAR could be a feasible option for achieving curative resection with fair survival outcomes in patients with borderline resectable or locally advanced pancreatic cancer. Further studies investigating the safety of the procedure and identifying proper surgical candidates with potential survival gains are necessary.

Clinicopathological Features and Prognosis of Resected Pancreatic Ductal Adenocarcinoma Patients with Claudin-18 Overexpression.

Claudin-18.2 (CLDN18.2) is specifically expressed in pancreatic precancerous lesions and pancreatic ductal adenocarcinoma (PDAC). We assessed the clinical characteristics of patients with CLDN18.2-overexpressing pancreatic cancer to identify patients who might benefit from CLDN18-targeted treatment. A total of 130 patients with surgically resected PDAC were investigated for the immunohistochemical expression of claudin-18 (CLDN18). The CLDN18 staining intensities (0-3+) and relative proportion of positive tumor cells were analyzed by two independent raters. Tumors positive for CLDN18 expression were defined as ≥80% of tumor cells with 2+ or 3+ staining intensity in a CLDN18 immunohistochemical assay. Positive CLDN18 expression was present in 41/130 (31.5%) surgically resected PDACs and the relative proportion of positive tumor cells and the staining intensity were directly correlated (p < 0.001). Positive CLDN18 expression was significantly associated with well-differentiated tumors (p < 0.001) and less regional node involvement (p = 0.045). The positive CLDN18-expressing group showed no statistical difference in median overall survival (17.4 months vs. 20.6 months, p = 0.770) compared to the negative CLDN18-expressing group. Distant nodal metastasis was more frequent in the positive CLDN18-expressing group (p = 0.011). CLDN18 is frequently expressed in PDAC, and high CLDN18-expressing PDACs showed some different clinicopathologic characteristics. High CLDN18 expression was not associated with prognosis in patients with surgically resected PDAC.

Comparison of infectious complications after spleen preservation versus splenectomy during laparoscopic distal pancreatectomy for benign or low-grade malignant pancreatic tumors: A multicenter, propensity score-matched analysis.

BACKGROUND: Previous studies have reported contrasting results regarding the advantages of spleen preservation during laparoscopic distal pancreatectomy (LDP) for preventing infectious complications. METHODS: A total of 3787 patients who underwent LDP for benign or low-grade malignant pancreatic disease in 92 centers across Korea and Japan were included in this retrospective study. Postoperative infectious complications and other complications were compared between LDP with splenectomy (LDPS) and LDP with spleen preservation (LSPDP) by propensity score matching (PSM) analysis. RESULTS: After PSM, the LSPDP group had a lower rate of overall infectious complications (P = .079) and a significantly lower rate of intra-abdominal abscess (P = .014) compared with the LDPS group. Within the LSPDP group, the vessel preservation subgroup had a significantly higher rate of infectious complications (P = .002) compared with the vessel resection subgroup. Low-volume centers had a higher rate of intra-abdominal abscess than high-volume centers in the LSPDP group (P = .001) and the splenic vessel preservation subgroup (P = .003). CONCLUSIONS: Spleen preservation in LDP for benign or borderline malignant pancreatic diseases was advantageous in lowering the risk of infectious complications, specifically intra-abdominal abscess. However, the risk of intra-abdominal abscess may differ according to the level of surgeon's experience.

Bile cholesterol and viscosity, the keys to discriminating adenomatous polyps from cholesterol polyps by a novel predictive scoring model.

BACKGROUND: Adenomatous gallbladder polyps, premalignant lesions of the gallbladder, have fatal outcomes, whereas cholesterol polyps have benign features. Herein, we proposed a novel, predictive scoring model of adenomatous polyps to distinguish them from cholesterol polyps, by analyzing bile components and bile viscosity. METHODS: Patients with gallbladder polyp pathologically confirmed after cholecystectomies were analyzed. After dividing patients into two groups (adenomatous or cholesterol polyps), the clinicopathologic profiles and bile nature, including components and viscosity were compared and a predictive scoring model for adenomatous polyps was assessed. RESULTS: Eleven adenomatous polyps and 96 cholesterol polyps were analyzed. The variables significantly associated with adenomatous polyps were age > 55 years (OR = 23.550, p = 0.020), bile viscosity< 7.5 s- 1 (OR = 22.539, p = 0.012), and bile cholesterol< 414.5 mg/dl (OR = 10.004, p = 0.023) and the points for each variable in the predictive scoring model were allocated as 3, 3, and 2, respectively. Final scores ranged from 0 to 8 points and the best performance of model at a cutoff of ≥6 points had 90.9% of sensitivity and 80.2% of specificity. CONCLUSIONS: Bile viscosity and bile cholesterol accompanied by age were revealed as significant predictors of adenomatous polyps, distinguishing them from cholesterol polyps of gallbladder. It can be the cornerstone for creating accurate guidelines for preoperatively determining treatment strategies of gallbladder polyps.

Clinical outcomes of primary aldosteronism based on lateralization index and contralateral suppression index after adrenal venous sampling in real-world practice: a retrospective cohort study.

BACKGROUND: We investigated whether the contralateral suppression index in aldosterone-producing adrenal adenoma could be used as a diagnostic criterion when catheterization in either right or left adrenal vein fails or when a discrepancy in the adrenal vein sampling (AVS) results and imaging findings occurs in the real-world practice. METHODS: We retrospectively reviewed 48 patients who had resistant hypertension (HTN) or hypokalemia with a biochemical diagnosis of primary aldosteronism and who underwent AVS from January 2009 to June 2017 at a tertiary referral hospital. Selection index (SI), lateralization index (LI), and contralateral suppression index (CSI) were calculated based on AVS results and the final clinical outcomes were evaluated. RESULTS: The catheterization of both adrenal veins was successful in 43 of 48 (89.6%) patients. The lateralization based only on LI was performed in 23 out of 43 (53.5%) patients. When CSI and LI were combined in decision making, the concordance between adrenal computed tomography scan and AVS for unilateral lesion improved from 59.3% (19/32) to 75.0% (24/32). CSI also correlated well with unilateral adrenal disease in the catheterization failure group. The final outcomes of HTN were better in the contralateral suppression group. CONCLUSION: CSI combined with LI could be a supplementary diagnostic tool in patients with non-lateralization or catheterization failure and predict the clinical outcomes of HTN in patients with primary aldosteronism.

Definitive concurrent chemoradiotherapy in locally advanced pancreatic cancer.

PURPOSE: Survival outcome of locally advanced pancreatic cancer has been poor and little is known about prognostic factors of the disease, especially in locally advanced cases treated with concurrent chemoradiation. This study was to analyze overall survival and prognostic factors of patients treated with concurrent chemoradiotherapy (CCRT) in locally advanced pancreatic cancer. MATERIALS AND METHODS: Medical records of 34 patients diagnosed with unresectable pancreatic cancer and treated with definitive CCRT, from December 2003 to December 2012, were reviewed. Median prescribed radiation dose was 50.4 Gy (range, 41.4 to 55.8 Gy), once daily, five times per week, 1.8 to 3 Gy per fraction. RESULTS: With a mean follow-up of 10 months (range, 0 to 49 months), median overall survival was 9 months. The 1- and 2-year survival rates were 40% and 10%, respectively. Median and mean time to progression were 5 and 7 months, respectively. Prognostic parameters related to overall survival were post-CCRT CA19-9 (p = 0.02), the Eastern Cooperative Oncology Group (ECOG) status (p < 0.01), and radiation dose (p = 0.04) according to univariate analysis. In multivariate analysis, post-CCRT CA19-9 value below 180 U/mL and ECOG status 0 or 1 were statistically significant independent prognostic factors associated with improved overall survival (p < 0.01 and p = 0.02, respectively). CONCLUSION: Overall treatment results in locally advanced pancreatic cancer are relatively poor and few improvements have been accomplished in the past decades. Post-treatment CA19-9 below 180 U/mL and ECOG performance status 0 and 1 were significantly associated with an improved overall survival.

Effects of dexmedetomidine on the ratio of T helper 1 to T helper 2 cytokines in patients undergoing laparoscopic cholecystectomy.

STUDY OBJECTIVES: To investigate the effect of dexmedetomidine on T helper 1 (Th1) and T helper 2 (Th2) cytokines and their ratio during and after surgery. DESIGN: Single-blinded, randomized, placebo-controlled clinical comparison study. SETTING: Academic medical center. PATIENTS: 46 adult, ASA physical status 1 and 2 patients scheduled for laparoscopic cholecystectomy. INTERVENTIONS: Patients were randomized to two groups: the dexmedetomidine group (n = 23), in which dexmedetomidine was infused with a 1.0 µg/kg loading dose followed by infusion of 0.5 µg/kg/h; or the saline group (n = 23). MEASUREMENTS: Interferon-gamma (IFN-gamma) and interleukin-4 (IL-4) as Th1 and Th2 cytokines, respectively, were quantified three times: after induction of anesthesia (T0), at the end of peritoneal closure (T1), and 60 minutes after surgery (T2). The IFN-gamma/IL-4 ratio was then calculated. MAIN RESULTS: The dexmedetomidine group displayed higher levels of IFN-gamma at T1 and T2 (42.30 pg/dL vs 6.91 pg/dL at T1 [P = 0.025]; 40.51 pg/dL vs 8.29 pg/dL at T2 [P = 0.030]) than the saline group. The dexmedetomidine group was also associated with higher ratios of IFN-gamma/IL-4 (1.22 vs 0.32, respectively, at T1 [P = 0.012]; 1.53 vs 0.13, respectively, at T2 [P = 0.012]). CONCLUSIONS: Dexmedetomidine plays an immunomodulatory role, shifting the Th1/Th2 cytokine balance toward Th1 in patients with surgical and anesthetic stress.

ERCC1 Can Be a Prognostic Factor in Hilar Cholangiocarcinoma and Extrahepatic Bile Duct Cancer, But Not in Intrahepatic Cholangiocarcinoma.

PURPOSE: There are three types of bile duct cancer, intrahepatic cholangiocarcinoma (ICC), hilar cholangiocarcinoma (HC), and extrahepatic cholangiocarcinoma (EHC). Despite different clinical presentation, the same protocol has been used in treatment of patients with these cancers. We analyzed clinicopathologic findings and protein expression in order to investigate the difference and the specific prognostic factors among these three types of cancers. MATERIALS AND METHODS: We conducted a retrospective review of 104 patients diagnosed with bile duct cancer at Seoul St. Mary's Hospital between January 1994 and May 2004. We performed immunohistochemical staining for p53, cyclin D1, thymidine phosphorylase, survivin, and excision repair cross-complementing group 1 (ERCC1). RESULTS: Of the 104 patients, EHC was most common (44.2%). In pathologic findings, perineural invasion was significantly less common in ICC. Overall survival was similar among the three types of cancer. Lymph node invasion, lymphatic, and venous invasion showed a significant association with survival outcome in ICC, however, the differentiation of histologic grade had prognostic significance in HC and EHC. No difference in protein expression was observed among these types of cancer, however, ERCC1 showed a significant association with survival outcome in HC and EHC, not in ICC. CONCLUSION: Based on our data, ICC showed different characteristics and prognostic factors, separate from the other two types of bile duct cancer. Conduct of further studies with a large sample size is required in order to confirm these data.

A small solitary non-parasitic hepatic cyst causing an intra-hepatic bile duct stricture: a case report.

INTRODUCTION: We report an unusual presentation of a small hepatic cyst causing cholangitis. CASE PRESENTATION: A 70-year-old Asian man was hospitalized for aggravated chronic pain in the right upper portion of his abdomen. Fever developed after admission. Laboratory tests revealed elevated hepatobiliary enzymes, inflammatory markers and carbohydrate antigen 19-9 without hyperbilirubinemia. Ultrasound and computed tomography demonstrated dilatation of the left intra-hepatic bile ducts. Endoscopic retrograde cholangiopancreatography showed that the right intra-hepatic bile ducts were normally filled with contrast medium, but the left intra-hepatic bile ducts were not seen in the confluence. A left hepatectomy was performed because a hidden malignancy could not be excluded. The surgical findings showed no tumor around the bile duct but rather a 2 cm cyst in segment four of Couinaud's category of the liver around the hilum. The pathology report was a solitary non-parasitic hepatic cyst compressing the bile duct. CONCLUSION: A very small solitary hepatic cyst might cause hepatic duct stricture if it is located near the hepatic hilum, and should be considered in the differential diagnosis of a hepatic duct stricture.

Elective laparoscopic repair after colonoscopic decompression for incarcerated morgagni hernia.

Plain radiographs of an 88-year-old woman who had experienced vomiting and abdominal distention for 3 days revealed a severely obstructed ileus, and abdominopelvic computed tomography revealed an incarcerated Morgagni hernia. The endoscope was passed through the constrictions from the diaphragmatic indentations and a thin catheter was placed for decompression. The obstructive ileus regressed markedly after the procedure; the patient underwent elective laparoscopic repair of the hernia 1 week later. This is believed to be the first case of endoscopic preoperative decompression for an incarcerated Morgagni hernia.