Laparoscopic Minor Liver Resections for Hepatocellular Carcinoma in the Posterosuperior Segments Using the Rubber Band Technique.

BACKGROUND: Although laparoscopic minor liver resections (LLR) of posterosuperior (PS) segments are technically challenging, several expert centers are increasingly performing this procedure. In the present study, we introduced novel techniques, including the rubber band traction method and positional changes, and compared surgical outcomes of LLR for hepatocellular carcinoma (HCC) located in PS segments with open minor liver resection (OLR). METHODS: From January 2008 to August 2019, 113 patients underwent laparoscopic (n = 55) or open (n = 58) minor liver resections for single small HCCs (<5 cm) located in PS segments. Propensity score matching in a 1:1 ratio was conducted to minimize preoperative selection bias, and surgical outcomes were compared between the two groups. RESULTS: There was no intraoperative mortality or reoperation in either group. One conversion to open surgery was necessary due to severe post-operative adhesions. The matched LLR group compared to OLR had significantly shorter operative time (215.16 vs. 251.41 min, P = 0.025), lesser blood loss (218.11 vs. 358.92 mL, P = 0.046), lower complication rate (8.1% vs. 29.7%, P = 0.018), and shorter hospital stay (7.03 vs. 11.78 days, P = 0.001). Intraoperative transfusion, R0 resection, resection margin, 5-year disease-free survival and 5-year overall survival were comparable. CONCLUSION: Our standardized LLR provided improved short-term outcomes and similar long-term outcomes, when compared with OLR. With advanced techniques and accumulated surgical experience, LLR can be the first option for HCC in PS segments at expert centers.

Laparoscopic pancreaticoduodenectomy reduces incidence of clinically relevant postoperative pancreatic fistula in soft pancreas with a smaller than 2 mm pancreatic duct.

BACKGROUND: Soft pancreas with small pancreatic duct is a known risk factor for postoperative pancreatic fistula (POPF). This study demonstrated the safety and feasibility of laparoscopic duct-to-mucosa pancreaticojejunostomy (PJ) and compared perioperative outcomes of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) in patients with soft pancreas and small pancreatic duct. METHODS: From January 2014 to December 2019, 183 patients underwent LPD and 91 patients underwent OPD by a single surgeon. Data on patients with soft pancreas and combined small pancreatic duct (≤ 2 mm) were retrospectively reviewed. Clinicopathologic characteristics, and perioperative outcomes were compared between LPD and OPD. We evaluated risk factors affecting clinically relevant POPF (CR-POPF). We also correlated calculated risks of POPF and CR-POPF between the two groups. RESULTS: We compared 62 patients in the LPD group and 34 patients in the OPD group. Perioperative outcomes showed less blood loss, shorter hospital stays, and less postoperative pain score on postoperative day (POD)#1 and #5 in LPD compared with OPD. Postoperative complications showed no differences between LPD and OPD. LPD group showed significantly reduced CR-POPF rates compared to the OPD group (LPD 11.3% vs. OPD 29.4%, p = 0.026). Multivariate analysis identified obesity (BMI ≥ 25), thick pancreas parenchyma and open surgery as independent predicting factors for CR-POPF. The LPD group showed less CR-POPF than the OPD group according to POPF risk groups. This difference was more prominent in a high-risk group. CONCLUSION: With appropriate laparoscopic technique, LPD is feasible and safe and reduces CR-POPF in soft pancreas with a small pancreatic duct.

Suppression of PROX1-mediated TERT expression in hepatitis B viral hepatocellular carcinoma.

Somatic mutations in the telomerase reverse transcriptase (TERT) promoter are related to telomerase activation and frequently occur at two hot spots located at -124 and -146 bp relative to the start codon in various cancers. Here, we investigated the occurrence and implications of genetic alterations in the TERT promoter in hepatitis B viral hepatocellular carcinoma (B viral HCC). TERT promoter mutations, especially -124C>T, clearly enhanced transcriptional activity in HCC cell lines. In contrast, TERT mRNA expression was lower in B viral HCC patients with TERT promoter mutations than in those without. We identified prospero homeobox protein 1 (PROX1) as a novel transcriptional activator of TERT; this protein was shown to have particularly strong binding affinity for the mutant TERT promoter. However, stable expression of the hepatitis B virus X (HBx) protein inhibited PROX1-mediated TERT expression in vitro. Our data suggest that TERT promoter mutations can enhance the promoter activity in HCC cell lines expressing PROX1 but are not the predominant mechanism of TERT upregulation in B viral HCC patients, based on the inhibition of PROX1-dependent transcriptional activation by HBx.

Downstaging with Localized Concurrent Chemoradiotherapy Can Identify Optimal Surgical Candidates in Hepatocellular Carcinoma with Portal Vein Tumor Thrombus.

BACKGROUND: Locally advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) has a poor oncological outcome. This study evaluated the oncological outcomes and prognostic factors of surgical resection after downstaging with localized concurrent chemoradiotherapy (CCRT) followed by hepatic arterial infusion chemotherapy (HAIC). METHODS: From 2005 to 2014, 354 patients with locally advanced HCC underwent CCRT followed by HAIC. Among these patients, 149 patients with PVTT were analyzed. Exclusion criteria included a total bilirubin ≥ 2 mg/dL, platelet count < 100,000/µL, and indocyanine green retention test (ICG R15) > 20%. During the same study period, 18 patients with PVTT underwent surgical resection as the first treatment. Clinicopathological characteristics and oncological outcomes between groups were compared. RESULTS: Among 98 patients in the CCRT group, 26 patients (26.5%) underwent subsequent curative resection. The median follow-up period was 13 months (range 1-131 months). Disease-specific survival differed significantly between the resection after localized CCRT group and the resection-first group {median 62 months (95% confidence interval [CI] 22.99-101.01) versus 15 months (95% CI 10.84-19.16), respectively; P = 0.006}. Multivariate analyses showed that achievement of radiologic response was an independently good prognostic factor for both disease-specific survival (P = 0.039) and disease-free survival (P = 0.001) CONCLUSIONS: Localized CCRT could be an effective tool for identifying optimal candidates for surgical treatment with favorable tumor biology. Furthermore, with a 26.5% resection rate and 100% response in PVTT for resection after CCRT, our localized CCRT protocol may be ideal for PVTT.

Surgical Strategy and Outcome in Patients Undergoing Pancreaticoduodenectomy After Gastric Resection: A Three-Center Experience with 39 Patients.

BACKGROUND: Stomach cancer is the second most commonly diagnosed cancer in Korea. Although the long-term survival outcome has improved, secondary primary tumors from periampullary regions are increasing inevitably and pancreaticoduodenectomy (PD) following gastrectomy is challenging. This study evaluates the surgical outcomes of PD following gastrectomy and suggests the optimum method for reconstruction. METHODS: Patients who underwent curative PD with a history of gastric resection between 2005 and 2015 were assessed retrospectively. PD was performed according to the standard fashion, with the aim of creating a new pancreaticobiliary limb with sufficient length (40-50 cm). Different reconstructive methods were employed during PD according to the previous gastrectomy type. RESULTS: A total of 3064 patients underwent PD, 39 of whom had previous gastrectomies including 12 with Billroth I gastrectomy, 20 with Billroth II gastrectomy, and seven patients with total gastrectomy (TG). In patients with Billroth I gastrectomy, all of the previous gastroduodenostomy site was resected for specimen retrieval. All previous esophagojejunostomy site was preserved in seven patients who had TG. In the Billroth II patients, the gastrojejunostomy site was preserved in 17 patients. Re-operation after PD was required in two patients, and 14 patients (36 %) developed pancreatic fistula and five (13 %) of grade B or higher. CONCLUSIONS: Our study has been the largest report so far of PD following gastric resection, and we were able to confirm the safety and the feasibility of PD procedure. We therefore suggest standardizing the reconstruction method for PD following gastrectomy based on the type of previous gastrectomy.

Practice guidelines for managing extrahepatic biliary tract cancers.

Backgrounds/Aims: Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021. Methods: Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop. Results: In November 2021, the finalized draft was presented for public scrutiny during a formal hearing. Conclusions: The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.

Early experiences in robotic single-site plus one port platform for complex hepatobiliary and pancreatic surgery.

BACKGROUND: Minimal invasive surgery in hepatobiliary and pancreatic (HBP) surgery has been accepted worldwide in recent years. However, applications of single-site laparoscopic surgery in complex HBP surgery have been limited due to difficulty in manoeuvring instruments and the limited range of motion resulting from clashing instruments. METHODS: To overcome the limitations, we have used the Da Vinci single-site surgical platform with one additional port in a Da Vinci Xi system to perform donor right hepatectomy, pancreaticoduodenectomy, and combined resection of the common bile duct and spleen vessels preserving distal pancreatectomy. RESULTS: In selected patients, using a robotic single-site plus one port system allowed the successful completion of complex HBP surgery. DISCUSSION: Complex HBP surgery can be performed safely in a stable environment using the robotic single-site plus one port system. Further exploration of a robotic single-site plus one port in complex HBP surgery is necessary.

Impact of adjuvant therapy in patients with invasive intraductal papillary mucinous neoplasms of the pancreas: an international multicenter cohort study.

BACKGROUND: Adjuvant therapy prolongs survival in patients with pancreatic ductal adenocarcinoma. However, no clear guidelines are available regarding the oncologic effects of adjuvant therapy (AT) in resected invasive intraductal papillary mucinous neoplasms (IPMN). The aim was to investigate the potential role of AT in patients with resected invasive IPMN. MATERIALS AND METHODS: From 2001 to 2020, 332 patients with invasive pancreatic IPMN were retrospectively reviewed in 15 centres in eight countries. Propensity score-matched and stage-matched survival analyses were conducted. RESULTS: A total of 289 patients were enroled in the study after exclusion (neoadjuvant therapy, unresectable disease, uncertain AT status, and stage IV). A total of 170 patients were enroled in a 1:1 propensity score-matched analysis according to the covariates. In the overall cohort, disease-free survival was significantly better in the surgery alone group than in the AT group ( P =0.003), but overall survival (OS) was not ( P =0.579). There were no significant differences in OS in the stage-matched analysis between the surgery alone and AT groups (stage I, P =0.402; stage II, P =0.179). AT did not show a survival benefit in the subgroup analysis according to nodal metastasis (N0, P =0.481; N+, P =0.705). In multivariate analysis, node metastasis (hazard ratio, 4.083; 95% CI, 2.408-6.772, P <0.001), and cancer antigen 19-9 greater than or equal to 100 (hazard ratio, 2.058; 95% CI, 1.247-3.395, P =0.005) were identified as adverse prognostic factors in resected invasive IPMN. CONCLUSION: The current AT strategy may not be recommended to be performed with resected invasive IPMN in stage I and II groups, unlike pancreatic ductal adenocarcinoma. Further investigations of the potential role of AT in invasive IPMN are recommended.

Prevention and management of intraoperative complication during single incision laparoscopic totally extraperitoneal repair.

Serious complications related to hernia surgeries have rarely been reported. One meta-analysis comparing laparoscopic and open mesh repair reported that 0.4% of potentially serious operative complications were reported. Previous studies have reported that uncommon serious intraoperative complications more frequently occur during laparoscopic inguinal hernia repairs. One study has shown that patients with history of lower abdominal surgery are at an increased risk of visceral injury during laparoscopic hernia repair. Vascular injuries at dissection and mesh fixation or suturing in the preperitoneal space typically involve the epigastric or aberrant obturator vessels crossing the Cooper's ligament. However, complications can occur at every step of the operation, although only few are reported. Therefore, we report our experiences of intraoperative complications during single-incision laparoscopic totally extraperitoneal hernia repair and how to prevent and manage intraoperative complications.

Outcomes of open versus single-incision laparoscopic totally extraperitoneal inguinal hernia repair using propensity score matching: A single institution experience.

PURPOSE: The aim of the current study was to compare the outcomes between open and single-incision laparoscopic totally extraperitoneal (SILTEP) inguinal hernia repair. METHODS: To compare the outcomes between the open and SILTEP groups, we performed propensity score matching to adjust for significant differences in patient characteristics. The outcomes were compared between the matched groups. RESULTS: Record review identified 477 patients who had undergone inguinal hernia repair from November 2016 to November 2018. Seventy-one patients were excluded from the propensity score matching because of age <18, femoral hernia, conventional 3-port laparoscopic repair, incarcerated hernia, and combined operation. SILTEP in 142 and open repair in 264 patients were identified. After propensity score matching, these individuals were grouped into 82 pairs. Spinal anesthesia was administered more often in the open group than in the SILTEP group. Operation time was significantly longer in the SILTEP group than in the open group (49.6 ± 17.4 vs. 64.8 ± 28.4 min, p < 0.001). However, urinary retention rates of the open group were significantly higher than that of the SILTEP group (11.0% vs. 0%, p = 0.003). The SILTEP group showed significantly lower pain scores at postoperative 6, 12, and 24 hours, and significantly lower rates of intravenous analgesic requirements through postoperative day 1 (30.5% vs. 13.4%, p = 0.008) compared with the open group. CONCLUSION: The outcomes of SILTEP repair were comparable to those of open repair. SILTEP repair may have advantages over open repair for reducing immediate postoperative pain (≤24 hours).

Role of postoperative adjuvant therapy in resected invasive intraductal papillary mucinous neoplasm of the pancreas: A multicenter external validation.

BACKGROUND: Adjuvant therapy is beneficial in prolonging survival in patients with pancreatic ductal adenocarcinoma (PDAC). However, no clear guidelines are available on the oncologic effect of adjuvant therapy in resected invasive intraductal papillary mucinous neoplasms (inv-IPMN). METHODS: In total, 551 patients with PDAC and 67 patients with inv-IPMN of the pancreas were reviewed. For external validation, 46 patients with inv-IPMN from six other Korean institutions were enrolled. Propensity score-matched analysis and stage-matched survival analysis were conducted. RESULTS: The mean follow-up durations in the inv-IPMN and PDAC groups were 43.36 months (SD, 42.34 months) and 43.35 months (SD, 35.62 months), respectively. The 5-year overall survival (OS) was significantly better in the resected inv-IPMN group than in the PDAC group in the overall stage-matched analysis (P < .001). In the inv-IPMN cohort, OS was better in the surgery alone group (P = .042). In subgroup analysis, no significant survival difference was found between the adjuvant therapy and surgery alone groups according to the stage (stage I; P = .285, stage II or III; P = .077). Multicenter external validation did not show a better OS in the adjuvant therapy group (P = .531). On multivariable analysis, only perineural invasion (PNI) was identified as an adverse prognostic factor in resected inv-IPMN (HR 4.844; 95% CI 1.696-13.838, P = .003). CONCLUSIONS: inv-IPMN has a more indolent course than PDAC. Current strategy of adjuvant therapy may not improve the OS in patients with resected inv-IPMN. Further investigations on the potential role of adjuvant therapy in inv-IPMN are mandatory.

Oncologic Outcomes of Extended Lymphadenectomy without Liver Resection for T1/T2 Gallbladder Cancer.

PURPOSE: This study provides a standardized operative strategical algorithm that can be applied to patients with T1/T2 gallbladder cancer (GBC). Our aim was to determine the oncologic outcome of radical cholecystectomy with para-aortic lymph node dissection without liver resection in T1/T2 GBC. MATERIALS AND METHODS: From January 2005 to December 2017, 164 patients with GBC underwent operations by a single surgeon at Severance Hospital. A retrospective review was performed for 113 of these patients, who were pathologically determined to be in stages T1 and T2 according to American Joint Committee on Cancer 7th guidelines. RESULTS: Of the 113 patients, 109 underwent curative resection for T1/T2 GBC; four patients who underwent palliative operations without radical cholecystectomies were excluded from further analyses. For all T1b and T2 lesions, radical cholecystectomy with para-aortic lymph node dissection was performed without liver resection. There were four GBC-related mortalities, and 5-year disease-specific survival was 97.0%. The median follow-up was 50 months (range: 5-145 months). In all T stages, the median was not reached for survival analysis. Five-year disease-specific survival for T1a, T1b, and T2 were 100%, 94.1%, and 97.1%, respectively. Five-year disease-free survival for T1a, T1b, and T2 were 100%, 87.0%, and 91.8%, respectively. CONCLUSION: Our results suggest that the current operative protocol can be applied to minimal invasive operations for GBC with similar oncologic outcomes as open approach. For T1/T2 GBC, radical cholecystectomy, including para-aortic lymph node dissection, can be performed safely with favorable oncologic outcomes.

Robotic Single-Site Plus One Port: Pancreas Enucleation.

PURPOSE: Laparoscopic approaches to enucleation of the pancreas have been frequently described. Here we present a case of robotic single-site plus one port pancreas enucleation. To our knowledge, this enucleation surgical technique is the first to be reported in the medical literature. METHODS: A 46-year-old male patient without previous medical or surgical history was incidentally diagnosed with a pancreatic mass during evaluation of intermittent right flank pain. Robotic single-site plus one port pancreas enucleation was performed using the Da Vinci single-site surgical platform with one additional port on November 16, 2016. Usual robotic instruments such as hook, bipolar, and vessel sealer with endo-wrist function could be used to facilitate effective surgical procedure with the additional port. The resected specimen was delivered through the umbilicus and a drain was not inserted. RESULTS: Total operation time was 124 min with total console time of 73 min. Estimated blood loss was 50 cm3. Final pathology result was neuroendocrine tumor, grade 1. The patient was discharged without any complications on postoperative day #4. CONCLUSIONS: Robotic single-site plus one port pancreas enucleation seems feasible with acceptable perioperative outcomes.

Association of preoperative total lymphocyte count with prognosis in resected left-sided pancreatic cancer.

BACKGROUND: Immunologic factors such as neutrophil-lymphocyte ratio and platelet-lymphocyte ratio play an important role in predicting the oncologic outcome of patients in pancreatic ductal adenocarcinoma (PDAC). It is hypothesized that host immunity represented by total lymphocyte count at diagnostic stage would influence oncologic outcome in left-sided PDAC. METHODS: Between January 1992 and August 2017, total of 112 patients who underwent distal pancreatectomy for left-sided PDAC were included and analysed. RESULTS: At the time of the diagnosis, total lymphocyte count at diagnosis of left-sided PDAC was 1.8 ± 0.7 103 /µL (mean value ± standard deviation). Among different cut-off values, 1.7 showed most powerful significant differences in long-term oncologic outcomes. The patients with preoperative lymphocyte count (≤1.7) was associated with early recurrence (median 8.4 months versus 18.1 months, P = 0.011) and shorter survival (median 18.6 months versus 35.9 months, P = 0.028). Patients with preoperative total lymphocyte count over 1.7 showed higher white blood cell count (P < 0.001), platelet count (P = 0.039), neutrophil count (P = 0.004) and monocyte count (P = 0.001). However, more interestingly, neutrophil-lymphocyte ratio (P < 0.001) and platelet-lymphocyte ratio (P < 0.001) were found to be significantly higher in those with total lymphocyte count less than 1.7. Lymphocyte to monocyte ratio was inversely related to preoperative total lymphocyte count (P < 0.001). Only age was identified to be significantly different (P = 0.007). However, other clinicopathological parameters generally known to be related to tumour aggressiveness, were not different between two groups. CONCLUSION: In conclusion, preoperative total lymphocyte at diagnostic stage is simple, and good prognostic factor in left-sided pancreatic cancer.

Rates of Serious Complications Estimated by the ACS-NSQIP Surgical Risk Calculator in Predicting Oncologic Outcomes of Patients Treated with Pancreaticoduodenectomy for Pancreatic Head Cancer.

BACKGROUND: The purpose of this study was to validate the predictive value of the oncologic outcome in addition to the validation of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator in patients treated with pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PPPD) for pancreatic head cancer. METHODS: From June 2005 to December 2014, 199 patients underwent PD or PPPD for pancreatic head cancer. Medical records were retrospectively reviewed for investigating general patient characteristics and any comorbid diseases. The calculated perioperative complication risks from the ACS NSQIP calculator were compared with observed complication rates. In a propensity score matching analysis, disease-free survival (DFS) and overall survival (OS) were estimated according to calculated severe complication rate (CSCR). RESULTS: The CSCR > 17.9% (n = 69) and CSCR < 17.9% (n = 130) groups were significantly different considering number of the retrieved lymph nodes (22.95 ± 14.0 vs 18.80 ± 10.1, p = 0.029), histologic grade (p = 0.0235), and incidence of lymphovascular invasion (p = 0.026). The CSCR < 17.9% group had longer DFS (17.0 vs. 11.0 months, p = 0.015), but the OS was similar between the groups (39.0 vs. 23.0 months, p = 0.48). In the 1:2 propensity score analysis, the CSCR < 17.9% group had longer DFS and OS (DFS 26.0 vs. 11.0 months, p = 0.009; OS 44.0 vs. 26.0 months, p = 0.023). CONCLUSION: The ACS NSQIP surgical risk calculator predicts surgical risk in patients with pancreatic head cancer who undergo PD or PPPD. Furthermore, this tool can help predict the prognosis of surgically treated pancreatic head cancer.

Role of common bile duct resection in T2 and T3 gallbladder cancer patients.

BACKGROUNDS/AIMS: Routine bile duct resection as part of the typical oncological resection for patients with advanced gallbladder cancer remains controversial with regard to, ultimately, curative value. The aim of this study was to compare oncological outcomes for patients undergoing surgery for gallbladder cancer with or without bile duct resection. METHODS: We recruited, for the purpose of this study, all patients who underwent surgical resection for T2 and T3 gallbladder cancer at Severance hospital, Seoul, Korea, during the period January 2000 and December of 2011. The patient data was reviewed retrospectively. RESULTS: The patients (n=149) recruited to participate in the study were divided into two groups according to their bile duct resection status: The bile duct resection group (BDR group, n=54); and, the bile duct non-resection group (BDNR group, n=95). Significant difference was found in lymph node retrieval between BDR and BDNR groups (15 vs. 5, respectively with p<0.001). There was no significant difference between the two groups with regard to the five year survival rate (43% in BDR group vs. 57% in BDNR group, p=0.339). Following multivariate analysis, lymph node metastasis, advanced T-stage, and total retrieved lymph nodes <6 were independent prognostic factors for poor survival in patients with T2 and T3 gallbladder cancer. CONCLUSIONS: The findings revealed by the current study suggest that the role of bile duct resection might be limited to improved staging, and offers no advantage in long-term survival. However, in view of the foregoing and given the minimal increase in morbidity associated with BDR, it should be actively considered as a treatment option for patients who present with findings suspicious for invasion around hepatoduodenal ligament.

Indocyanine Green Perfusion Imaging-Guided Laparoscopic Pancreaticoduodenectomy: Potential Application in Retroperitoneal Margin Dissection.

BACKGROUND: During laparoscopic pancreaticoduodenectomy (LPD), dissecting uncinate process from the superior mesenteric artery (SMA) will determine one of the important surgical margins (retroperitoneal margin) for predicting oncological outcomes and the quality of LPD. However, clear identification of the division line for retroperitoneal margin is not easy as the uncinate process of the pancreas is anatomically very close to SMA and intermingled with the nerve plexus and soft tissues around SMA. In this study, we present data regarding the potential usefulness of indocyanine green (ICG)-enhanced approach in obtaining retroperitoneal margin during LPD. METHODS: From January to September 2017, medical records of patients who underwent LPD for periampullary pathological conditions were retrospectively reviewed. ICG (5 mg/2 cm3) was prepared and intravenously injected when dissecting uncinate process of the pancreas. Perioperative outcomes, including gender, age, diagnosis, body mass index, operation time, estimated blood loss, transfusion, presence of postoperative pancreatic fistulas (POPFs), and length of hospital stay, were evaluated. RESULTS: During the study period, a total of 37 patients underwent LPD for periampullary pathological lesions. Among them, ICG-enhanced dissection of uncinate process of the pancreas was applied in 10 patients (27%). All patients were able to obtain margin-negative resection. There were no significant differences between the perioperative outcomes of patients who did and did not undergo ICG-enhanced approach. DISCUSSION: ICG perfusion-based laparoscopic dissection of retroperitoneal margin is feasible and safe in LPD. This intraoperative visual difference can provide the surgeon with very helpful real-time visual information. Further study is mandatory.

Oncologic outcomes after radical surgery for periampullary cancer in octogenarians.

BACKGROUNDS/AIMS: Interest in treatments for elderly patients has increased with life expectancy, and various studies have reported on the safety and feasibility of radical surgery in elderly patients with cancer. Here, we investigated oncologic outcomes of periampullary cancer in octogenarians. METHODS: We retrospectively reviewed medical records of 68 patients over 80 years of age who were diagnosed with periampullary cancer and were eligible for surgery; we analyzed overall survival (OS) and immediate postoperative complications and mortality. RESULTS: There were no significant differences in mean age, disease type, oncologic features, comorbidities, or nutritional status between the patients who had surgery and those who did not. Five patients (20.0%) had major postoperative complications, but there was no immediate postoperative mortality. Patients who had surgery (n=25) had better OS (29.3 months; 95% confidence interval [CI]: 5.6-53.0) than did those who did not (n=43, OS: 7.6 months; 95% CI: 3.2-12.0 months; p<0.001). Similarly, patients with distal common bile duct cancer who underwent surgery had better OS than those who did not (surgery group: n=13, OS: 29.3 months, 95% CI: 8.9-49.7; non-surgery group: n=15, OS: 5.7 months, 95% CI: 4.2-7.2 months; p=0.002). CONCLUSIONS: Radical surgery for octogenarian patients with periampullary cancer is safe, feasible, and expected to result in better survival outcomes, especially for patients with common bile duct cancer.

Negative oncologic impact of poor postoperative pain control in left-sided pancreatic cancer.

AIM: To investigate the association between postoperative pain control and oncologic outcomes in resected pancreatic ductal adenocarcinoma (PDAC). METHODS: From January 2009 to December 2014, 221 patients were diagnosed with PDAC and underwent resection with curative intent. Retrospective review of the patients was performed based on electronic medical records system. One patient without records of numerical rating scale (NRS) pain intensity scores was excluded and eight patients who underwent total pancreatectomy were also excluded. NRS scores during 7 postoperative days following resection of PDAC were reviewed along with clinicopathologic characteristics. Patients were stratified into a good pain control group and a poor pain control group according to the difference in average pain intensity between the early (POD 1, 2, 3) and late (POD 5, 7) postoperative periods. Cox-proportional hazards multivariate analysis was performed to determine association between postoperative pain control and oncologic outcomes. RESULTS: A total of 212 patients were dichotomized into good pain control group (n = 162) and poor pain control group (n = 66). Median follow-up period was 17 mo. A negative impact of poor postoperative pain control on overall survival (OS) was observed in the group of patients receiving distal pancreatectomy (DP group; 42.0 mo vs 5.0 mo, P = 0.001). Poor postoperative pain control was also associated with poor disease-free survival (DFS) in the DP group (18.0 mo vs 8.0 mo, P = 0.001). Patients undergoing pancreaticoduodenectomy or pylorus-preserving pancreaticoduodenectomy (PD group) did not show associations between postoperative pain control and oncologic outcomes. Poor patients' perceived pain control was revealed as an independent risk factor of both DFS (HR = 4.157; 95%CI: 1.938-8.915; P < 0.001) and OS (HR = 4.741; 95%CI: 2.214-10.153; P < 0.001) in resected left-sided pancreatic cancer. CONCLUSION: Adequate postoperative pain relief during the early postoperative period has important clinical implications for oncologic outcomes after resection of left-sided pancreatic cancer.