Single-incision versus conventional multiport laparoscopic cholecystectomy in acute cholecystitis according to disease severity: single center retrospective study in Korea

Purpose@#The safety of single-incision laparoscopic cholecystectomy (SILC) for acute cholecystitis (AC) has not yet been confirmed. @*Methods@#This single-center retrospective study included patients who underwent laparoscopic cholecystectomy (LC) for AC between April 2010 and December 2020.Propensity scores were used to match patients who underwent SILC with those who underwent conventional multiport LC (CMLC) in the entire cohort and in the two subgroups. @*Results@#A total of 1,876 patients underwent LC for AC, and 427 (22.8%) underwent SILC. In the propensity score-matched analysis of the entire cohort (404 patients in each group), the length of hospital stay (2.9 days vs. 3.5 days, p = 0.029) was shorter in the SILC group than in the CMLC group. No significant differences were observed in other surgical outcomes. In grade I AC (336 patients in each group), the SILC group showed poorer surgical outcomes than the CMLC group, regarding operation time (57.6 minutes vs. 52.4 minutes, p = 0.001) and estimated blood loss (22.9 mL vs. 13.1 mL, p = 0.006). In grade II/III AC (58 patients in each group), there were no significant differences in surgical outcomes between the two groups. Postoperative pain outcomes were also not significantly different in the two groups, regardless of severity. @*Conclusion@#This study demonstrated that SILC had similar surgical and pain outcomes to CMLC in patients with AC; however, subgroup analysis showed that SILC was associated with poor surgical outcomes than CMLC in grade I AC. Therefore, SILC should be carefully performed in patients with AC by experienced hepatobiliary surgeons.

Optimal drain management following complicated laparoscopic cholecystectomy for acute cholecystitis: a propensity-matched comparative study

Purpose@#This study was performed to investigate the effect of drain placement on complicated laparoscopic cholecystectomy (cLC) for acute cholecystitis (AC). @*Methods@#This single-center retrospective study reviewed patients with AC who underwent cLC between January 2010 and December 2020. cLC was defined as open conversion, subtotal cholecystectomy, adjacent organ injury during surgery, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL. One-toone propensity score matching was performed to compare the surgical outcomes between patients with and without drain on cLC. @*Results@#A total of 216 patients (mean age, 65.8 years; 75 female patients [34.7%]) underwent cLC, and 126 (58.3%) underwent intraoperative abdominal drainage. In the propensity score-matched cohort (61 patients in each group), early drain removal (≤postoperative day 3) was performed in 42 patients (68.9%). The overall rate of surgical site infection (SSI) was 10.7%. Late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications (13.1% vs. 21.4% vs. 47.4%, p = 0.006), postoperative hospital stay (3.8 days vs. 4.4 days vs. 12.7 days, p < 0.001), and SSI (4.9% vs. 11.9% vs. 31.6%, p = 0.006). In the multivariate analysis, late drain removal was the most significant risk factor for organ space SSI. @*Conclusion@#This study demonstrated that drain placement is not routinely recommended, even after cLC for AC. When placing a drain, early drain removal is recommended because late drain removal is associated with a higher risk of organ space SSI.

Efficacy of sentinel lymph node biopsy with radioisotope alone and the prediction of sentinel node status using PET-CT in breast cancer

Purpose@#Sentinel lymph node biopsy (SLNB) using both a radioactive isotope (RI) and blue dye is considered highly effective; however, there were limitations with the use of both agents in some hospitals, and blue dye has been shown to have some adverse effects. Additionally, preoperative prediction of sentinel lymph node (SLN) status using the maximum standardized uptake value (SUVmax) on positron emission tomography-computed tomography (PET-CT) can help avoid unnecessary axillary dissection or SLNB. Thus, we evaluated the efficacy and oncologic safety of SLNB using an RI alone in terms of long-term outcomes and determined the association between SLN metastasis and SUVmax of the primary tumor. @*Methods@#This retrospective study was conducted at Konyang University Hospital between March 2011 and May 2018. Overall, 142 patients with breast cancer who underwent SLNB using an RI alone were enrolled. Data on identification and false-negative rates were collected. The SUVmax of primary tumors on PET-CT were analyzed for their association with SLN metastasis. @*Results@#The identification and false-negative rates were 98.6% and 0%, respectively. There was no axillary local recurrence in patients with negative SLN findings. The correlation between the SUVmax of the primary tumor and SLN status was significant (r=0.249, P=0.005); the cutoff value for negative SLN metastasis was <2.15. @*Conclusion@#The single agent method using an RI is not inferior to other methods and serves as a feasible option for SLNB. And the number of excised SLNs could be minimized when the SUVmax of primary tumor is extremely low.

Efficacy of sentinel lymph node biopsy with radioisotope alone and the prediction of sentinel node status using PET-CT in breast cancer

Purpose@#Sentinel lymph node biopsy (SLNB) using both a radioactive isotope (RI) and blue dye is considered highly effective; however, there were limitations with the use of both agents in some hospitals, and blue dye has been shown to have some adverse effects. Additionally, preoperative prediction of sentinel lymph node (SLN) status using the maximum standardized uptake value (SUVmax) on positron emission tomography-computed tomography (PET-CT) can help avoid unnecessary axillary dissection or SLNB. Thus, we evaluated the efficacy and oncologic safety of SLNB using an RI alone in terms of long-term outcomes and determined the association between SLN metastasis and SUVmax of the primary tumor. @*Methods@#This retrospective study was conducted at Konyang University Hospital between March 2011 and May 2018. Overall, 142 patients with breast cancer who underwent SLNB using an RI alone were enrolled. Data on identification and false-negative rates were collected. The SUVmax of primary tumors on PET-CT were analyzed for their association with SLN metastasis. @*Results@#The identification and false-negative rates were 98.6% and 0%, respectively. There was no axillary local recurrence in patients with negative SLN findings. The correlation between the SUVmax of the primary tumor and SLN status was significant (r=0.249, P=0.005); the cutoff value for negative SLN metastasis was <2.15. @*Conclusion@#The single agent method using an RI is not inferior to other methods and serves as a feasible option for SLNB. And the number of excised SLNs could be minimized when the SUVmax of primary tumor is extremely low.

Which Patients Are a Better Candidate of Laparoscopic Repair in Obturator Hernia Patients?

Purpose@#Obturator hernia is a difficult disease to diagnose. If a surgical treatment is delayed in obturator hernia, a bowel resection may be required due to strangulation. The surgical treatment of this disease is to use a classical laparotomy. Recently, the laparoscopic approach has been reported and reviewed for efficiency. We checked the indicators that determine the most appropriate surgical method according to the patient’s condition. @*Methods@#In the study, a single-institution, retrospective analysis of surgical patients undergoing an obturator hernia surgery between 2003 and 2018 was performed. The patients were divided into a laparoscopic group (5 patients underwent laparoscopic repair; no intestinal resection) and an open group (13 patients who underwent open repair; 10 with and 3 without intestinal resection). The outcomes were compared between the groups. We analyzed the relevant factors that could predict the proper method of surgery. @*Results@#A total 18 patients were included in the study. All patients were female, with body mass index (BMI) of under 21 kg/m2. Of the various factors, only the WBC and CRP counts were the factors that had shown significant differences between the two groups. It is noted that patients with open surgery had a higher WBC counts (10406 versus 6520/μl; p=0.011) and CRP counts (7.84 vs. 0.32 mg/dl; p=0.027). @*Conclusion@#Obturator hernia can be treated with a laparoscopic surgery. The choice of surgical treatment can be considered in advance through the review of the patient’s WBC count or CRP count.

The Usefulness of Preoperative Colonoscopic Tattooing with Autologous Blood for Localization in Laparoscopic Colorectal Surgery

Purpose@#In colorectal cancer surgery, it is important to have accurate resection margins. However, it is challenging to localize lesions during laparoscopy. Therefore, to reduce surgical errors, many preoperative localizing methods have been introduced. In this study, we aimed to assess the preoperative feasibility and safety of autologous blood tattooing. @*Methods@#A total of 11 patients underwent preoperative colonoscopic autologous blood tattooing from August 2017 to February 2020. At the start of the surgery, the surgeon assessed the patients for the precision of visibility and other complications such as abscess or spillage. The patients’ characteristics, outcomes, and complications were collected retrospectively. @*Results@#The study comprised 8 men and 3 women, with an average age of 63 years. Ten patients showed precise visibility, and no localization errors were observed during surgery. No complication was observed in all patients. @*Conclusion@#Preoperative autologous blood tattooing is a very useful and safe technique because it has high visibility with no complications. This method does not require additional agents or facilities. A large-scale study will be required to develop standard guidelines.

Single Incision Laparoscopic Appendectomy for Management of Complicated Appendicitis: Comparison between Single-Incision and Conventional

PURPOSE: Single incision laparoscopic appendectomy (SILA) is a widely used surgical procedure for treatment of appendicitis with better cosmesis. However, many surgeons generally tend to choose conventional multiport laparoscopic appendectomy regarding with complicated appendicitis. The aim of this study is to demonstrate the safety and feasibility of SILA for treatment of complicated appendicitis by comparison with 3-ports conventional laparoscopic appendectomy (CLA). METHODS: Retrospective chart review of patients diagnosed appendicitis at single hospital during January 2015 to May 2017 collected 500 patients. Among 134 patients with complicated appendicitis, we compared outcomes for 29 patients who got SILA and 105 patients who got CLA. RESULTS: 179 and 321 patients were treated by SILA and CLA, respectively. 134 (26.8%) patients were treated for complicated appendicitis, 29 patients by SILA and 105 patients by CLA, respectively. There was no case converted to open or added additional trocar in both groups. There were no differences in demographics with regard to age, sex, body mass index (BMI), and American society of anesthesiologists (ASA) scores. There was no difference in mean operating time (58.97±18.53 (SILA) vs. 57.57±21.48 (CLA), p=0.751). The drain insertion rate (6.9% vs 37.1%, p=0.001) and the length of hospital stay (2.76±1.41 vs. 3.97±2.97, p=0.035) were lower in SILA group with significance. There was no significant difference in the rate of surgical site infection (6.9% vs. 6.7%, p=1.000). CONCLUSION: This study demonstrates that SILA is a feasible and safe procedure for treatment of complicated appendicitis.

Evolution of the Konyang Standard Method for single incision laparoscopic cholecystectomy: the result from a thousand case of a single center experience

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is increasingly performed worldwide. Accordingly, the Konyang Standard Method (KSM) for SILC has been developed over the past 6 years. We report the outcomes of our procedures. METHODS: Between April 2010 and December 2016, 1,005 patients underwent SILC at Konyang University Hospital. Initially 3-channel SILC with KSM was changed to 4-channel SILC using a modified technique with a snake retractor for exposure of Calot triangle; we called this a modified KSM (mKSM). Recently, we have used a commercial 4-channel (Glove) port for simplicity. RESULTS: SILC was performed in 323 patients with the KSM, in 645 with the mKSM, and in 37 with the commercial 4-channel port. Age was not significantly different between the 3 groups (P = 0.942). The postoperative hospital days (P = 0.051), operative time (P < 0.001) and intraoperative bleeding volume (P < 0.001) were significantly improved in the 3 groups. Drain insertion (P = 0.214), additional port insertion (P = 0.639), and postoperative complications (P = 0.608) were not significantly different in all groups. Postoperative complications were evaluated with the Clavien-Dindo classification. There were 3 cases (0.9%) over grade IIIb (bile duct injury, incisional hernia, duodenal perforation, or small bowel injury) with KSM and 3 (0.5%) with mKSM. CONCLUSION: We evaluated the evolution of the KSM for SILC. The use of the mKSM with a commercial 4-channel port may be the safest and most effective method for SILC.

Human epidermal growth factor receptor 2 expression in gastric cancer patients treated with curative intent gastrectomy

PURPOSE: This study aimed to clarify the association between human epidermal growth factor receptor 2 (HER-2) status and the clinicopathologic factors of patients who underwent curative intent gastrectomy.METHODS: From June 2011 to May 2015, curative intent gastrectomy was performed in 441 patients at Konyang University Hospital. Among them, we evaluated the HER-2 status in 113 patients. Data on clinicopathologic parameters such as age, sex, histological subtype, endoscopic Lauren classification, tumor location, size, presence of lymphovascular invasion, invasion depth, pathologic stage, HER-2 overexpression, recurrence and survival were obtained. In this study, pathological HER-2 intensity scores of 0, 1+, and 2+ were assumed to be negative, 3+ only was to be positive for overexpression.RESULTS: In a total of 113 cases who underwent curative intent gastrectomy with HER-2 testing, 16 (14.2%) cases had positivity of HER-2 overexpression. HER-2 overexpression had significant associations with tumor stage (19.0% in I-IIIb vs. 2.9% in IIIc-IV, P=0.036). Survival analysis of HER2 overexpression has no significant difference.CONCLUSION: In this study, HER-2 overexpression rate was 14.2% and patient tumor stage had significant association with HER-2 overexpression.

Risk factors for conversion to conventional laparoscopic cholecystectomy in single incision laparoscopic cholecystectomy

PURPOSE: The aim of this study was to investigate the risk factors for conversion to conventional laparoscopic cholecystectomy (CLC) in single incision laparoscopic cholecystectomy (SILC) along with the proposal for procedure selection guidelines in treating patients with benign gallbladder (GB) diseases. METHODS: SILC was performed in 697 cases between April 2010 and July 2014. Seventeen cases (2.4%) underwent conversion to conventional LC. We compared these 2 groups and analyzed the risk factors for conversion to CLC. RESULTS: In univariate analysis, American Society of Anesthesiologist score > 3, preoperative percutaneous transhepatic GB drainage status and pathology (acute cholecystitis or GB empyema) were significant risk factors for conversion (P = 0.010, P = 0.019 and P < 0.001). In multivariate analysis, pathology (acute cholecystitis or GB empyema) was significant risk factors for conversion to CLC in SILC (P < 0.001). CONCLUSION: Although SILC is a feasible method for most patients with benign GB disease, CLC has to be considered in patients with acute cholecystitis or GB empyema because it is likely to result in inadequate visualization of the Calot's triangle and greater bleeding risk.

Predictive factor for excessive myelosuppression in patients receiving chemotherapy for breast cancer

PURPOSE: Myelosuppression, particularly neutropenia, is one of the most frequent and serious toxicity seen in patients with breast cancer undergoing systemic chemotherapy. However, the predictive factors for development of severe neutropenia in chemotherapy remain unknown. We therefore evaluated predictive factors for excessive myelosuppression.METHODS: We retrospectively analyzed 341 patients with breast cancer treated with chemotherapy from 2000 to 2012. Clinicopathological characteristics, number of using of granulocyte colony-stimulating factor (G-CSF), and pretreatment hematologic values were extracted from the electronic medical record system. Patients were sorted 2 groups by number of using G-CSF in each chemotherapeutic regimens; group 1 is more G-CSF (within high 20 percentile) and 2 less G-CSF using group (within lower 20 percentile).RESULTS: Number of using G-CSF was ranged 0–83 (mean 10.76). One hundred one patients were in group 1 and 65 patients were in group 2. Mean of number of G-CSF using was 0.21 in group 1 and 28.02 in group 2. Pretreatment white blood cell, hemoglobin and platelet count were lower in group 2 than in group 1 (6.88×10³/µL vs. 5.97×10³/µL, 12.63 g/dL vs. 11.90 g/dL, and 275.95×10⁴ µL vs. 227.37×10⁴ µL). There were no statistically differences in other clinicopathologic characteristics such as age, body mass index or comorbidities, hormonal receptor, stage, and other pretreatment hematologic values.CONCLUSION: Pretreatment white blood cell count, hemoglobin and platelet count can be used to identify patients at increased risk of significant myelosuppression undergoing chemotherapy with breast cancer. This information can be used to target high-risk patients for prophylactic treatment.

Safety and Feasibility of Self-Expandable Metallic Stent Insertion for the Right-Side Colonic Malignant Obstruction and Its Clinical Benefits

PURPOSE: The efficacy of stenting for the right-side colonic malignant obstruction is unknown. The purpose of this study was to evaluate the safety and feasibility of self-expandable metallic stent insertion for the right-side colonic malignant obstruction and its clinical benefits. METHODS: We retrospectively reviewed clinical data from 460 patients who underwent right hemicolectomy for right-side colon cancer from January 2006 to January 2014 at Korea University Anam Hospital. Twenty four patients who developed malignant obstruction in the right -side colon were identified and analyzed. RESULTS: Self-expandable metallic stent insertion was attempted in 14 patients, and initial technical success was achieved in 13 patients (92.9%). No immediate stent-related complications were reported. Complete relief of obstruction was achieved in all of the 13 patients. Eleven patients who failed stenting underwent emergency operation. All of the 13 patients with stent underwent laparoscopic surgery and only one case was converted to open. Only three patients in the emergency group underwent laparoscopic surgery but one was converted. Operative time and number of retrieved lymph nodes did not differ between the two groups. Postoperative hospital stay (9.8+/-3.2 in stent group vs. 16.3+/-10.9 days in emergency group, p=0.082) tended to be shorter in the stent group. Estimated blood loss (38.5+/-138.7 in stent group vs. 381.8+/-411.9 in emergency group, p=0.010) and duration for resuming diet (3.2+/-2.2 in stent group vs. 6.6+/-7.0 days in emergency group, p=0.017) were significantly better in the stent group. CONCLUSION: Self-expandable metallic stent appears to be safe and feasible in the right-side colonic malignant obstruction. It facilitates minimally invasive surgery and may result in better short-term surgical outcome.

Four-channel single incision laparoscopic cholecystectomy using a snake retractor: comparison between 3- and 4-channel SILC 4-channel single incision cholecystectomy

PURPOSE: Single incision laparoscopic cholecystectomy (SILC) is a widely used method of performing cholecystectomy. A common technique used in SILC is a 3-channel method. However, exposure of Calot's triangle is limited in conventional 3-channel SILC. Therefore, we herein report the adequacy and feasibility of 4-channel SILC using a snake retractor. METHODS: Four hundred and fifteen SILC cases were performed between April 2010 and February 2013. We performed 326 SILC cases between April 2010 and September 2012 using the 3-channel method. We introduced a snake retractor for liver traction in October 2012, and 89 cases of 4-channel SILC using snake retractor have been performed since. RESULTS: Thirty patients (9.2%) in the 3-channel SILC group, and 23 patients (25.8%) in the 4-channel SILC group, were treated with percutaneous transhepatic gallbladder drainage insertion because of acute inflammation of the gallbladder (GB) before operation (P < 0.001). The mean operating time was 53.0 +/- 25.8 minutes in the 3-channel SILC group and 51.9 +/- 18.6 minutes in the 4-channel SILC group (P = 0.709). In the 3-channel SILC group, mean hospital stay was 3.0 +/- 3.3 days whereas it was 2.6 +/- 0.9 days in the 4-channel SILC group (P = 0.043). There were a total 9 cases (2.1%) of additional port usages, 6 cases (1.8%) in the 3-channel SILC group and 3 cases (3.4%) in the 4-channel SILC group (P = 0.411), due to cystic artery bleeding and bile leakage from gallbladder bed, but there were no open conversions. CONCLUSION: Benign diseases of the GB can be operated on using SILC with the 4-channel method using a snake retractor.

Current Status and Future Prospect of Robotic Surgery in Korea

Since the first clinical application of "the da Vinci system" in 2005 in Korea, robotic surgery, an emerging technology in minimally invasive surgery (MIS), has been rapidly adopted in a variety of surgical fields, and approximately 7,000 robotic surgeries have been performed annually in recent years. In past years, Korean surgeons have played a pivotal role in development of robotic surgery, particularly in the general surgery field. A major advantage of robotic surgery is to make a more precise procedure possible, especially in a confined area with magnified three-dimensional vision, enhanced dexterity by endowrist and stable camera control, and better ergonomics, thus adds the benefits of MIS, such as improvement of oncologic surgery quality and better functional preservation. For these reasons, it has been used prominently in prostate, thyroid, and rectal surgery. However, it is also true that several controversies such as less evidence for efficacy and cost-effectiveness, a longer operation time, and absence of haptic sensation have continued. In this article, we reviewed the current status of robotic surgery mainly based on a report from National Evidence-based Healthcare Collaborating Agency (NECA) and discussed the future prospects on the basis of recent literature and our clinical experiences.

POSSUM, P-POSSUM, and Cr-POSSUM Scoring Systems as Predictors of Postoperative Morbidity and Mortality in Elderly Colorectal Cancer Patients

PURPOSE: The Physiological and Operative Severity Score for the enumeration of Morbidity and Mortality (POSSUM), the Portsmouth-POSSUM (P-POSSUM), and the colorectal-POSSUM (Cr-POSSUM) are relative scoring systems for the prediction of postoperative morbidity and mortality. This study is designed to evaluate the usefulness of each scoring system in elderly colorectal cancer patients undergoing major colorectal surgery. METHODS: From January 2000 to May 2008, the authors retrospectively analyzed the medical records of 251 elderly colorectal cancer patients who had undergone surgery. Collected data were analyzed using the Mann-Whitney U-test, a risk stratification analysis, and a receiver-operator characteristic (ROC) curve to evaluate the usefulness and the accuracy of each scoring system. RESULTS: All the predicted morbidity and mortality rates calculated by using the three POSSUM systems were higher than the observed morbidity and mortality rates. A risk stratification analysis showed a considerable correlation in risk prediction between the observed data and the calculated data. The ROC curves showed that all three POSSUM scoring systems had quite high accuracies as predictors of postoperative morbidity and mortality. POSSUM and P-POSSUM were more accurate than Cr-POSSUM. CONCLUSION: All three scoring systems have a tendency for overestimation. The accuracies of POSSUM, P-POSSUM, and Cr-POSSUM as predictors are acceptance, and POSSUM and P-POSSUM are more accurate than Cr-POSSUM for prediting postoperative morbidity and mortality.