The chronological change of indications and outcomes for single-incision laparoscopic cholecystectomy: a Korean multicenter study.

BACKGROUND: Although single-incision laparoscopic cholecystectomy (SILC) is a common procedure, the change in its surgical indications and perioperative outcomes has not been analyzed. METHODS: We collected the clinical data of patients who underwent pure SILC in 9 centers between 2009 and 2018 and compared the perioperative outcomes. RESULTS: In this period, 6497 patients underwent SILC. Of these, 2583 were for gallbladder (GB) stone (39.7%), 774 were for GB polyp (11.9%), 994 were for chronic cholecystitis (15.3%), and 1492 were for acute cholecystitis (AC) (23%). 162 patients (2.5%) experienced complication, including 20 patients (0.2%) suffering from biliary leakage. The number of patients who underwent SILC for AC increased over time (p = 0.028), leading to an accumulation of experience (27.4 vs 23.7%, p = 0.002). The patients in late period were more likely to have undergone a previous laparotomy (29.5 vs 20.2%, p = 0.006), and to have a shorter operation time (47.0 vs 58.8 min, p < 0.001). Male (odds ratio [OR]; 1.673, 95% confidence interval [CI] 1.090-2.569, p = 0.019) and moderate or severe acute cholecystitis (OR; 2.602, 95% CI 1.677-4.037, p < 0.001) were independent predictive factors for gallbladder perforation during surgery, and open conversion (OR; 5.793, 95% CI 3.130-10.721, p < 0.001) and pathologically proven acute cholecystitis or empyema (OR; 4.107, 95% CI 2.461-6.854, p < 0.001) were related with intraoperative gallbladder perforation CONCLUSION: SILC has expanded indication in late period. In this period, the patients had shorter operation times and a similar rate of severe complications, despite there being more numerous patients with AC.

Reduced port minimally invasive distal pancreatectomy: single-port laparoscopic versus robotic single-site plus one-port distal pancreatectomy.

BACKGROUND: Minimally invasive surgery appears to be developing in multiple directions, including single-port laparoscopic (SPL), single-port robotic, reduced port laparoscopic, or single-site plus one-port robotic approach. The aim of study was to compare the short-term perioperative variables and outcomes of patients undergoing reduced port minimally invasive distal pancreatectomy (DP) via the SPL, or robotic single-site plus one-port (RSS + 1) approach. METHODS: The medical records of 35 patients were retrospectively reviewed, who underwent SPL-DP (n = 22) or RSS + 1 DP (n = 13) at Korea University Ansan Hospital and Yonsei University Severance Hospital. RESULTS: The mean operation time in SPL group was significantly higher than that of RSS + 1 group (281 vs 192, p = .001). The mean blood loss in SPL was significantly larger than that of RSS + 1 group (163 vs 12, p = .002). The mean length of free resection margin in SPL group was significantly longer than that of RSS + 1 group (2.1 vs 0.4 cm, p = .001). Spleen was significantly preserved in SPL group (54.5 vs 7.7%, p = .001). All RSS + 1 cases had tumors located near spleen hilum (p < .001). SPL approach had significantly grade IIIa complications (p = .014). Moreover, the mean hospital stay in SPL group was significantly longer than that of RSS + 1 group (14.4 vs 7.4 days, p = .004). Postoperative pancreatic fistula (POPF) was significantly observed in longer operation time (p = .043) and smaller tumor size (p = .037) in the univariate analysis. Higher BMI was significantly important factor for prolonged operation time (p = .034) in the multivariate analysis. Prolonged hospital stay was related to spleen preservation (p = .014) in the multivariate analysis. CONCLUSIONS: Both SPL and RSS + 1 are technically feasible and safe. RSS + 1-DP is superior to SPL-DP in terms of operation time, blood loss, severe complications, and hospital stay. SPL-DP shows advantages in terms of single wound site, less trocar usage, higher rate of spleen preservation, and wider range of operative field.

A new fluorescence imaging technique for visualizing hepatobiliary structures using sodium fluorescein: result of a preclinical study in a rat model.

BACKGROUND: Near-infrared fluorescence imaging has been recently applied in the field of hepatobiliary surgery. Our objective was to apply blue light fluorescence imaging to cholangiography and liver mapping during laparoscopic surgery. Therefore, we designed a preclinical study to evaluate the feasibility of using blue light fluorescence for cholangiography and liver mapping in a rat model. METHODS: Sodium fluorescein solution (1 mL to each individual) were administered intravenously to 20 male Sprague-Dawley rats (6 weeks old, 200-250 g), after laparotomy. Whole abdominal organs were observed under blue light (at a wavelength of 440-490 nm) emitted from a commercialized LED curing light. RESULTS: Immediately after the tracer solution was administered into the circulatory system of the rat, it was possible to visualize the location of the kidneys and the bile duct under blue light emitted from the light source. The liver was vaguely stained green by the tracer, while the ureters were not. After establishing biliary retention via duct clamping in the left lateral segment of the liver, the green color of the segment became distinct by the tracer, which showed vague coloration following release of the clamp. CONCLUSION: We established the preclinical basis for using blue light fluorescence cholangiography and liver mapping in this study. The clinical feasibility of these techniques during laparoscopic cholecystectomy and hepatectomy remained to be demonstrated.

Systematic review of the clinical significance of lymph node micrometastases of pancreatic adenocarcinoma following surgical resection.

OBJECTIVES: The aim of this study is to perform a systematic review of the clinical impact of lymph node micrometastasis in pancreatic adenocarcinoma following surgical resection. METHODS: A systematic review was conducted and published literature were searched using "pancreas or pancreatic" and "cancer or carcinoma or neoplasm", and "micrometastasis or micrometastses" in the PubMed, EMBAE, and Web of Science. RESULTS: Thirteen publications with 726 patients and 3701 lymph nodes were included in this systematic review. The detection method was immunohistochemical stains or polymerase chain reaction. The pooled proportion of patients with positive lymph node micrometastasis was 43.1% (95% Confidence interval (CI) 0.254-0.628). The pooled proportion of positive lymph node micrometastasis (number of positive lymph node micrometastasis/total number of lymph nodes examined) was 10.8% (95% CI 4.8-22.6). Among the conventional H &E negative patients, the reported 5-year survival rates of the patients without lymph node micrometastases vs. those with lymph node micrometastases in the ranged from 50% to 61% and from 0% to 36%, respectively Patients with lymph node micrometastasis showed poorer survival (Hazard ratio 4.29, 95% CI 1.27-14.41). CONCLUSIONS: The presence of lymph node micrometastasis is associated with poorer survival. Lymph node micrometastasis is applicable to stratify the risk of recurrence and the need for adjuvant therapy of post-resection patients with pancreatic adenocarcinoma in the conventional H & E lymph node negative patients.

High occupational stress and low career satisfaction of Korean surgeons.

Surgery is a demanding and stressful field in Korea. Occupational stress can adversely affect the quality of care, decrease job satisfaction, and potentially increase medical errors. The aim of this study was to investigate the occupational stress and career satisfaction of Korean surgeons. We have conducted an electronic survey of 621 Korean surgeons for the occupational stress. Sixty-five questions were used to assess practical and personal characteristics and occupational stress using the Korean occupational stress scale (KOSS). The mean KOSS score was 49.31, which was higher than the average of Korean occupational stress (45.86) or that of other specialized professions (46.03). Young age, female gender, long working hours, and frequent night duties were significantly related to the higher KOSS score. Having spouse, having hobby and regular exercise decreased the KOSS score. Multiple linear regression analysis showed that long working hours and regular exercise were the independent factors associated with the KOSS score. Less than 50% of surgeons answered that they would become a surgeon again. Most surgeons (82.5%) did not want to recommend their child follow their career. Korean Surgeons have high occupational stress and low level of career satisfaction.

Surgical strategy for T2 and T3 gallbladder cancer: is extrahepatic bile duct resection always necessary?

PURPOSE: Resection of the extrahepatic bile duct is not performed uniformly in gallbladder cancer. The study investigated the clinical significance of resection of extrahepatic bile duct (EHBD) in T2 and T3 gallbladder cancer. METHODS: Between 2000 and 2010, 71 T2 or T3 gallbladder cancer patients who underwent R0 resection at Korea University Medical Center were included. Clinicopathological data were reviewed retrospectively. Survival analysis and comparison between EHBD resection and non-resection groups were performed. RESULTS: The 32 men and 39 women had 49 T2 tumors and 22 T3 tumors. The overall survival rate was 67.8 % at 3 years and 47.2 % at 5 years. In multivariate analysis for overall survival, lymphovascular invasion and lymph node metastasis were significant independent predictors. Comparing the patients according to EHBD resection, the EHBD resection group demonstrated significantly longer hospital stay, longer operative time, more transfusion requirement, more extensive liver resection, and less treatment of neoadjuvant therapy. Significantly higher proportions of perineural invasion and lymph node metastasis were noted in the EHBD resection group. There were no statistically significant differences in survival between the EHBD resection and non-resection groups. CONCLUSIONS: Resection of extrahepatic bile duct was not always necessary in T2 and T3 cancers. However, the patients who undergo resection of extrahepatic bile duct tended to have more aggressive tumor characteristics and undergo more aggressive surgical approach. To enhance overall survival for the patients with T2 and T3 gallbladder cancers, surgeons should try to perform R0 resection including EHBD resection.

Laparoscopic fluorescence imaging technique for visualizing biliary structures using sodium fluorescein: the result of a preclinical study in a porcine model.

Purpose: Near-infrared fluorescence imaging has been recently applied in the field of hepatobiliary surgery. Our objective was to apply blue-light fluorescence cholangiography during laparoscopic surgery. Therefore, we designed a preclinical study to evaluate the feasibility of using blue-light fluorescence for cholangiography in a porcine model. Methods: Five millimeters of sodium fluorescein (SF) solution was administered into the gallbladder of 20 male 3-way crossbred (Landrace × Yorkshire × Duroc) pigs in laparoscopic approach. The biliary tree was observed under blue light (a peak wavelength of 450 nm) emitted from a commercialized light-emitting diode (LED) light source (XLS1 extreme, Chammed). Results: In 18 of 20 porcine models, immediately after SF solution was administered into the gallbladder, it was possible to visualize the biliary tree under blue light emitted from the LED light source. Conclusion: This study provided a preclinical basis for using blue-light fluorescence cholangiography using SF in laparoscopic surgery. The clinical feasibility of blue-light fluorescence imaging techniques for laparoscopic cholecystectomy remained to be demonstrated.

Fourteen year surgical experience of gallbladder cancer: validity of curative resection affecting survival.

BACKGROUND/AIMS: Early diagnosis and R0 resection of gallbladder cancer offer a chance for cure. The aims of this retrospective study were to determine the clinicopathologic prognostic factors affecting survival and recurrence. METHODOLOGY: Between 1995 and 2008, a total of 69 patients with gallbladder cancer who underwent surgical exploration or resection were reviewed retrospectively. RESULTS: Of the 69 patients, 34 achieved R0 resection (49.3%). The overall survival rates were 36.6% at 3 years and 24.4 % at 5 years. Multivariate analysis for overall survival demonstrated that non-R0 resection, lymph node dissection, infiltrative tumors, moderate to poor differentiation and depth of invasion were significant independent predictors of poor prognosis. Recurrence occurred in 21 patients. The seventh edition of American Joint Committee on Cancer staging system provided relatively better prediction of survival in patients with gallbladder cancer. CONCLUSIONS: R0 resection and lymph node dissection is an important surgical strategy to improve overall survival. Infiltrative tumor was an independent prognostic factor for disease free survival.

Reliability of continuous suture of pancreaticojejunostomy after pancreaticoduodenectomy.

BACKGROUND/AIMS: Currently, there seems to be no optimized method of pancreaticojejunostomy, and numerous modifications have been used to reduce postoperative pancreatic fistula after pancreaticoduodenectomy. The aim of the present study was to assess the efficacy of continuous sutures for duct-to-mucosa pancreaticojejunostomy in pancreaticoduodenectomy and find predictive risk factors of postoperative pancreatic fistula. METHODOLOGY: We retrospectively reviewed the medical records of 112 patients who underwent pancreaticoduodenectomy, which included patient's demographics, disease-related factors and operative risk factors. RESULTS: Between the interrupted suture and continuous suture groups, there was no significant difference in presence of preoperative biliary drainage, pancreas texture, the pancreatic duct diameter and the prevalence of coronary artery disease. Postoperative pancreatic fistula developed in 21 (18.8%) of the 112 patients who underwent pancreaticoduodenectomy. Only preoperative biliary drainage and operation type showed significant differences for developing pancreatic fistula in a multivariate analysis. CONCLUSIONS: The study revealed that the incidence of pancreatic fistula was similar in both the continuous and interrupted suture groups of pancreaticojejunostomy. Continuous suture group had shorter operative time, less damage, fewer knots and less tension than interrupted sutures. Therefore, we concluded that the continuous suture method is feasible and safe to apply to reconstructing pancreaticojejunostomy.

Single-incision multiport laparoscopic cholecystectomy for a patient with situs inversus totalis: report of a case.

Laparoscopic cholecystectomy has become the standard treatment for symptomatic cholelithiasis in patients with situs inversus totalis (SIT). Nowadays, single-incision multiport laparoscopic surgery is safe and feasible for treating benign gallbladder disease. We report a case of successful single-incision multiport laparoscopic cholecystectomy for a patient with SIT, and describe its technical advantages.

Expression and clinical significance of cell cycle regulatory proteins in gallbladder and extrahepatic bile duct cancer.

Disruption of cell cycle controls is a pathognomonic feature of all malignant cells. Therefore, we immunohistochemically investigated the relationship between cell cycle regulatory proteins and clinicopathologic features in order to identify the biomarkers related to the outcome of patients with biliary tract cancer (BTC). A cohort of paraffin-embedded specimens were selected from 36 patients, including 18 gallbladder and 18 extrahepatic bile duct cancers, who underwent curative or palliative surgical resection at Korea University Medical Center from June 1998 to December 2004. Tissue microarrays were used to investigate the immunohistochemical staining for p21, p27, p53, cyclin D1, bcl2, and Ki-67. Univariate and multivariate survival analyses were performed to determine the prognostic significance of each protein expression. Absence of p21 expression independently predicted poor outcome in all cases. Well-differentiated tumor was found to be an independent good prognostic factor in gallbladder cancer. Absence of p21 expression and moderately to poorly differentiated tumor were found to be an independent poor prognostic factor in patients with negative for neural invasion. Absence of p21 and bcl2 were found to be an independent poor prognostic factor in patients with no lymph node metastasis. Absence of p21 expression was a significant independent poor prognostic factor in BTC, partly in patients with biologically less aggressive phenotypes. This finding suggests that determination of p21 expression in surgically resected specimens may provide prognostic information in addition to conventional pathologic findings for patients with BTC, especially those who have biologically less aggressive phenotypes.

Incidental gallbladder cancer diagnosed following laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the treatment of choice for benign gallbladder disease. Gallbladder cancers have been found following LC. The aim of the present study was to evaluate the survival outcome and prognosis of incidental gallbladder cancer diagnosed after LC. METHODS: From January 2002 to December 2007, 3,145 patients underwent LC at the Department of Surgery, Korea University Medical Center. Of these, 33 patients (1.05%) were diagnosed with gallbladder cancer after LC. Clinicopathological characteristics were retrospectively reviewed in this study. RESULTS: Of the 33 patients studied, 9 were men and 24 were women. Laparoscopic cholecystectomy alone was performed in 26 patients, and additional radical surgery was performed in 7 others. Regarding tumor staging, there were 2 Tis, 6 T1a, 4 T1b, 17 T2, and 4 T3 tumors. Male patients had a significantly higher incidence of moderately and poorly differentiated tumors (P < 0.001), T2 and T3 tumors (P = 0.02), additional second operations (P = 0.046), and recurrence (P = 0.016). The cumulative 1-, 3-, and 5-year survival rates were 87.2, 73.1, and 47.0%, respectively. Univariate analysis revealed that significant prognostic factors for poorer survival were male gender (P = 0.026), age older than 65 years (P = 0.013), the presence of inflammation (P = 0.009), moderately or poorly differentiated tumor (P < 0.001), nonpolypoid gross type (P = 0.003), and pT stage (P < 0.001). Tumor differentiation was a significantly independent predictor of poor prognosis. CONCLUSIONS: Male patients exhibited aggressive tumor characteristics. Laparoscopic cholecystectomy is an adequate treatment for pT1 tumors. For pT2 and pT3 patients, additional radical surgery might be needed to achieve a tumor-free surgical margin, along with lymph node dissection.

Methicillin-resistant Staphylococcus aureus screening is important for surgeons.

BACKGROUNDS/AIMS: Perioperative surgical site infection (SSI) remains a morbid complication even in successful surgical procedures. We encountered an unusual experience of a methicillin-resistant Staphylococcus aureus (MRSA)-related SSI outbreak in our hospital; therefore, we conducted an epidemiologic analysis to determine the origin of SSIs due to MRSA. METHODS: Among 102 consecutive patients who underwent hepatobiliopancreatic operations, SSIs occurred in eight cases. Infection surveillance regarding the operative environment was carried out. We analyzed the possible risk factors for this infectious outbreak in our institution. RESULTS: Patients with SSI tended to be older (p=0.293), had variable operation fields (p=0.020), more cancer-related operation (p=0.003), less laparoscopic surgery (p=0.007), performed in operation room 1 (p=0.004), prolonged operation time (p<0.001) and had longer hospital stays (p=0.002). After propensity score (PS) matching, there was the only significant difference in the participation of surgeon D as a second assistant (p=0.001) between the SSI and non-SSI group. After PS matching, surgeon D as a second assistant was the only significant risk factor for MRSA SSI in the univariate (p=0.001) and multivariate analysis (p=0.004, hazard ratio=25.088, 95% confidence interval=2.759-228.149). CONCLUSIONS: Outbreak of SSIs occurred due to transmission of MRSA from a surgeon to patients despite the standard regulation of infection control. These SSIs were associated with an excessive incidence of surgeon's nasal and hand carriage of the MRSA strain identified in the surgeon via cultures. We recommend the preoperative regular nasal and hand screening for MRSA among surgeons.

Single-port versus conventional laparoscopic distal pancreatectomy: a propensity score matched analysis and a learning curve of single-port approach.

BACKGROUND: Single-port laparoscopic approaches are well established in the field of minimally invasive surgery; however, single-port laparoscopic distal pancreatectomy (SPLDP) has not been evaluated in a large number of distal pancreatic neoplasms. We aimed to compare single-port laparoscopic distal pancreatectomy outcomes with conventional laparoscopic distal pancreatectomy (LDP) outcomes. METHODS: We retrospectively evaluated the medical records of 101 patients who underwent SPLDP (n = 26) or LDP (n = 75). We performed 1:1 propensity score matching between the two groups. Consequently, 26 patients were included in each group. We analyzed the learning curve based on the operation time in SPLDP. RESULTS: Single-port laparoscopic distal pancreatectomy could be performed with fewer trocars (P < 0.001) and assistants (P < 0.001). However, compared to the LDP group, mean operation time was longer (278.9 vs. 178.7 min, P < 0.001) and splenic vessel preservation rates were lower (0% vs. 46.2%, P < 0.001) in the SPLDP group. The mean pain visual analogue scale score was significantly lower at postoperative day 1 (P < 0.001) and day 2 (P < 0.001) in the SPLDP group. The learning curve was determined in the 12th case for SPLDP. CONCLUSIONS: Single-port laparoscopic distal pancreatectomy is comparable in safety to conventional laparoscopic approaches for distal pancreatic neoplasms, with fewer trocars, assistants and less pain; however, operation time was longer.

Clinical significance of post-hepatectomy hepatic failure in patients with liver metastases from colorectal cancer.

BACKGROUNDS/AIMS: This study attempted to identify risk factors for development of post-hepatectomy hepatic failure (PHF) and its effect on long-term survival of patients with liver metastases from colorectal cancer. METHODS: We carried out a retrospective study of 143 patients who had been diagnosed with liver metastases from colorectal cancer and who had undergone hepatectomy between 2003 and 2010. We allocated these patients to PHF and non-PHF groups, using the definition of the International Study Group of Liver Surgery, and compared the clinical factors of the two groups, using Cox regression and Kaplan-Meier analysis to evaluate the differences in overall survival (OS) and recurrence-free survival (RFS) between these groups. RESULTS: The PHF group comprised 19 patients (13.3%); all had Grade A PHF. Independent risk factors for development of PHF were metachronous liver metastases and major hepatectomy. The differences between the PHF and non-PHF groups in OS or RFS were not statistically significant; however, the PHF group tended to have a worse prognosis. Multivariate analysis revealed significant associations between OS and the factors of poor differentiation of the primary colorectal cancer, major hepatectomy, and positive resection margin. CONCLUSIONS: Major hepatectomy is an important risk factor for PHF in patients with liver metastases from colorectal cancer. The pathological characteristics of the primary tumor are more important as predictors than is Grade A PHF.

Clinical significance of pancreatic intraepithelial neoplasia in resectable pancreatic cancer on survivals.

PURPOSE: Noninvasive precursor lesions for pancreatic adenocarcinoma include pancreatic intraepithelial neoplasia (PanIN), intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm. PanIN is often found synchronously adjacent to resected pancreatic ductal adenocarcinoma (PDAC) tumors. However, its prognostic significance on outcome after PDAC resection is unknown. The purpose of the current study was to determine if the presence of PanIN has a prognostic or predictive effect on survival after resection for PDAC with curative intent. METHODS: We retrospectively reviewed the clinicopathologic data of patients who underwent pancreatectomy for PDAC from January 2002 to January 2013. Intraductal papillary mucinous lesions and mucinous cystic neoplasms were excluded. All available postoperative imaging and clinical follow-up data were reviewed. RESULTS: There were 95 patients who underwent pancreatectomy. Tumors were most commonly located in the pancreas head and as such pancreaticoduodenectomy was the most commonly performed operation. The median tumor size was 3.2 cm. An absence of PanIN lesions was identified in 39 patients (41%). Of the patients with PanIN lesions, high-grade PanIN (grade 3) was the most common type (64.3%) followed by grade 2 (28.6%). There was no significant difference in overall survival or disease-free survival between the non-PanIN and PanIN groups. CONCLUSION: The presence or absence of PanIN lesions did not affect survival in patients undergoing resection for pancreatic cancer. However, patients with high-grade PanINs tended to have better overall survival. Larger studies with longer follow up are needed to accurately determine its clinical significance.

VEGF Overexpression Predicts Poor Survival in Hepatocellular Carcinoma.

OBJECTIVE: The aim of this study was to investigate the clinicopathological and immunohistochemical (including VEGF, Akt, HSP70, and HSP20 expression) factors that affect the overall and disease-free survival of HCC patients following surgical resection. METHODS: 234 patients with HCC following surgical resection were enrolled. Clinicopathological and survival data were analyzed, and immunohistochemical staining was performed on tissue microarray sections using the anti-VEGF, anti-Akt, anti-HSP70, and anti-HSP27 antibodies. RESULTS: The 3- and 5-year overall survival rates were 86.5 and 81.54%, respectively. Multivariate analysis revealed that VEGF expression (P = 0.017, HR = 2.573) and T stage (P < 0.001, HR = 4.953) were independent prognostic factors for overall survival. Immunohistochemical staining showed that the expression of Akt, HSP70, and HSP27 did not affect the overall survival rate. The 3- and 5-year disease-free survival rates were 58.2 and 49.4%, respectively. Compared to the VEGF(-)/(+) group, the VEGF(++)/(+++) group demonstrated significantly higher proportion of patients with AFP levels > 400 ng/mL, capsule invasion, and microvascular invasion. CONCLUSION: VEGF overexpression was associated with capsule invasion, microvascular invasion, and a poor overall survival rate.

A new glove port for single incision procedure.

Single-incision laparoscopic surgery has gained increasing attention due to its potential to improve the benefits of laparoscopic surgery. However, inconvenience remains for inexperienced surgeons during surgery when instruments conflict with each other, and a glove port is used hesitantly for such diagnosis related groups (DRG) because of its high cost. Authors made a new glove port by an odd surgical gloves and one wound protectors. This glove port is ease to make besides being convenient to us, and inexpensive. This new glove port has the benefit of easy utilization and cost effectiveness for surgeons performing single-incision laparoscopic surgery.

Protective effect of ischemic postconditioning against hepatic ischemic reperfusion injury in rat liver.

PURPOSE: The efficiency of ischemic postconditioning (IPC) was evaluated in a rat model of ischemic liver. Concentration of survivin of liver tissue correlated with the degree of antiapoptosis, so survivin was estimated to evaluate the efficiency of IPC on ischemic reperfusion (IR) injury. METHODS: Twenty-four healthy rats were divided to three groups (SHAM, IR, and IPC). Rats in the SHAM group displayed no change during 3 hours. Rats in the IR group were ischemic within 1 hour of clamping the left hepatic artery and left portal vein. Reperfusion for 2 hours was then done. IPC group, intermittent 2, 3, 5, and 7 minutes of reperfusion followed by 1 hour of warm ischemia. Two-minute reocclusion was done after each reperfusion. Rat sera were analyzed for AST and ALT, and Western blot analysis of rat liver tissue of rats evaluated malondialdehyde (MDA) and survivin. RESULTS: MDA in the liver tissue of rats in the IR and IPC group were significantly high than in the liver tissue of the SHAM group (P = 0.003 and P = 0.008, respectively). Survivin was higher in the IPC group than in the SHAM and IR groups (P = 0.021 and P = 0.024, respectively). CONCLUSION: IPC could not prevent lipid oxidation in liver cell mitochondria, but did aid in the regeneration of ischemic injured liver cells. The results indicate that IPC can suppress the apoptosis of liver cells and reduce reperfusion injury of liver tissue.

Disease recurrence patterns and analysis of clinicopathological prognostic factors for recurrence after resection for distal bile duct cancer.

Surgical resection is the treatment of choice for bile duct cancers. The aim of this study was to investigate disease recurrence patterns and prognostic factors for recurrence of distal bile duct cancers after surgical resection. A retrospective study was performed on 122 patients with distal bile duct cancers who underwent R0 or R1 surgical resection at Korea University Guro Hospital from 1991 to 2010. Sites of initial disease recurrence were classified as locoregional or distant. Univariate and multivariate analyses were performed to investigate the factors affecting recurrence. Of the 122 patients, 80 patients developed recurrence. The disease-free survival rate was 63.1 per cent at one year and 36.4 per cent at three years. The patterns of recurrence at diagnosis were locoregional in 25 patients, locoregional and distant metastasis in 14 patients, and distant metastasis in 41 patients. Multivariate analyses revealed that recurrence pattern, lymph node metastasis, and differentiation are independent prognostic factors affecting disease-free survival. R status (marginal significance) and tumor differentiation were independent prognostic factors associated with locoregional recurrence. Differentiation and lymph node metastasis were independent prognostic factors associated with distant metastasis. The prognosis after recurrence was poor with a 1-year survival rate after recurrence of 26.1 per cent. Adjuvant chemo- or radiation therapy, delivered in patients mainly with R1 resection or with presence of lymph node metastasis, did not demonstrate the survival benefit. Significant factors for recurrence were tumor differentiation and lymph node metastasis. Therefore, close follow-up and adjuvant therapy will be necessary in patients with lymph node metastasis or poorly differentiated tumor.