Conventional versus helical blade screw insertion following the removal of the femoral head screw: a biomechanical evaluation using trochanteric gamma 3 locking nail versus PFN antirotation.

OBJECTIVE: When a hip screw needs to be changed, choosing between the conventional (C-type) and helical blade (H-type) types is difficult. In this biomechanical study, we compared these two screw types relative to the type of the initial screw used. METHODS: C- or H-type screws were inserted (leading screw) in three types of polyurethane bone models (Sawbone, Pacific Research Laboratories, Inc., Washington, USA: 130 × 180 × 40 mm) of different bone mineral densities (pounds per cubic feet [PCF] 5, 80 kg/m3; PCF 10, 160 kg/m3; and PCF 15, 240 kg/m3), and then successively or alternately inserted (following screw) after the leading screw removal. An original model (original C and H) of a leading screw without removal was created as a control. The strengths of resistance to pullout (PO) and rotational stress were measured. For each experimental condition, there were 30 experimental models. RESULTS: The original C screw was superior in PO strength, and the original H-type screw was superior in rotational strength. When the C- or H-type screw was the leading screw, using the C-type screw again as the following screw (C1-C2, H1-C2) showed the greatest resistance to PO, and using the H-type screw as the following screw (C1-H2, H1-H2) showed superior resistance to rotational strength. However, the rotational strength of the C2 screw decreased by more than 50% compared with that of the original C screw. Moreover, the PO and rotational strengths of the H2 screw decreased to less than 30% overall compared with those of the original H screw. CONCLUSION: The H-type screw should be used for second-time screw insertion procedures in cases where it is difficult to choose between PO and rotational strengths.

The Effective Fixation Level for Cosmetic Lateral Canthoplasty.

BACKGROUND: In previous reports of lateral canthoplasty, the components of the inferior retinaculum were mostly secured to the lateral orbital rim at a level around the pupil or superior limbus. However, that level is not adjustable in young patients who want to lengthen the short palpebral fissure for cosmetic purposes. Moreover, the anchoring method based on the palpebral portion can also be inconvenient and ineffective. Thus, the authors report an effective fixation level of the lateral orbital rim to lengthen and widen the lateral palpebral fissure. METHODS: From June 2015 to August 2017, 202 women and 44 men underwent cosmetic lateral canthoplasty (mean age 28.4 ±â€Š2.8 years old). The lower lid component of the lateral retinaculum was identified and selectively released through a small incision at the lateral commissure. Then, the released retinaculum was secured to the periosteum of the inner aspect of the lateral orbital wall. The fixation level corresponded to the most concave portion or immediately below the most concave point (1 to 2 mm below). RESULTS: Cosmetic lateral canthoplasty was successfully performed in all cases. No severe complications were observed. There were some minor complications. In most cases, the lateral palpebral fissure was naturally reshaped into a wider and brighter contour. Almost all of the patients were satisfied with the results of the treatment. CONCLUSIONS: The anchoring procedure at the most concave portion of the lateral orbital rim, which corresponds to the level of the inferior edge of the limbus or medial epicanthus, consistently resulted in a brighter and wider shape of the lateral palpebral fissure. Fixation based on the bony portion, compared to palpebral portion, offers several advantages as follows: effective lengthening and widening the lateral palpebral fissure; ease of application; symmetry with consistent final results; and minimal occurrences of overcorrection and undercorrection.

Totally laparoscopic or robot-assisted pancreaticoduodenectomy versus open surgery for periampullary neoplasms: separate systematic reviews and meta-analyses.

OBJECTIVE: To compare perioperative and oncologic outcomes of pure (totally) laparoscopic pancreaticoduodenectomy (TLPD) or robot-assisted pancreaticoduodenectomy (RAPD) with those of conventional open pancreaticoduodenectomy (OPD). METHODS: A systematic literature search was performed using PubMed, EMBASE, and Cochrane library databases. Studies comparing TLPD with OPD and RAPD with OPD were included; only original studies reporting more than 10 cases for each technique were included. Studies were combined using a random-effects model to report heterogeneous data, or a fixed-effects model was applied. RESULTS: TLPD involved longer operative time (weighted mean difference [WMD]: 116.85 min; 95% confidence interval [CI] 54.53-179.17) and significantly shorter postoperative hospital stay (WMD: -3.68 days; 95% CI -4.65 to -2.71). Overall morbidity and postoperative pancreatic fistula were not significantly different between TLPD and OPD. RAPD was associated with a longer operative time, less intraoperative blood loss, and shorter hospital stay. Oncologic outcomes were not significantly different among the procedure types. CONCLUSIONS: Compared to OPD, TLPD and RAPD were feasible and oncologically safe procedures. However, there are no prospective studies, and the majority of the studies on TLPD and RAPD have remained in the early training phase. In addition to randomized controlled trials or prospective studies, new data from the late training phase of learning experiences should also be analyzed.

A single-center experience with the laparoscopic Warshaw technique in 122 consecutive patients.

BACKGROUND: Preservation of the spleen in distal pancreatectomy has recently attracted considerable attention. Our current study aimed in the first instance to define the safety of lap-WT in relation to the capacity of this technique to achieve preservation of the spleen and secondly to investigate the effectiveness of a planned lap-WT procedure or early conversion to lap-WT in selected patients with a large tumor attached to the splenic vessels. METHODS: Among 1056 patients who underwent a laparoscopic distal pancreatectomy between January 2005 and December 2014 at our hospital, 122 (24.6 %) underwent lap-WT which were analyzed. The 122 patients were categorized into two groups chronologically (early group: 2005-2012, late group: 2013-2014). RESULTS: The median follow-up was 35 months, and the median operation time was 181 min. The median postoperative hospital stay was 7 days, and the median estimated blood loss was 316 ml. Postoperative complications occurred in 9 patients (7.3 %), including 4 patients (3.2 %) with major pancreatic fistula (ISGPF grade B, C). A reoperation to address postoperative bleeding was needed in one patient. During a median follow-up of 35 months, there were no clinical significant splenic infarctions or gastric varices in any case. All patients were observed conservatively. In patients in the late group who underwent the lap-WT, the mean operating time (171 vs. 205 min, p = 0.001) and mean estimated blood loss (232.1 vs. 370.0 ml, p = 0.017) were significantly less than the early group cases who received lap-WT. CONCLUSIONS: A lap-WT is a safe treatment strategy in select cases when used as a way of preserving the spleen. When splenic vessel preservation is technically challenging, for example when the tumor is enlarged or is attached to the splenic vessels, planned lap-WT or early conversion to lap-WT may be a feasible option.

Anatomical Resection But Not Surgical Margin Width Influence Survival Following Resection for HCC, A Propensity Score Analysis.

BACKGROUND: The effects of the surgical resection margin on the clinical outcomes in hepatocellular carcinoma (HCC) cases remain controversial. The objective of this study was to further examine this issue. METHODS: The details of all HCC patients who underwent hepatectomy between December 1999 and December 2009 at the Division of Hepatobiliary and Pancreas Surgery, Asan Medical Center were analyzed retrospectively. We divided 1022 HCC patients into two groups according to the most significant surgical margin length. To overcome any bias due to differences in the distribution of covariates between the two groups, the patients were in a matched 1:1 ratio by propensity score analysis. RESULTS: A surgical margin ≤1 mm was identified as the most significant surgical margin in both disease-free survival (DFS) and overall survival (OS) (p = 0.008 and p = 0.026, respectively). However, many clinicopathological factors were different between the resection margin ≤1 mm and >1 mm groups. To reduce these different clinicopathological factors, propensity score matching was performed using 21 selected factors. After matching, no significant difference was found in DFS and OS between the two groups (p = 0.688, p = 0.398). In addition, there was no significant difference in the intrahepatic recurrence rate and pattern between the resection margin groups. Except for the preoperative patient's status and tumor stage, significant risk factors in OS were anatomical resection and postoperative morbidity (p = 0.002, p = 0.001). CONCLUSION: We identified that the widths of the resection margin in resectable hepatocellular carcinoma did not influence the postoperative recurrence rates, overall survival, and recurrence pattern in multivariable analysis as well as propensity score match analysis.

Improved survival after palliative resection of unsuspected stage IV pancreatic ductal adenocarcinoma.

BACKGROUND: Palliative resection of stage IV pancreatic ductal adenocarcinoma (PDAC) has not shown its benefit until now. In our retrospective review, we compared the results of palliative resection to non-resection. METHODS: Between 2000 and 2009, metastasis of PDAC was confirmed in the operating room in 150 patients. 35 underwent palliative resection (resection group; R) and 115 did bypass or biopsy. 35 patients (biopsy or bypass group: NR) in the 115 patients were matched with the patients undergoing resection for tumor size and the metastasis of peritoneal seeding. Demographic, clinical, operative data and survival were analyzed. RESULTS: There was no significant difference of major complication (Clavien-Dindo classification 3-5) between two groups. There was no 30-day mortality in either group. More patients in R received postoperative chemotherapy (82.9% vs. 57.1%; P = 0.019). Multivariate analysis showed resection and postoperative chemotherapy as independent factor related to survival (hazard ratio, 0.44; 95% CI, 0.25-0.76; P = 0.003). Patients in R showed better survival rates compared to those in NR (P < 0.001). CONCLUSION: Our study suggests resection for stage IV PDAC can be associated with increased survival. In patients of stage IV PDAC, palliative resection with chemotherapy could have some benefit in selected patients.

Matched Case-Control Analysis Comparing Laparoscopic and Open Pylorus-preserving Pancreaticoduodenectomy in Patients With Periampullary Tumors.

OBJECTIVES: To evaluate the safety, feasibility, and oncologic outcomes of laparoscopic pylorus-preserving pancreaticoduodenectomy (L-PPPD) to treat periampullary tumors. The clinical outcomes of L-PPPD were compared with open pylorus-preserving pancreaticoduodenectomy (O-PPPD). BACKGROUND: Despite recent advances in laparoscopic pancreatic surgery, few studies have compared L-PPPD with O-PPPD. The safety, short-term clinical benefits, and oncologic outcomes of L-PPPD remain controversial. METHODS: Between January 2007 and December 2012, a total of 2192 patients diagnosed with periampullary tumors were treated with curative resection at our institution. Of these patients, 137 underwent a laparoscopic approach and 2055 an open technique. A retrospective study was performed to evaluate the safety, feasibility, and oncologic outcomes of L-PPPD compared with O-PPPD. RESULTS: The mean operation time for the L-PPPD group was longer than for the O-PPPD group (P < 0.001). Estimated blood loss was similar, as was the incidence of complications, such as pancreatic fistula and delayed gastric empting (P > 0.05). The mean number of analgesic injections administered was lower in the L-PPPD group than in the O-PPPD group (P < 0.001), and the mean duration of the postoperative hospital stays was shorter (P < 0.001). The surgical resection margins and the number of lymph nodes in the resected specimens did not differ between the 2 groups, and there was no significant difference in overall survival curves. CONCLUSIONS: L-PPPD had the typical advantages of minimally invasive abdominal procedures, such as less pain, shorter hospital stay, and quicker recovery. It is technically safe and feasible, and has favorable oncologic outcomes in comparison with O-PPPD in patients with periampullary tumors.

Laparoscopic central pancreatectomy for benign or low-grade malignant lesions in the pancreatic neck and proximal body.

INTRODUCTION: Laparoscopic central pancreatectomy (LCP) is a parenchyma-sparing minimally invasive surgical technique for removal of benign or low-grade malignant lesions from the neck and proximal body of the pancreas. The aim of this study was to compare the short- and long-term clinical outcomes of LCP with those of other pancreatectomies. METHODS: During the study period, January 2007 to December 2010 (median follow-up 40.6 months), 287 pancreatectomies were performed for lesions in the neck and proximal body of the pancreas. To compare the clinical outcomes of LCP and other pancreatectomies, 26 cases of LCP, 14 cases of open central pancreatectomy (OCP), and 96 cases of extended laparoscopic distal pancreatectomy (E-LDP) were selected. RESULTS: Tumor sizes in the LCP (2.2 cm) and OCP (2.9 cm) groups were smaller than in the E-LDP (4.0 cm) group. Mean operation time in the LCP group (350.2 min) was longer than in the OCP (270.3 min) and E-LDP groups (210.6 min). There were more surgical complications in the LCP (38.5 %) and OCP groups (50 %) than in the E-LDP group (14.6 %). Mean duration of postoperative hospital stay was 13.8 days for the LCP group, which was significantly shorter than for the OCP group (22.4 days). New-onset diabetes was less frequent after LCP than after E-LDP (11.5 vs. 30.8 %). CONCLUSIONS: In selected patients with small and benign tumors in the pancreatic neck and proximal body LCP leads to increased postoperative morbidity but earlier postoperative recovery than OCP, and excellent postoperative pancreatic function (compared with E-LDP). LCP should, therefore, be considered a valid therapeutic option for selected patients.

Improved outcomes in liver transplantation in children with acute liver failure.

OBJECTIVE: The aim of our study was to review the experiences of a living donor-dominant transplantation program for children with acute liver failure (ALF). METHODS: Data were derived from the retrospective chart review of 50 children with ALF in a major liver center in the Republic of Korea. RESULTS: A total of 50 children with ALF underwent 47 (94%) primary living donor liver transplantations and 3 (6%) cadaveric liver transplantations. The cumulative survival rates of the grafts at 1 and 5 years were 81.9% and 79.2%, respectively. The overall retransplantation rate was 12%. The cumulative survival rates of these patients at 1 and 5 years were all 87.9%. Most incidents of mortality followed the failure of the preceding graft. We observed no mortalities among donors. Based on multivariate analysis, children who had pretransplant thrombocytopenia or had to use the molecular adsorbent recycling system preoperatively were related to the graft loss. Age younger than 2 years and a hyperacute onset (within 7 days) of hepatic encephalopathy were associated with pretransplant thrombocytopenia. CONCLUSIONS: Living donor-dominant transplantation program in the present study demonstrates tolerable achievements in terms of clinical outcomes of recipients and donors; however, putative factors, such as pretransplant thrombocytopenia, seem to play unclear roles in a poor prognosis following transplantation.

Laparoscopic spleen-preserving distal pancreatectomy: comparative study of spleen preservation with splenic vessel resection and splenic vessel preservation.

BACKGROUND: Spleen-preserving laparoscopic distal pancreatectomy (SPLDP) can be performed with splenic vessel resection (SVR) or splenic vessel preservation (SVP). The purpose of this comparative study was to evaluate the clinical outcomes of patients who underwent SPLDP with SVR or SVP at a single institution. METHODS: We retrospectively reviewed the records of 246 patients who underwent SPLDP at Asan Medical Center, Seoul, Korea, for benign or low-grade malignant tumors found in the body or tail of the pancreas between November 2005 and November 2011. RESULTS: In total, 206 patients (83.7 %) were managed by SVP. SVR was performed in the remaining 40 (16.3 %) cases. There were no significant differences between the SVP and SVR groups in terms of intraoperative blood loss (378 ± 240 vs. 328 ± 204 ml, respectively; P = 0.240) and operating time (193.4 ± 59.1 vs. 204.4 ± 51.8 min, respectively; P = 0.492). Sixty-seven (32.5 %) and 10 patients (25 %) had complications in the SVP and SVR groups, respectively (P = 0.347). At 3 days after surgery, the rates of splenic infarction were 16.0 % (33/206) in the SVP group and 52.5 % (21/40) in the SVR group, but all recovered within 12 months on postoperative computed tomography. The time of recovery from splenic infarction was 3.6 ± 3.1 and 4.7 ± 3.7 months in the SVP and SVR groups, respectively. At 6 months, the rates of gastric varices were 1.9 % in the SVP group and 35 % in the SVR group (P < 0.001) with no progression at 12 months. No gastrointestinal bleeding occurred at a median follow-up of 34 months (range = 12-84). CONCLUSIONS: SPLDP with SVR can be used for patients with large and benign or low-grade malignant tumors that distort and compress vessel course, as the higher rate of early splenic ischemia and perigastric varices is acceptable.

What is the better choice for T1b gallbladder cancer: simple versus extended cholecystectomy.

BACKGROUND: There is debate over whether T1b gallbladder cancer (GBC) should be treated by simple cholecystectomy (SC) or by extended cholecystectomy (EC). The aim of this study is to compare and analyze the results of these two procedures. PATIENTS AND METHODS: The archived medical records of 805 patients with GBC who had undergone surgical resection in Asan Medical Center, or were referred from other hospitals after undergoing surgery, between 1997 and 2010 were retrospectively reviewed. Of these, 85 patients were diagnosed with pathologic stage T1b (muscular layer) GBC. By using propensity scoring, the EC group and the SC group were matched in the proportion of 1:2; so, 54 patients were enrolled in this study. RESULTS: Among the 54 pathologic stage T1b cancer patients, SC was performed in 36 (66.7 %) and EC in 18 (33.4 %). The mean operation time and hospital stay after surgery of the SC group was significantly shorter than in the EC group (83.2 vs. 356.4 min, 7.8 vs. 15.2 days; both p = 0.000). Disease recurrence was noted in four cases (11.1 %), all in the SC group; 50 % of recurred patients experienced recurrence at the lymph node. There was no significant intergroup difference in the 5-year survival rate (5-YSR) (88.8 % for SC vs. 93.3 % for EC, p = 0.521). CONCLUSIONS: In this study, for stage T1b GBC, both EC and SC offered similar cure rates. However, recurrence is associated with SC and inadequate lymph node dissection (LND). Therefore, EC including regional LND may be justified and preferred because of the possibility of lymph node metastasis and the accurate assessment of stage (LN status), except that the patients have a high risk of operation.

Design Optimization of Additive Manufactured Edgeless Simple Cubic Lattice Structures under Compression.

This study proposed an optimization framework and methodologies to design edgeless lattice structures featuring fillet and multipipe functions. Conventional lattice structures typically experience stress concentration at the sharp edges of strut joints, resulting in reduced mechanical performance and premature failure. The proposed approach aimed to improve the compression behavior of lattice structures by introducing edgeless features. Through finite element analysis, the optimized fillet edgeless simple cubic unit cell with a fillet radius to strut radius ratio of 0.753 showed a 12.1% improvement in yield stress and a 144% reduction in stress concentration. To validate the finite element analysis, experimental compressive tests were conducted, confirming that the introduction of edgeless functions improved the compressive strength of lattice structures manufactured through additive manufacturing. The optimized fillet edgeless simple cubic lattice structure exhibited the most effective improvement. This approach has promising potential for lattice structure applications.

Biomechanical and Biological Assessment of Polyglycelrolsebacate-Coupled Implant with Shape Memory Effect for Treating Osteoporotic Fractures.

Poly(glycerol sebacate) is a biocompatible elastomer that has gained increasing attention as a potential biomaterial for tissue engineering applications. In particular, PGS is capable of providing shape memory effects and allows for a free form, which can remember the original shape and obtain a temporary shape under melting point and then can recover its original shape at body temperature. Because these properties can easily produce customized shapes, PGS is being coupled with implants to offer improved fixation and maintenance of implants for fractures of osteoporosis bone. Herein, this study fabricated the OP implant with a PGS membrane and investigated the potential of this coupling. Material properties were characterized and compared with various PGS membranes to assess features such as control of curing temperature, curing time, and washing time. Based on the ISO 10993-5 standard, in vitro cell culture studies with C2C12 cells confirmed that the OP implant coupled with PGS membrane showed biocompatibility and biomechanical experiments indicated significantly increased pullout strength and maintenance. It is believed that this multifunctional OP implant will be useful for bone tissue engineering applications.

Feasibility of 3D-Printed Locking Compression Plates with Polyether Ether Ketone (PEEK) in Tibial Comminuted Diaphyseal Fractures.

The applicability of a polyether ether ketone locking compression plate (PEEK LCP) fabricated using FDM (fused deposition modeling)-based 3D printing to treat actual patients was studied. Three different tests-bending, axial compression, and axial torsion-were conducted on tibial non-osteoporotic comminuted diaphyseal fracture samples fixed with the commercial titanium alloy LCP and 3D-printed PEEK LCP. Comparing the outcomes of these tests revealed that the commercial titanium alloy LCP underwent plastic deformation in the bending and axial torsion tests, though the LCP did not fail even when an external force greater than the maximum allowable load of the tibia fixture of the LCP was applied. Elastic deformation occurred in the 3D-printed PEEK LCP in the bending and axial torsion tests. However, deformation occurred even under a small external force, and its stiffness was 10% compared to commercial titanium alloy LCP. Thus, 3D-printed PEEK LCP can be applied to the fracture conditions in non-weight-bearing regions. The experimental results reveal detailed insights into the treatment of actual patients by considering the stiffness and high toughness of 3D-printed PEEK LCP.

Safe Optimal Tear Drop View for Spinopelvic Fixation Using a Three-Dimensional Reconstruction Model of the Pelvis.

Background: Spinopelvic fixation (SPF) has been a challenge for surgeons despite the advancements in instruments and surgical techniques. C-arm fluoroscopy-guided SPF is a widely used safe technique that utilizes the tear drop view. The tear drop view is an image of the corridor from the posterior superior iliac spine to the anterior inferior iliac spine (AIIS) of the pelvis. This study aimed to define the safe optimal tear drop view using three-dimensional reconstruction of computed tomography images. Methods: Three-dimensional reconstructions of the pelvises of 20 individuals were carried out. By rotating the reconstructed model, we simulated SPF with a cylinder representing imaginary screw. The safe optimal tear drop view was defined as the one embracing a corridor with the largest diameter with the inferior tear drop line not below the acetabular line and the lateral tear drop line medial to the AIIS. The distance between the lateral border of the tear drop and AIIS was defined as tear drop index (TDI) to estimate the degree of rotation on the plane image. Tear drop ratio (TDR), the ratio of the distance between the tear drop center and the AIIS to TDI, was also devised for more intuitive application of our simulation in a real operation. Results: All the maximum diameters and lengths were greater than 9 mm and 80 mm, respectively, which are the values of generally used screws for SPF at a TDI of 5 mm and 10 mm in both sexes. The TDRs were 3.40 ± 0.41 and 3.35 ± 0.26 in men and women, respectively, at a TDI of 5 mm. The TDRs were 2.26 ± 0.17 and 2.14 ± 0.12 in men and women, respectively, at a TDI of 10 mm. Conclusions: The safe optimal tear drop view can be obtained with a TDR of 2.5 to 3 by rounding off the measured values for intuitive application in the actual surgical field.

Validation of the Finite Element Model versus Biomechanical Assessments of Dental Implants and Total Knee Replacements.

Computer modeling and simulation (CM&S) technology is widely used in the medical device industry due to its advantages such as reducing testing time and costs. However, the developer's parameter settings during the modeling and simulation process can have a significant impact on the results. This study developed a test model for the rotational shear strength of dental implants and the constraint force of total knee replacements based on CM&S technology and proposes ideal parameters to ensure reliability. For dental implants, the load area and sliding contact conditions were considered, and for total knee replacements, the friction coefficient, medial-lateral displacement, valgus-varus rotation, and elastic modulus were considered. By comparing the simulation results and mechanical tests, boundary conditions with an error rate of less than 1.5% were selected. When a jig (gripper and collector) was applied with the same boundary conditions, an error rate of 48~22% occurred; otherwise, it was confirmed that the error rate was within 10~0.2%. The FE model was verified with an error of 2.49 to 3% compared to the mechanical test. The friction coefficient variable had the greatest influence on the results, accounting for 10 to 13%, and it was confirmed that valgus-varus rotation had a greater influence on the results than medial-lateral displacement. Relatively, the elastic modulus of the insert had the least effect on the results. These research results are expected to make CM&S techniques useful as a medical device digital development tool (M3DT) in the development of total knee replacements and dental implants.

Long-term clinical outcome of the surgically resected intraductal papillary neoplasm of the bile duct.

BACKGROUND & AIMS: Intraductal papillary neoplasm of the bile duct (IPNB) is a biliary neoplasm with predominant intraductal papillary growth and various degrees of malignant transformation. Although IPNB has been recently added to the WHO classification, the classification system needs refinements. METHODS: We retrospectively reviewed 93 non-invasive and invasive IPNB cases, surgically resected from 1996 to 2006. To further characterize their biologic behavior, we modified the WHO classification into a 4-tier category system in which non-invasive IPNB cases with complex fused or cribriform papillae were separately designated. Epithelial types such as intestinal, gastric, pancreatobiliary, and oncocytic type were determined by morphology and mucin core protein immunohistochemistry. Resection margins were classified based on their microscopic appearances. The prognostic values of mucinous histology and MUC1 protein expression were also determined. RESULTS: IPNB with complex fused or cribriform papillae showed a worse prognosis than IPNB with simple papillae and one such case showed a metachronous metastasis. In addition, a positive surgical margin including dysplasia was associated with worse outcomes. Among the invasive IPNB cases, MUC1-positive tumors were more aggressive than MUC1-negative tumors. CONCLUSIONS: We propose that non-invasive IPNB with complex fused or cribriform papillae might be better classified as mucosa-confined cholangiocarcinoma rather than IPNB with high grade dysplasia. In addition, aggressive further resection is recommended when a positive surgical margin including dysplasia is reported during intraoperative histopathological evaluation.

Successful liver transplantation following veno-arterial extracorporeal membrane oxygenation in a child with fulminant Wilson disease and severe pulmonary hemorrhage: a case report.

Massive pulmonary hemorrhage and other serious cardiopulmonary diseases in patients with fulminant hepatitis result not only in graft failure but also mortality after LT. ECMO is used to treat children with cardiorespiratory failure refractory to conventional intensive care. We describe a five-yr-old girl with genetically confirmed fulminant Wilson disease and severe pulmonary hemorrhage who underwent successful primary LT following veno-arterial ECMO. To our knowledge, this is the first report of successful primary LT in a patient using veno-arterial ECMO. The present case demonstrates that ECMO, as a bridging modality to LT, may be necessary to manage both massive pulmonary hemorrhage and possible graft loss because of hypoxemia.

Early experience of laparoscopic complete en bloc excision for choledochal cysts in adults.

BACKGROUND: For choledochal cyst, the treatment of choice is total excision of the cyst because there is a risk of biliary cancer including the gallbladder. The current report describes the authors' early experiences using their technique of laparoscopic en bloc excision of choledochal cysts with Roux-en-Y biliary reconstruction. METHODS: Between September 2009 and July 2011, laparoscopic excision for choledochal cyst was attempted for 20 patients at the Division of Hepatobiliary and Pancreatic Surgery, Asan Medical Center. Clinical, radiologic, and surgical data were analyzed retrospectively. RESULTS: The mean age of the patients was 37.8 ± 11.1 years (range, 18-65 years), and the male-to-female ratio was 1:4.0 (4:16). According to Todani's classification, there were four type 1a cases, seven type 1c cases, and nine type 4a cases. The mean operation time was 395.8 ± 58.7 min. No perioperative transfusions were required. The average body mass index was 23.5 ± 4.04 kg/m(2). Conversion to laparotomy was required for seven patients (35 %) due to bleeding (n = 1), Roux loop venous congestion (n = 1), abdominal obesity (n = 2), and severe fibrosis and inflammation around the cyst (n = 3). No malignancies were identified. Of the 13 patients who underwent laparoscopy, the jejunojejunostomy was created extracorporeally for the first 2 patients and intracorporeally for the subsequent 11 patients. All hepaticojejunostomies were performed intracorporeally. Oral feeding was resumed on postoperative day 3. The mean postoperative hospital stay was 9.3 days (range, 8-36 days). No major complications or mortalities occurred. CONCLUSIONS: The morbidity and mortality rates for the authors' method are comparable with previously reported results. Although the conversion rate, mean operation time, and hospital stay were greater than reported in some studies, this probably reflected the authors' learning curve for this technically challenging procedure. They believe laparoscopic approaches will eventually become an advantageous treatment option for laparotomy offered to selected choledochal cyst patients.

Practical usefulness of minor grooves of the hepatic surface for liver resection.

BACKGROUND/AIMS: The clinical relevance of grooves of the hepatic surface has not been clearly identified. The aim of the present study was to examine the association of minor grooves and liver segmentations, and to evaluate the usefulness of grooves for liver resection. METHODOLOGY: Between January 2005 and December 2010, 482 patients with hepatic resection for liver disease were included in this study. We performed glissonean pedicle transection methods for hepatic resection to identify sectors or segments of the liver and examined location, size, depth and relationship with intersegmental line of the hepatic grooves. RESULTS: Diaphragmatic grooves were located on anatomical border between right lobe and left lobe and within right anterior sector. The minor grooves were more commonly observed in the right lobe than in the left lobe. The minor grooves between segment V and VI, and segment V and VI were easy to perform monosegmentectomy and right anterior sectionectomy on, respectively. These minor grooves were also helpful to determine the resection margin for non-anatomical resection. CONCLUSIONS: Minor grooves were often observed in line with sector or segment, or near to inter-segmental or sectorial border. The anatomical knowledge of hepatic grooves including minor type may be of help for hepatobiliary surgeons and radiologists to understand liver segmentation.