Hepatitis B Virus DNA-Level Change is Associated With Tumor Recurrence in Patients With Resected Hepatitis B Virus Hepatocellular Carcinoma.

INTRODUCTION: To investigate the significance of perioperative hepatitis B virus (HBV) DNA changes for predicting recurrence in patients with HBV-related hepatocellular carcinoma (HCC) undergoing liver resection (LR). METHODS: From 2013 to 2020, 241 patients with HBV-related HCC who underwent LR in five Hallym university-affiliated hospitals were enrolled. The serum HBV DNA level, together with other clinicopathological variables, was analyzed for association with HCC recurrence. RESULTS: Preoperatively, 99 patients had undetectable HBV DNA and 142 had detectable viral levels. Of those with detectable viral levels, 72 rapidly progressed to undetectable levels within 3 mo after LR (Rapid group), and 70 showed persistently detectable levels (Nonrapid group). The Rapid group had a better recurrence-free survival (RFS) rate than the Nonrapid group (1-y, 3-y RFS = 75.4%, 57.3%, versus 54.7%, 39.9%, respectively, P = 0.012). In the subgroup analysis, the Rapid group had a better RFS rate in early stages (1-y, 3-y RFS = 82.6%, 68.5%, versus 62.8%, 45.8%, respectively, P = 0.005); however, the RFS rates between the two groups were comparable in the advanced stage (1-y, 3-y RFS = 61.1%, 16.7% versus 45.5%, 22.7%, respectively, P = 0.994). Among the 142 patients with preoperatively detectable HBV DNA, persistently detectable HBV DNA within 3 mo postoperatively (hazard ratio [HR] = 1.7, P = 0.022), large tumor size (HR = 2.7, P < 0.001), multiple tumors (HR = 3.2, P < 0.001), and microvascular invasion (HR = 1.7, P = 0.028) were independent risk factors for RFS in multivariate analysis. CONCLUSIONS: Rapidly undetectable HBV DNA after LR is associated with a better prognosis for recurrence in patients with HCC. Therefore, appropriate treatment and/or screening may be necessary for patients who do not return to undetectable HBV DNA after LR.

Impact of the COVID-19 pandemic on the outcomes of laparoscopic appendectomy for acute appendicitis.

Purpose: This retrospective study aimed to evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on the time interval from symptom onset to surgery and on the operative outcomes of laparoscopic appendectomy for patients with acute appendicitis. Methods: Between October 2018 and July 2021, laparoscopic appendectomy was performed in 502 patients with acute appendicitis admitted to Hallym University Chuncheon Sacred Heart Hospital in Chuncheon, Korea. We compared demographic data, serum levels of inflammatory markers, time to event of appendicitis, and operative outcomes between the pre-COVID-19 and post-COVID-19 pandemic groups. Results: Laparoscopic appendectomy was performed in 271 patients in the pre-COVID-19 group and in 231 patients in the post-COVID-19 group. There were no differences in baseline characteristics, serum inflammatory marker levels, or the proportions of complicated appendicitis between the groups (25.1%, pre-COVID-19 vs. 31.6%, post-COVID-19; P = 0.106). The time intervals between symptom onset and hospital arrival (24.42 hours vs. 23.59 hours, P = 0.743) and between hospital arrival and the start of surgery (10.12 hours vs. 9.04 hours, P = 0.246) did not increase post-COVID-19. The overall 30-day postoperative complication rate did not differ significantly between the groups (9.6% vs. 10.8%, P = 0.650), and the severity of 30-day postoperative complications was also similar in both groups (P = 0.447). Conclusion: This study demonstrates that hospitalization and surgeries were not delayed in patients with acute appendicitis and that the operative outcomes of laparoscopic appendectomy did not worsen despite the COVID-19 pandemic.

Sarcopenia with systemic inflammation can predict survival in patients with hepatocellular carcinoma undergoing curative resection.

Background: This study aimed to examine the prognostic significance of sarcopenia combined with systemic inflammation in patients who underwent curative hepatectomy for hepatocellular carcinoma (HCC). Methods: Between January 2010 and July 2019, we identified 159 patients with HCC who underwent curative hepatectomy at three institutional centers. We retrospectively analyzed clinicopathological outcomes, surgical outcomes, platelet lymphocyte ratio (PLR) as a systemic inflammatory marker, and computed tomography (CT)-assessed sarcopenia at the third lumbar vertebra level (L3). Results: Sarcopenia was noted in 74 (46.5%) of 159 patients and was significantly associated with male sex, low body mass index (BMI), and high PLR. In the multivariate analysis, sarcopenia [hazard ratio (HR): 2.127, P=0.026] and high PLR (HR: 1.971, P=0.038) were associated with a decrease in overall survival (OS) but not in recurrence-free survival (RFS). The combination of sarcopenia and PLR status stratified the 5-year OS into 82.0% (non-sarcopenia and a low PLR), 68.3% (sarcopenia or a high PLR), and 44.4% (sarcopenia and a high PLR) (P=0.001). In the multivariate analysis, "sarcopenia and a high PLR" and "sarcopenia or a high PLR" were revealed to be significant predictors of OS (HR: 4.300, P=0.001 and HR: 2.723, P=0.010, respectively). Conclusions: Sarcopenia and high PLR were significantly associated with poor OS. The combination of these two factors may be useful for predicting survival of patients with HCC undergoing curative hepatectomy.

Hybrid Appendectomy in Pediatric Appendicitis: A Comparative Analysis of Single-Port and Multiport Laparoscopic Appendectomy.

Background: Hybrid appendectomy (HA) has the technical advantages of the excellent visual field provided by laparoscopic surgery and is fast and easy similar to open surgery. We aimed to compare the safety and effectiveness of HA with single- and multiport laparoscopic appendectomy (SPLA and MPLA) in pediatric patients with acute appendicitis. Materials and Methods: This retrospective study compared the short-term operative outcomes between HA, SPLA, and MPLA groups. From January, 2010 to December, 2019, 239 patients aged <12 years who underwent laparoscopic appendectomy for acute appendicitis were included. The primary outcome was the 30-day postoperative complication rate, stratified according to the modified Clavien-Dindo classification. Results: In 239 patients, HA was more frequently performed in patients with a low body mass index (17.42 versus 18.97 kg/m2 in the SPLA group versus 18.44 kg/m2 in the MPLA group, P = .029) and tended to be more frequently adopted in uncomplicated appendicitis. In uncomplicated appendicitis, the HA group had a significantly shorter operation time than the MPLA group (31.77 versus 40.09 min, P < .001), but had a comparable operation duration with the SPLA group. The rate of 30-day postoperative complications was not significantly different between the groups (HA 7.6% versus SPLA 7.8% versus MPLA 5.4%, P = .841). The postoperative time to resume water intake was significantly longer in the SPLA group than in the HA and MPLA groups (P = .008). Conclusions: HA showed a short operation time, fast functional recovery, and acceptable postoperative complication rate in patients with uncomplicated appendicitis and can be safely and effectively performed in these patients.

Learning Curve in Laparoscopic Pancreaticoduodenectomy: Using Risk-Adjusted Cumulative Summation Methods.

Background: Laparoscopic pancreaticoduodenectomy (LPD) is one of the most technically challenging operations of minimally invasive surgery. We aimed to analyze the learning curve of a single surgeon who conducted 115 LPDs at a single center. Materials and Methods: From August 2015 to August 2020, 115 patients underwent LPD. Patient characteristics and perioperative variables were retrospectively collected and analyzed. Cumulative summation (CUSUM) and risk-adjusted cumulative summation (RA-CUSUM) analyses were used to evaluate the LPD learning curve. All variables were compared after dividing the learning curve phases. Results: After 74 cases, operative time improved based on the CUSUM analysis of the operation time. From the RA-CUSUM analysis, three distinct phases of the learning curve were identified (phase I: 1-42 cases, phase II: 43-73 cases, and phase III: 74-115 cases). The mean operative time was significantly lower in phase III compared with that in phases I and II (348.5 minutes versus 444.6 minutes and 439.9 minutes, P < .001 and P < .001, respectively). The rate of estimated blood loss >500 mL was significantly decreased among the three phases (P = .017). The conversion rate significantly decreased from 11.9% in phase I to 6.5% in phase II to 0% in phase III (P = .023). The rates of overall complication (Clavien-Dindo >IIIA), postoperative pancreatic fistula, and postpancreatectomy hemorrhage were significantly decreased as phases progressed. Postoperative hospital stay, 30-day mortality, and 30-day readmission did not significantly differ among phases. Conclusions: According to learning curve analyses, the LPD failure rate plateaued after 42 cases and stabilized after 73 cases.

Outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography versus primary LCBDE for managing cholecystocholedocholithiasis.

OBJECTIVE: This study was performed to compare the outcomes of laparoscopic common bile duct exploration (LCBDE) after failed endoscopic retrograde cholangiopancreatography (ERCP) versus primary LCBDE for managing cholecystocholedocholithiasis. METHODS: We retrospectively analyzed data from 59 patients who underwent LCBDE during laparoscopic cholecystectomy (LC) for managing cholecystocholedocholithiasis from January 2013 to August 2019. The patients underwent either primary LCBDE plus LC (Group I) or LCBDE plus LC after failed ERCP (Group II). The demographics, reason for ERCP failure, perioperative details, and postoperative outcomes were evaluated. RESULTS: CBD stone removal using preoperative ERCP failed in 31 patients (Group II) because of remaining stones after ERCP (n = 9), failed cannulation (n = 6), failed sedation (n = 6), a periampullary diverticulum (n = 5), previous Billroth II gastrectomy (n = 3), a huge stone (n = 1), and an impacted stone (n = 1). The CBD stone clearance rate was >96% in both groups. The mean operative time, hospital stay, overall complication rate, and open conversion rate were not significantly different between the two groups. CONCLUSIONS: When extraction of CBD stones by ERCP is likely to be difficult or fail, primary LCBDE is an acceptable alternative treatment for managing cholecystocholedocholithiasis.

Laparoscopic versus open pancreaticoduodenectomy for pancreatic neuroendocrine tumors: a single-center experience.

BACKGROUND: The efficacy and outcomes of laparoscopic resection for pancreatic neuroendocrine tumors (PNETs) are well established; however, specific data regarding the outcomes of laparoscopic pancreaticoduodenectomy (L-PD) are limited. The purpose of the present study was to compare the clinical and oncological outcomes following L-PD versus open PD (O-PD) in patients with PNETs. METHODS: This retrospective study included 149 patients with PNETs who underwent PD at the Asan Medical Center between January 2006 and December 2017. In 58 patients, a laparoscopic approach was used (L-PD group), and in 91, an open technique was used (O-PD group). RESULTS: The mean operative time was longer in the L-PD group than in the O-PD group (417.4 min vs. 362.2 min; p = 0.002), and the mean duration of postoperative stay was shorter in the L-PD group (12.6 days vs. 17.8 days; p < 0.001). The estimated blood loss (433.2 ml vs. 415.0 ml; p = 0.824) and the overall complication rate (34.5% vs. 38.5%; p = 0.624) did not significantly differ between the two groups. Regarding the oncological outcomes, there were no significant differences in the resection margins, tumor size, tumor grading, or T/N stage. The number of harvested lymph nodes in the L-PD group was lower than that in the O-PD group (7.1 vs. 10.8; p = 0.002). The 3-year overall survival rate was 91.9% in the L-PD group and 93.6% in the O-PD group (p = 0.974). The 3-year disease-free survival rate was 94.8% in the L-PD group and 86.7% in the O-PD group (p = 0.225). CONCLUSIONS: L-PD is feasible for the treatment of PNETs in selected patients and has the advantages of short recovery time and reduced hospital stay. The survival rate was similar in both groups; however, due to the difference in the harvested lymph nodes, a randomized trial should confirm the oncological safety of L-PD for PNETs.

Time-trend and recurrence analysis of pancreatic neuroendocrine tumors.

This study aimed to evaluate the evolving trends in clinicopathological features of pancreatic neuroendocrine tumors and to analyze the predictors of recurrence after curative resection. Data collected retrospectively from a single center between January 1990 and December 2017 were analyzed. Patients were categorized chronologically into three groups for evolving time-trend analysis. Overall, 542 patients (300 female, 55.4%) underwent surgical resection for pancreatic neuroendocrine tumors, including 435 (80.3%) with non-functional tumors. Time-trend analysis revealed that the surgically resected pancreatic neuroendocrine tumor number increased consistently; however, the incidental non-functional pancreatic neuroendocrine tumor number also increased over time (P < 0.001). The 5- and 10-year disease-free survival rates were 86.4 and 81.3%, respectively. The overall recurrence rate was 13.7%, and the most common site of recurrence was the liver. The median time to recurrence after primary surgery was 19.0 (range 0.8-236.3) months, and the median survival time after recurrence was 22.6 (range 0.4-126.9) months. On multivariate analysis, grade G3 pancreatic neuroendocrine tumors (hazard ratio 4.51; P < 0.001), lymph node metastasis (hazard ratio 2.46; P = 0.009), lymphovascular invasion (hazard ratio 3.62; P = 0.004), perineural invasion (hazard ratio 2.61; P = 0.004) and resection margin (hazard ratio 4.20; P = 0.003) were independent prognostic factors of disease-free survival. The surgically resected pancreatic neuroendocrine tumor number increased over time mainly because of an increase in incidentally discovered non-functional pancreatic neuroendocrine tumors. Grade G3 pancreatic neuroendocrine tumors, lymph node metastasis, lymphovascular invasion, perineural invasion and a positive resection margin were significant predictors of worse disease-free survival in patients with surgically resected pancreatic neuroendocrine tumors.

The 100 most influential manuscripts on hepatocellular carcinoma: a bibliometric analysis.

OBJECTIVE: Citation analysis represents one of the best available methods to identify the most influential articles. This study aimed to identify and characterize the top 100 highly cited articles (T100) that focus on hepatocellular carcinoma and to reveal the trends in accomplishments within this field. METHODS: A search of the Thomson Reuters Web of Science citation indexing database was conducted using terms related to hepatocellular carcinoma. The T100 were selected and analyzed further based on the number of citations, authorship, year of publication, journal, country of origin, institution, and article type. RESULTS: Hepatology published the highest number of papers (n = 15), and the United States produced the highest number of contributions (n = 31). Barcelona University was the institution with the highest number of articles in the T100 (n = 9). The T100 articles included 35 observational studies, 13 randomized control studies, 25 basic research articles, 18 reviews, seven clinical guidelines, and two meta-analyses. CONCLUSIONS: This is the first bibliometric study to identify the most influential papers in hepatocellular carcinoma research. This report presents major advances and changes in research regarding hepatocellular carcinoma and can serve as a guide for writing a citable article.

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.