Diagnostic performance of a novel ultrasound-based quantitative method to assess liver steatosis in histologically identified nonalcoholic fatty liver disease.

AIMS: To investigate the diagnostic performance of ultrasound-guided attenuation parameter (UGAP) for the detection of hepatic steatosis in nonalcoholic fatty liver disease (NAFLD) cohorts using histopathology as the reference standard andcomparing it with that of various imaging modalities. MATERIALS AND METHODS: A total of 87 subjects who underwent UGAP, controlled attenuation parameter (CAP), and magnetic resonance imaging-based proton density fat fraction (MRI-PDFF) between December, 2020 and January, 2022 were enrolled. Of these patients, 38 patients had NAFLD. The association between UGAP and clinical and imaging parameters was assessed using Pearson's or Spearman's correlations. The area under the receiver operating characteristic curve (AUROC) was used to evaluate the diagnostic performance. RESULTS: The UGAP and MRI-logPDFF demonstrated strong positive correlations (correlation coefficient= 0.704, P <0.0001). UGAP showed excellent diagnostic performance for distinguishing steatosis grade ≥1 with an AUROC of 0.821 (95% confidence interval [CI], 0.729-0.913), which was comparable to that of MRI-PDFF (0.829, 95%CI, 0.723-0.936). The AUROCs of BUSG (B-mode ultrasonography) (0.766, 95% CI, 0.767-0.856) and CAP (0.788, 95% CI, 0.684-0.891) were slightly lower than those of UGAP. The AUROCs of UGAP, MRI-PDFF, CAP, and BUSG for detecting steatosis grade ≥2 were 0.796 (95% CI, 0.616-0.975), 0.971 (95% CI, 0.936-1.000), 0.726 (95% CI, 0.561-0.891) and 0.774 (95% CI, 0.612-0.936), respectively. CONCLUSION: UGAP may be a valuable potential screening tool as a first-line assessment of liver steatosis in patients with NAFLD.

Effect of resection margin status on recurrence pattern and survival in distal pancreatectomy for left-sided pancreatic ductal adenocarcinoma.

BACKGROUND: The association of resection margin status with recurrence and survival after pancreatectomy for pancreas ductal adenocarcinoma (PDAC) remains controversial. The aim of this study was to identify the effect of R1 resection on recurrence pattern and survival after distal pancreatectomy for left-sided PDAC. METHODS: Patients who underwent distal pancreatectomy for PDAC at two high-volume institutions between January 2010 and December 2017 were retrospectively reviewed. Perioperative characteristics, pathological outcomes, recurrence pattern, and survival data were collected to compare R0 resection and R1 resection. RESULTS: Among 558 patients who underwent distal pancreatectomy for PDAC, 158 patients (28.3%) showed R1 resection margin. R1 patients were associated with large tumor size (3.3 cm vs. 3.7 cm, p = .006) and lower number of positive lymph nodes (1.3 vs. 2.0, p = .001). Median overall survival (37.3 months vs. 20.1 months, p < .001) and recurrence-free survival (14.6 months vs. 6.9 months, p < .001) significantly differed between the R0 and R1 groups. Disease recurrence patterns were not statistically different between the two groups (p = .182). Among the recurrence patterns, peritoneal carcinomatosis had the shortest recurrence-free survival (5.6 months, p < .05) and overall survival (13.6 months, p < .05) compared with all other recurrence patterns. CONCLUSIONS: R1 resection margin after distal pancreatectomy was associated with poor survival and early recurrence. There is no significant difference in recurrence pattern between R0 and R1. Among the recurrence patterns, peritoneal carcinomatosis showed the worst prognosis.

Short- and long-term outcomes of subtotal/total colectomy in the management of obstructive left colon cancer.

PURPOSE: Surgical management of obstructive left colon cancer (OLCC) is still a matter of debate. The classic Hartmann procedure (HP) has a disadvantage that requires a second major operation. Subtotal colectomy/total abdominal colectomy (STC/TC) with ileosigmoid or ileorectal anastomosis is proposed as an alternative procedure to avoid stoma and anastomotic leakage. However, doubts about morbidity and functional outcome and lack of long-term outcomes have made surgeons hesitate to perform this procedure. Therefore, this trial was designed to provide data for morbidity, functional outcomes, and long-term outcomes of STC/TC. METHODS: This study retrospectively analyzed consecutive cases of OLCC that were treated by STC/TC between January 2000 and November 2020 at a single tertiary referral center. Perioperative outcomes and long-term outcomes of STC/TC were analyzed. RESULTS: Twenty-five descending colon cancer (45.5%) and 30 sigmoid colon cancer cases (54.5%) were enrolled in this study. Postoperative complications occurred in 12 patients. The majority complication was postoperative ileus (10 of 12). Anastomotic leakage and perioperative mortality were not observed. At 6 to 12 weeks after the surgery, the median frequency of defecation was twice per day (interquartile range, 1-3 times per day). Eight patients (14.5%) required medication during this period, but only 3 of 8 patients required medication after 1 year. The 3-year disease-free survival was 72.7% and 3-year overall survival was 86.7%. CONCLUSION: The risk of anastomotic leakage is low after STC/TC. Functional and long-term outcomes are also acceptable. Therefore, STC/TC for OLCC is a safe, 1-stage procedure that does not require diverting stoma.

Regulation of Hepatocyte Nuclear Factor 4α Attenuated Lipotoxicity but Increased Bile Acid Toxicity in Non-Alcoholic Fatty Liver Disease.

Hepatocyte nuclear factor 4 alpha (HNF4α) is a key master transcriptional factor for hepatic fat and bile acid metabolic pathways. We aimed to investigate the role of HNF4α in non-alcoholic fatty liver disease (NAFLD). The role of HNF4α was evaluated in free fatty acid-induced lipotoxicity and chenodeoxycholic acid (CDCA)-induced bile acid toxicity. Furthermore, the role of HNF4α was evaluated in a methionine choline deficiency (MCD)-diet-induced NAFLD model. The overexpression of HNF4α reduced intracellular lipid contents and attenuated palmitic acid (PA)-induced lipotoxicity. However, the protective effects of HNF4α were reversed when CDCA was used in a co-treatment with PA. HNF4α knockdown recovered cell death from bile acid toxicity. The inhibition of HNF4α decreased intrahepatic inflammation and the NAFLD activity score in the MCD model. Hepatic HNF4α inhibition can attenuate bile acid toxicity and be more effective as a therapeutic strategy in NAFLD patients; however, it is necessary to study the optimal timing of HNF4α inhibition.

Correlation between cholecystectomy and development of non-alcoholic liver disease in the mouse model.

Background: Several clinical studies have suggested a strong correlation between cholecystectomy and the incidence of non-alcoholic fatty liver disease (NAFLD) although the exact correlation and causal relationship are unclear. This study aimed to investigate whether cholecystectomy increases the incidence of NAFLD or aggravates pre-existing NAFLD. Methods: Standard diet-fed and high-fat (HF) diet-fed mice were subjected to sham operation and cholecystectomy. In study 1, 20 standard diet-fed C57BL/6N mice were sacrificed at months 1, 2, and 4 post-surgery. Meanwhile, in study 2, 25 HF diet-induced NAFLD C57BL/6N mice were biopsied at months 2 and 3 post-surgery and sacrificed at month 6 post-surgery. The hepatic fatty acid and bile acid metabolic pathways and the hepatic bile composition were evaluated. Results: The bodyweight and biochemical parameters (hepatic enzyme, triglyceride, and cholesterol levels) were not significantly different between the standard diet-fed sham and cholecystectomy groups. The NAFLD activity score and the levels of hepatocyte apoptosis markers (Krt18 expression and DNA fragmentation) and de novo lipid synthesis genes were not significantly different between the standard diet-fed sham and cholecystectomy groups. Cholecystectomy did not exacerbate hepatic steatosis, inflammation, and ballooning in the HF diet-fed mice. Hepatic bile acid composition was not markedly different in the sham and cholecystectomy groups fed on standard or HF diet. Cholecystectomy significantly downregulated Cyp7a1 and Cyp27a1 mRNA levels at months 1 and 4 post-surgery but did not affect the degree of steatosis and triglyceride levels. Analysis of bile acid metabolism revealed that taurine-conjugated bile acids were significantly downregulated in the standard diet-fed and high-fat diet-fed mice, but the histological and biochemical parameters were not markedly different. Conclusions: Cholecystectomy did not increase the incidence of NAFLD in standard diet-fed mice. Additionally, NAFLD incidence was not significantly different between the HF diet-fed sham and cholecystectomy groups. Furthermore, the histological parameters were not markedly different between the sham and cholecystectomy groups fed on standard or HF diet. These findings suggest that cholecystectomy does not induce NAFLD.

Validation of a scoring system to predict bladder dysfunction after laparoscopic rectal cancer surgery.

PURPOSE: A recent trend in  urinary catheter management in patients who underwent laparoscopic rectal cancer surgery is early removal. However, some patients develop bladder dysfunction and require urinary re-catheterization. In 2016, a scoring system to predict bladder dysfunction after laparoscopic rectal cancer surgery was developed in our institution. The aim of this study was to demonstrate the validity of this scoring system and to determine the suitability of patients for early removal of urinary catheter. METHODS: A single-center, retrospective study from a prospective database was conducted on 234 patients who underwent elective laparoscopic rectal cancer surgery between January 2016 and December 2019. According to bladder dysfunction predictive score, the urinary catheter was removed on the first postoperative day (low-risk group) and fifth postoperative day (high-risk group). After catheter removal, all patients were managed using in-house protocols. RESULTS: Of 234 patients, 130 (55.6%) were classified as a low-risk group. The overall incidence of bladder dysfunction was 8.5% (11/130) in the low-risk group and 13.5% (14/104) in the high-risk group. CONCLUSION: The scoring system developed to predict bladder dysfunction showed good overall performance for discriminating between patients suitable or not for early removal of urinary catheter after laparoscopic rectal cancer surgery.

Comparison of blowhole colostomy and loop ostomy for palliation of acute malignant colonic obstruction.

PURPOSE: Surgery to create a stoma for decompression might be required for unresectable stage IV cancer patients with complete colonic obstruction. The aim of this study was to compare the results of blowhole colostomy with those of loop ostomy. METHODS: Palliative ileostomy or colostomy procedures performed at a single center between January 2011 and October 2020, were analyzed retrospectively. Fifty-nine patients were identified during this period. The demographic characteristics and outcomes between the blowhole colostomy group (n=24) and the loop ostomy group (n=35) were compared. RESULTS: The median operative time tended to be shorter in the blowhole colostomy group (52.5 minutes; interquartile range [IQR], 43-65) than in the loop ostomy group (60 minutes; IQR, 40-107), but the difference did not reach statistical significance (P=0.162). The median length of hospital stay was significantly shorter with blowhole colostomy (blowhole, 13 days [IQR, 9-23]; loop, 21 days [IQR, 14-37]; P=0.013). Mean cecum diameter was significantly larger in the blowhole group than in the loop group (8.83±1.91 cm vs. 6.78±2.36 cm, P=0.001), and the emergency operation rate was higher in the blowhole group than in the loop group (22 of 24 [91.7%] vs. 23 of 35 [65.7%], P=0.021). CONCLUSION: In surgical emergencies, diverting a blowhole colostomy can be safe and effective for palliative management of colonic obstruction in patients with end-stage cancer and might reduce the operative time in emergent situations.

ALS-L1023 from Melissa officinalis Alleviates Liver Fibrosis in a Non-Alcoholic Fatty Liver Disease Model.

ALS-L1023 is an ingredient extracted from Melissa officinalis L. (Labiatae; lemon balm), which is known as a natural medicine that suppresses angiogenesis. Herein, we aimed to determine whether ALS-L1023 could alleviate liver fibrosis in the non-alcoholic fatty liver disease (NAFLD) model. C57BL/6 wild-type male mice (age, 6 weeks old) were fed a choline-deficient high-fat diet (CDHFD) for 10 weeks to induce NAFLD. For the next 10 weeks, two groups of mice received the test drug along with CDHFD. Two doses (a low dose, 800 mg/kg/day; and a high dose, 1200 mg/kg/day) of ALS-L1023 were selected and mixed with feed for administration. Obeticholic acid (OCA; 10 mg/kg/day) was used as the positive control. Biochemical analysis revealed that the ALS-L1023 low-dose group had significantly decreased alanine transaminase and aspartate transaminase. The area of fibrosis significantly decreased due to the administration of ALS-L1023, and the anti-fibrotic effect of ALS-L1023 was greater than that of OCA. RNA sequencing revealed that the responder group had lower expression of genes related to the hedgehog-signaling pathway than the non-responder group. ALS-L1023 may exert anti-fibrotic effects in the NAFLD model, suggesting that it may provide potential benefits for the treatment of liver fibrosis.

Early experience with laparoscopic treatment of liver tumors using a separable cluster electrode with a no-touch technique.

INTRODUCTION: Radiofrequency ablation (RFA) is one of the best curative treatments for hepatocellular carcinoma in selected patients, and this procedure can be applied either percutaneously or laparoscopically. Laparoscopic RFA has the benefit of direct visual control of the RFA procedure. Cluster electrodes (Octopus RF electrodes) can create a common ablation zone. AIM: Using these two methods (laparoscopic approach and no touch technique), this present study evaluated the technical and clinical outcomes of early experience with laparoscopic RFA and a no-touch technique. MATERIAL AND METHODS: Between November 2015 and November 2018, 21 patients underwent laparoscopic RFA for hepatocellular carcinoma with a no-touch technique using cluster electrodes. Laparoscopic RFA is recommended for patients with a contraindication for surgical resection, patients wants and a relative contraindication for conventional percutaneous RFA, such as lesions adjacent to the gastrointestinal tract, gallbladder, bile duct, or heart. RESULTS: In the 21 tumors, 2 were treated with a single electrode, 12 with 2 electrodes, and 7 tumors with 3 electrodes. The mean time of ablation per lesion was 20.43 ±8.77 min. There was no mortality, local tumor progression, delayed destructive biliary damage, or liver abscess at the follow-up computed tomography. No technical failures occurred. CONCLUSIONS: Laparoscopic RFA can access lesions for which percutaneous RFA is contraindicated or risky. Cluster electrodes can create sufficient ablation zones without contact and can achieve a sufficient margin with a low complication rate and no tumor dissemination. Therefore, laparoscopic RFA with a no-touch technique might be a safe and feasible treatment for HCC tumor in selected patients.

Prognostic value of carcinoembryonic antigen and carbohydrate antigen 19-9 in periampullary cancer patients receiving pancreaticoduodenectomy.

BACKGROUND: We assessed the use of serum concentrations of carbohydrate antigen (CA) 19-9 and carcinoembryonic antigen (CEA) measured during the preoperative diagnostic workup as prognostic factors for survival in patients with periampullary carcinoma. METHODS: A retrospective review of patients diagnosed with periampullary carcinoma who underwent radical surgery was conducted. Factors related to the survival of periampullary carcinoma patients, including CA 19-9 and CEA, were analyzed. RESULTS: The mean age of the 112 patients included in the results was 66.41 ± 10.513 years. In the study, the percentage of patients with elevated serum CA 19-9 and CEA concentrations was 65.2% and 24.1%, respectively. CA 19-9 concentrations were correlated with the tumor stage, pre-operative jaundice, and lymphovascular invasion, but CEA concentrations were not. The median overall survival was longer for the normal serum CA 19-9 group than the group with increased CA 19-9 (56 months vs. 25 months, p = 0.003); however, there was no statistically significant difference between the normal serum CEA group and the group with increased CEA (43 months vs. 25 months, p = 0.077). Independent factors related to overall survival were sex, age, stage, presence of jaundice, lymphovascular invasion, perineural invasion, margin status, and elevated serum CA 19-9 concentrations. CONCLUSIONS: Periampullary carcinoma patients with elevated serum CA 19-9 concentrations at diagnosis are expected to have poor overall survival. CA 19-9 may be a useful marker for predicting prognosis in patients with periampullary carcinoma at the time of diagnosis.

Clinicopathological characteristics and outcomes of gastrointestinal stromal tumors with high progranulin expression.

BACKGROUND & AIMS: Progranulin (PGRN) is known to promote tumorigenesis and proliferation of several types of cancer cells. However, little is known about the clinicopathological features of patients with gastrointestinal stromal tumors (GISTs) with regard to PGRN expression. METHODS: A retrospective analysis was performed on patients with GISTs who underwent curative surgical resection between 2007 and 2017. PGRN expression was evaluated by immunohistochemical (IHC) analysis and semi-quantitatively categorized (no expression, 0; weak, 1+; moderate, 2+; strong, 3+). Tumors with a staining intensity of 2+ or 3+ were considered high PGRN expression. RESULTS: Fifty-four patients were analyzed; 31 patients (57%) were male. The median age at surgery was 60 years (range, 33-79), and the most common primary site was the stomach (67%). Thirty-five patients (65%) had spindle histology; 42 patients (78%) were separated as a high-risk group according to the modified National Institutes of Health (NIH) classification. High PGRN-expressing tumors were observed in 27 patients (50%), had more epithelioid/mixed histology (68% vs. 32%; p = 0.046), and KIT exon 11 mutations (76% vs. 24%; p = 0.037). Patients with high PGRN-expressing tumors had a worse recurrence-free survival (RFS) (36% of 5-year RFS) compared to those with low PGRN-expressing tumors (96%; p<0.001). Multivariate analysis showed that high PGRN expression and old age (>60 years) were independent prognostic factors for poor RFS. CONCLUSIONS: High PGRN-expressing GISTs showed more epithelioid/mixed histology and KIT exon 11 mutations. PGRN overexpression was significantly associated with poor RFS in patients with GISTs who underwent curative resection.

Effect of abdominal binder after laparoscopic cholecystectomy on enhanced recovery: a randomized controlled trial.

Purpose: The purpose of this randomized controlled trial was to compare the effects of abdominal binder after laparoscopic cholecystectomy. Methods: From August to December 2020, 66 patients who were set to undergo cholecystectomy were selected for a prospective trial at Kangbuk Samsung Hospital, Seoul, Republic of Korea, and their clinical characteristics and postoperative surgical outcomes were evaluated. Among 66 patients, 33 patients belong to the abdominal binder group and the other 33 patients belong to the control group. Results: The average hospital stay was 2.46 ± 1.29 days, and was not significantly different between the two groups. The average postoperative pain score (visual analogue scale, 0-10) 12, 24, and 48 hours after surgery were not significantly different. However, the degree of comfort score was significantly higher for the control group patients (2.56 vs. 3.33, p < 0.001). Time to the first ambulation, walking ability, return of bowel function, time to full diet resumption, and the numbers of analgesics and antiemetics administered were not significantly different between the two groups. Conclusion: No postoperative recovery benefit and no reduction in hospital stay was found in patients who used an abdominal binder while undergoing laparoscopic cholecystectomy. Statistically, between the group that used the binder and the one that did not, no significant differences in surgical outcome nor postoperative outcome were observed. The only exception was that the degree of comfort score was significantly higher in the control group. Therefore, in terms of patient benefit and convenience, wearing an abdominal binder after laparoscopic cholecystectomy is not recommended.

Safety of appendectomy during pregnancy in the totally laparoscopic age.

Purpose: Acute appendicitis is the most common nonobstetric indication for surgical intervention during pregnancy. In the argument of the optimal surgical approach to acute appendicitis in pregnancy, laparoscopy seems to be won with a similar complication rate and shorter postoperative recovery than open. We aimed to compare perioperative outcomes of appendectomy in pregnant and nonpregnant women in the totally laparoscopic age. Methods: We retrospectively analyzed 556 nonincidental appendectomies performed in women (aged 18-45 years) between January 2014 and December 2018. To reduce the confounding effects, we used propensity score considering the variables age, American Society of Anesthesiologists physical status classification, and the operative finding; whether the appendicitis was simple or complicated. After propensity score matching, the outcomes of 15 pregnant women were compared with those of the 30 nonpregnant women. Results: All the operations were performed with laparoscopy. Most of the pregnant cases were in their first and second trimester. The postoperative morbidity rate was significantly higher in the pregnant group before propensity score matching; however, the significance disappeared after matching. Operative outcomes and the parameters related to the postoperative recovery were not different between the two groups. Two patients in their first trimester decided to terminate the pregnancy after appendectomy. One patient in her second trimester experienced preterm labor which was resolved spontaneously. There was no other obstetric adverse outcome. Conclusion: In the laparoscopy age, appendectomy during pregnancy is safe and not associated with a significantly increased risk of postoperative complication.

Laparoscopic repair of inguinal hernias: Risk factors for urinary retention and chronic pain after totally extraperitoneal repair and transabdominal preperitoneal repair.

Purpose: There are various opinions about the postoperative complications of the two methods for laparoscopic inguinal hernia surgery; totally extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP). The aim of this study was to compare the postoperative course after TAPP and TEP, focusing on immediate postoperative pain, incidence of postoperative urinary retention (POUR), and chronic pain. Methods: This study retrospectively analyzed a consecutive series of 344 inguinal hernia patients who were treated with laparoscopic surgery between November 2016 and December 2019 at a single tertiary referral center. Results: Patient demographics did not differ significantly between the groups. The operation time was significantly shorter in the TEP group than in the TAPP group (43.1 ± 14.9 minutes vs. 63.5 ± 16.5 minutes, p < 0.001). The postoperative pain scores were significantly lower in the TEP group than in the TAPP group immediately (3.6 ± 1.3 vs. 4.4 ± 1.1, p < 0.001) and 6 hours (1.5 ± 1.4 vs. 2.3 ± 1.8, p < 0.001) after the operation. The other complications did not differ significantly between the groups. Age was a significant risk factor for POUR (odds ratio [OR], 1.083; 95% confidence interval [CI], 1.018-1.151; p = 0.011), and history of benign prostate hyperplasia (BPH) was a significant risk factor for chronic pain (OR, 5.363; 95% CI, 1.028-27.962; p = 0.046). Conclusion: TEP and TAPP seem to be safe and effective for laparoscopic inguinal hernia repair and have similar postoperative outcomes. Age was a significant risk factor for POUR, and BPH history was a significant risk factor for chronic pain.

Surgical outcomes of percutaneous transhepatic gallbladder drainage in acute cholecystitis grade II patients according to time of surgery.

BACKGROUND: The objective of this study was to determine the appropriate timing for surgical intervention for Grade II acute cholecystitis patients. The study compares the clinical outcomes of patients in Group A, who were treated with early laparoscopic cholecystectomy (ELC) within the first two weeks of hospitalization, and Group B, treated with delayed laparoscopic cholecystectomy (DLC) after recovering from symptoms and that received conservative treatment and were discharged for more than two weeks. METHODS: From November 2011 to June 2019, from a total of 196 acute cholecystitis patients that received percutaneous transhepatic gallbladder drainage (PTGBD) insertion, we conducted a retrospective review of the group that received early laparoscopic cholecystectomy within 2 weeks and the group that received delayed laparoscopic cholecystectomy. The clinical characteristics and post-treatment outcomes were evaluated. RESULTS: In all patients treated with PTGBD insertion, Group A, the patients who were treated with ELC, showed a significantly longer mean operative time than Group B, the patients who were treated with DLC (72.46 ± 46.396 vs. 54.08 ± 27.12, P = 0.001). Similarly, Group A showed a significantly longer postoperative hospital stay compared to Group B (5.71 ± 5.062 vs. 4.27 ± 2.931, P = 0.014). CONCLUSION: In patients with Grade II acute cholecystitis with PTGBD insertion, DLC produces better outcomes with shorter hospital stay and operative time than ELC. These results suggest that DLC may lead to a better outcome than ELC, specifically when deciding the timing for laparoscopic cholecystectomy in patients diagnosed with acute Grade II cholecystitis.

Glycemic Status, Insulin Resistance, and Risk of Pancreatic Cancer Mortality in Individuals With and Without Diabetes.

INTRODUCTION: The impact of glycemic status and insulin resistance on the risk of pancreatic cancer in the nondiabetic population remains uncertain. We aimed to examine the association of glycemic status and insulin resistance with pancreatic cancer mortality in individuals with and without diabetes. METHODS: This is a cohort study of 572,021 Korean adults without cancer at baseline, who participated in repeat screening examinations which included fasting blood glucose, hemoglobin A1c, and insulin, and were followed for a median of 8.4 years (interquartile range, 5.3 -13.2 years). Vital status and pancreatic cancer mortality were ascertained through linkage to national death records. RESULTS: During 5,211,294 person-years of follow-up, 260 deaths from pancreatic cancer were identified, with a mortality rate of 5.0 per 10 person-years. In the overall population, the risk of pancreatic cancer mortality increased with increasing levels of glucose and hemoglobin A1c in a dose-response manner, and this association was observed even in individuals without diabetes. In nondiabetic individuals without previously diagnosed or screen-detected diabetes, insulin resistance and hyperinsulinemia were positively associated with increased pancreatic cancer mortality. Specifically, the multivariable-adjusted hazard ratio (95% confidence intervals) for pancreatic cancer mortality comparing the homeostatic model assessment of insulin resistance ≥75th percentile to the <75th percentile was 1.49 (1.08-2.05), and the corresponding hazard ratio comparing the insulin ≥75th percentile to the <75th percentile was 1.43 (1.05-1.95). These associations remained significant when introducing changes in insulin resistance, hyperinsulinemia, and other confounders during follow-up as time-varying covariates. DISCUSSION: Glycemic status, insulin resistance, and hyperinsulinemia, even in individuals without diabetes, were independently associated with an increased risk of pancreatic cancer mortality.

Impacts on outcomes and management of preoperative magnetic resonance cholangiopancreatography in patients scheduled for laparoscopic cholecystectomy: for whom it should be considered?

PURPOSE: We evaluated the impact of preoperative magnetic resonance cholangiopancreatography (MRCP) on patient outcomes, and found which patients should be considered for MRCP before cholecystectomy. METHODS: We performed retrospective analysis of 2,072 patients that underwent cholecystectomy for benign gallbladder disease from January 2014 to June 2017. Patients were grouped as CT only group (n = 737) and MRCP group (n = 1,335), including both CT and MRCP (n = 1,292) or MRCP only (n = 43). The main outcome measure was associated with complications after cholecystectomy, and the secondary outcomes were hospital stay, readmission, and events that could impact patient management due to addition of MRCP. RESULTS: There were no statistical differences in occurrence of intraoperative or postoperative complications or readmission rate between the 2 groups. Hospital stay was about 0.6 days longer in the MRCP group. However, MRCP group was more susceptible to complications due to underlying patient demographics (older age, higher frequency of diabetes, and higher level of the inflammatory markers). MRCP diagnosed common bile duct (CBD) stones in 6.5% of patients (84/1,292) without CBD stones in CT, and bile duct anomalies were identified in 41 patients (3.2%). Elevated γ-GT was the only independent factor for additional detection of CBD stones (adjusted odds ratio [OR], 2.89; P = 0.029) and subsequent biliary procedures (adjusted OR, 3.34; P = 0.018) when additional MRCP was performed. CONCLUSION: MRCP is valuable for identification of bile duct variation and CBD stones. Preoperative MRCP can be considered, particularly in patients with elevated γ-GT, for proper preoperative management and avoidance of complications.

Diagnostic Performance and Prognostic Relevance of FDG Positron Emission Tomography/Computed Tomography for Patients with Extrahepatic Cholangiocarcinoma.

OBJECTIVE: We aimed to evaluate the diagnostic value and prognostic relevance of FDG positron emission tomography/computed tomography (PET-CT) in extrahepatic cholangiocarcinoma patients. MATERIALS AND METHODS: This study included 234 extrahepatic cholangiocarcinoma patients who underwent FDG PET-CT between June 2008 and February 2016. The diagnostic performance of FDG PEG-CT was compared to that of contrast-enhanced multidetector row CT (MDCT) and MRI. Independent prognosticators for poor survival were also assessed. RESULTS: The sensitivity of FDG PET-CT for detecting primary tumor and regional lymph node metastases was lower than that of MDCT or MRI (p < 0.001), whereas the specificity and positive predictive value for detecting regional lymph nodes metastases was significantly better in FDG PET-CT compared to MDCT and MRI (all p < 0.001). There was no significant difference in the diagnostic yield of distant metastases detection among three diagnostic imaging techniques. In a multivariate analysis, maximum standardized uptake values (SUVmax) of the primary tumor (adjusted hazard ratio [HR], 1.75; 95% confidence interval [CI], 1.13-2.69) and of the metastatic lesions ≥ 5 (adjusted HR, 8.10; 95% CI, 1.96-33.5) were independent contributors to poor overall survival in extrahepatic cholangiocarcinoma patients. In a subgroup analysis of 187 patients with periductal infiltrating type of cholangiocarcinoma, an SUVmax of the primary tumor ≥ 5 was associated with an increased risk of regional lymph node (adjusted odds ratio [OR], 1.60; 95% CI, 0.55-4.63) and distant metastases (adjusted OR, 100.57; 95% CI, 3.94-2567.43) at diagnosis as well as with poor overall survival (adjusted HR, 1.81; 95% CI, 1.04-3.15). CONCLUSION: FDG PET-CT showed lower sensitivity for detecting primary tumor and regional lymph node involvement than MDCT and MRI. However, the SUVmax of primary tumors and metastatic lesions derived from FDG PET-CT could have significant implications for predicting prognoses in extrahepatic cholangiocarcinoma patients.

Routine Intraoperative Bacterial Culture May Be Needed in Complicated Appendicitis.

PURPOSE: Choosing the appropriate antibiotic is important for treatment of complicated appendicitis. However, increasing multidrug resistant bacteria have been a serious problem for successful treatment. This study was designed to identify bacteria isolated from patients with complicated appendicitis and reveal their susceptibilities for antibiotics and their relationship with patient clinical course. METHODS: This study included patients diagnosed with complicated appendicitis and examined the bacterial cultures and antimicrobial susceptibilities of the isolates. Data were retrospectively collected from medical records of Kangbuk Samsung Hospital from January 2008 to February 2018. RESULTS: The common bacterial species cultured in complicated appendicitis were as follows: Escherichia coli (n=113, 48.9%), Streptococcus spp. (n=29, 12.6%), Pseudomonas spp. (n=23, 10.0%), Bacteriodes spp. (n=22, 9.5%), Klebsiella (n=11, 4.8%), and Enterococcus spp. (n=8, 3.5%). In antibiotics susceptibility testing, the positive rate of extended-spectrum beta lactamase (ESBL) was 9.1% (21 of 231). The resistance rate to carbapenem was 1.7% (4 of 231), while that to vancomycin was 0.4% (1 of 231). E. coli was 16.8% ESBL positive (19 of 113) and had 22.1% and 19.5% resistance rates to cefotaxime and ceftazidime, respectively. Inappropriate empirical antibiotic treatment (IEAT) occurred in 55 cases (31.8%) and was significantly related with organ/space surgical site infection (SSI) (7 of 55, P=0.005). CONCLUSION: The rate of antibiotic resistance organisms was high in community-acquired complicated appendicitis in Koreans. Additionally, IEAT in complicated appendicitis may lead to increased rates of SSI. Routine intraoperative culture in patients with complicated appendicitis may be an effective strategy for appropriate antibiotic regimen.

Increased Risk of Neoplasms in Adult Patients Undergoing Interval Appendectomy.

PURPOSE: The low rate of recurrent appendicitis after initial nonsurgical management of complicated appendicitis supports the recently implemented strategy of omitting routine interval appendectomy. However, several reports have suggested an increased incidence rate of neoplasms in these patients. We aimed to identify the risk of neoplasms in the population undergoing interval appendectomy. METHODS: This study retrospectively analyzed consecutive cases of appendicitis that were treated surgically between January 2014 and December 2018 at a single tertiary referral center. Patients were divided into 2 groups depending on whether they underwent immediate or interval appendectomy. Demographics and perioperative clinical and pathologic parameters were analyzed. RESULTS: All 2,013 adults included in the study underwent surgical treatment because of an initial diagnosis of acute appendicitis. Of these, 5.5% (111 of 2,013) underwent interval appendectomy. Appendiceal neoplasm was identified on pathologic analysis in 36 cases (1.8%). The incidence of neoplasm in the interval group was 12.6% (14 of 111), which was significantly higher than that of the immediate group (1.2% [22 of 1,902], P < 0.001). CONCLUSION: The incidence rate of neoplasms was significantly higher in patients undergoing interval appendectomy. These findings should be considered when choosing treatment options after successful nonsurgical management of complicated appendicitis.