Practice guidelines for managing extrahepatic biliary tract cancers.

Backgrounds/Aims: Reported incidence of extrahepatic bile duct cancer is higher in Asians than in Western populations. Korea, in particular, is one of the countries with the highest incidence rates of extrahepatic bile duct cancer in the world. Although research and innovative therapeutic modalities for extrahepatic bile duct cancer are emerging, clinical guidelines are currently unavailable in Korea. The Korean Society of Hepato-Biliary-Pancreatic Surgery in collaboration with related societies (Korean Pancreatic and Biliary Surgery Society, Korean Society of Abdominal Radiology, Korean Society of Medical Oncology, Korean Society of Radiation Oncology, Korean Society of Pathologists, and Korean Society of Nuclear Medicine) decided to establish clinical guideline for extrahepatic bile duct cancer in June 2021. Methods: Contents of the guidelines were developed through subgroup meetings for each key question and a preliminary draft was finalized through a Clinical Guidelines Committee workshop. Results: In November 2021, the finalized draft was presented for public scrutiny during a formal hearing. Conclusions: The extrahepatic guideline committee believed that this guideline could be helpful in the treatment of patients.

Early outcomes of single-port robotic left lateral sectionectomy in patients with hepatic tumor.

Purpose: Laparoscopic left lateral sectionectomy (L-LLS) stands as a cornerstone procedure in hepatobiliary minimal surgery, frequently employed for various benign and malignant liver lesions. This study aimed to analyze the peri- and postoperative surgical outcomes of single-port robotic left lateral sectionectomy (SPR-LLS) vs. those of L-LLS in patients with hepatic tumors. Methods: From January 2020 through June 2023, 12 patients underwent SPR-LLS. During the same period, 30 L-LLS procedures were performed. In total, 12 patients in the robotic group and 24 patients in the laparoscopic group were matched. Results: When the SPR-LLS and L-LLS groups were compared, the operation time was longer in the SPR-LLS group with less blood loss and shorter hospital stay. Postoperative complications were observed in 3 patients in the L-LLS group (12.5%) and 1 patient in the SPR-LLS group (8.3%). Conclusion: SPR-LLS using the da Vinci SP system was comparable to laparoscopic LLS in terms of surgical outcomes. SPR-LLS was associated with lower blood loss and less postoperative length of stay compared to L-LLS. These findings suggest that left lateral sectionectomy is technically feasible and safe with the da Vinci SP system in select patients.

The novel use and feasibility of hemostatic oxidized regenerated cellulose agent (SurgiGuard®): multicenter retrospective study.

Background: SurgiGuard® is an absorbent hemostatic agent based on oxidized regenerated cellulose. The efficacy, effects and safety of SurgiGuard® are equivalent to existing hemostatic agents in animal experiments. This study was designed to confirm that the use of SurgiGuard® alone is effective, safe and feasible compared to combination with other hemostatic methods. Methods: We retrospectively reviewed clinical data from 12 surgery departments in seven tertiary centers in South Korea nationwide. All surgeries were performed between January and December 2018. Results: A total of 807 patients were enrolled; 447 patients (55.4%) had comorbidities. The rate of major surgery (operative time ≥4 hours) was 44% (n=355 patients). Regarding the type of SurgiGuard® used in surgery, more than 70% of minor surgeries used non-woven types. In major surgery, more than five SurgiGuards® were used in 7.3% (26 patients), and the proportion of co-usage (with four other hemostatic products) was 19.7% (70 patients). The effectiveness score was higher when SurgiGuard® was used alone in both major (5.3±0.5 vs. 5.1±0.6, P=0.048) and minor surgery (5.4±0.6 vs. 5.2±0.4, P<0.001). Seven patients had immediate re-bleeding, and all of them used SurgiGuard® and other products together. Nine patients reported adverse effects, such as abscess, bleeding, or leg swelling, but we found no direct correlation with SurgiGuard®. Conclusions: SurgiGuard® exhibited greater effectiveness when used alone. No direct adverse effects associated with SurgiGuard® use were reported, and SurgiGuard® had stable feasibility. Prospective comparative studies are needed in the future.

Feasibility and Efficacy of Single-Port Robotic Cholecystectomy Using the da Vinci SP® Platform.

Background: Single-incision laparoscopic cholecystectomy, first introduced in 1995, features acceptable cosmetic outcomes and postoperative pain control. The outcomes of single-port cholecystectomy by laparoscopy and robots were recently examined in many studies owing to surgeon and patient preference for minimally invasive surgery. A next-level da Vinci robotic platform was recently released. This study aimed to evaluate the feasibility and efficacy of robotic cholecystectomy (RC) using the da Vinci SP® system. Methods: In this retrospective observational single-center study, we analyzed the medical records of 304 patients who underwent RC between March 1, 2017 and May 31, 2021. Results: Of the 304 patients, the da Vinci Xi® (Xi) was used in 159 and the da Vinci SP® (SP) was used in 145. The mean operation time was 45.7 mins in the SP group versus 49.8 mins in the Xi group. The mean docking time of the SP group was shorter than that of the Xi group (5.7 min vs 8.8 min; p = 0.024). The mean immediate postoperative numerical rating scale (NRS) score was 4.0 in the SP group and 4.3 in the Xi group, showing a significant difference (p = 0.003). A separate analysis of only patients with acute cholecystitis treated with the da Vinci SP® showed that the immediate postoperative NRS score in the acute group was higher than that in the nonacute group. Conclusions: This study demonstrated acceptable results of single-site cholecystectomy using da Vinci SP®. Thus, pure single-port RC using the da Vinci SP® for various benign gallbladder diseases may be an excellent treatment option.

Case report of pure single-port robotic left lateral sectionectomy using the da Vinci SP system.

INTRODUCTION: Since its first appearance in the early 1990s, laparoscopic hepatic resection has become increasingly accepted and recognized as safe as laparotomy. The recent introduction of robotic surgery systems has brought new innovations to the field of minimally invasive surgery, such as laparoscopic surgery. The da Vinci line of surgical systems has recently released a true single-port platform called the da Vinci SP system, which has 3 fully wristed and elbowed instruments and a flexible camera in a single 2.5 cm cannula. We present the first case of robotic liver resection using the da Vinci SP system and demonstrate the technical feasibility of this platform. PATIENT CONCERNS AND DIAGNOSIS: A 63-year-old woman presented with elevated liver function test results and abdominal pain. Computed tomography (CT) and magnetic resonance cholangiopancreatography showed multiple intrahepatic duct stones in the left lateral section and distal common bile duct stones near the ampulla of Vater. INTERVENTIONS: The docking time was 8 minute. The patient underwent successful da Vinci SP with a total operation time of 135 minute. The estimated blood loss was 50.0 ml. No significant intraoperative events were observed. OUTCOMES: The numerical pain intensity score was 3/10 in the immediate postoperative period and 1/10 on postoperative day 2. The patient was discharged on postoperative day 5 after verifying that the CT scan did not show any surgical complications. CONCLUSION: We report a technique of left lateral sectionectomy, without the use of an additional port, via the da Vinci SP system. The present case suggests that minor hepatic resection is technically feasible and safe with the new da Vinci SP system in select patients. For the active application of the da Vinci SP system in hepatobiliary surgery, further device development and research are needed.

Collapsing focal segmental glomerulosclerosis in a patient with oral cavity cancer: A case report.

RATIONALE: Focal segmental glomerulosclerosis (FSGS) is one of the most common glomerular diseases, leading to end-stage renal disease. Among the 5 variants of FSGS, the collapsing variant is rare and has the worst prognosis. Solid and hematologic malignancies are associated with glomerular diseases, such as membranous nephropathy, minimal change disease, and FSGS. However, squamous cell carcinoma of the oral cavity is rarely associated with nephrotic syndrome, especially FSGS. PATIENT CONCERNS: A 55-year-old woman diagnosed with oral cavity cancer presented with generalized edema with heavy proteinuria and renal dysfunction after neoadjuvant chemotherapy and wide surgical excision. DIAGNOSIS: Renal biopsy shows segmental or global collapse of glomerular capillaries with marked hyperplasia and swelling of overlying epithelial cells, suggesting a collapsing variant of FSGS. INTERVENTIONS: After the renal biopsy, we prescribed oral prednisolone at a dose of 1 mg/kg/day. Despite immunosuppressive treatment, renal function deteriorated, and hemodialysis was started. OUTCOMES: After 23 sessions of hemodialysis and high-dose oral glucocorticoid treatment, renal function gradually improved, and oral glucocorticoid therapy was discontinued after 8 months. Currently, this patient is in a cancer-free state and has normal renal function without proteinuria. LESSONS: Unusual collapsing FSGS might be associated with neoadjuvant chemotherapy and wide surgical excision in patients with oral cavity cancer. Proper diagnostic workup, such as renal biopsy and high-dose glucocorticoid therapy, might have helped recover from nephrotic syndrome and acute renal injury in cancer patients.

Prognostic value of the lymph node metastasis in patients with ampulla of Vater cancer after surgical resection.

BACKGROUNDS/AIMS: Patients with Ampulla of Vater cancer have a better prognosis than those with other periampullary cancers. This study aimed to determine the prognostic impact of lymph node metastasis on survival in patients with ampulla of Vater cancer after surgical resection. METHODS: From 1991 to 2016, we retrospectively reviewed data on 104 patients with ampulla of Vater cancer who had received pancreaticoduodenectomy. Clinicopathologic factors such as lymph node ratio (LNR) and number of metastatic lymph nodes that influence survival were statistically analyzed. RESULTS: 5-year survival rate after resection was 57.8%. Mean number of retrieved and metastatic lymph nodes was 13 and 0.95, respectively. In patients with lymph node metastasis, the median number of metastatic lymph nodes and was 1, and the mean LNR was 0.18. LNR ＞0.2 was a significant prognostic factor for overall survival. Patients with 0 or 1 metastatic lymph nodes had better survival than those with ≥2 metastatic lymph nodes. Univariate analysis revealed that histologic differentiation of tumor, lymph node metastasis, and T stage were significant prognostic factors for overall survival. Multivariate analysis revealed that tumor differentiation and number of metastatic lymph nodes were independent prognostic factors for survival. CONCLUSIONS: Pancreaticoduodenectomy is an appropriate surgical procedure with acceptable long-term survival for ampulla of Vater cancer. Patients with LNR ＞0.2 and ≥2 positive lymph node metastasis had a poor survival. Tumor differentiation and ≥2 metastatic lymph nodes were independent significant prognostic factors for overall survival. Curative resection with lymph node dissection might control lymph node spread and enhance survival outcomes.

Effects of the proximity of metastasis to the central vessels of the liver on surgical outcomes and survival in colorectal cancer with liver metastasis.

BACKGROUND: Resectability of liver metastasis is important to establish a treatment strategy for patients with colorectal cancer. We aimed to evaluate the effect of the distance from metastasis to the centre of the liver on surgical outcomes and survival after hepatectomy. METHODS: The clinical data of a total of 155 patients who underwent hepatectomy for colorectal cancer with liver metastasis were retrospectively reviewed. We measured the minimal length from metastasis to the bifurcation of the portal vein at the primary branch of the Glissonean tree and defined it as 'centrality'. The postoperative outcomes and survival among the patients were then analysed. RESULTS: Anatomic resections were more frequently performed, and the operative time was longer in the patients with high centrality (≤1.5 cm) than in the patients with low centrality (>1.5 cm). A size of ≥5 cm for the largest lesion, a number of lesions of ≥3 and centrality of ≤1.5 cm were found to be the independent risk factors of a positive resection margin after hepatectomy. The patients with high centrality showed worse recurrence-free survival than those with low centrality; however, there was no significant difference found in the overall survival. In the multivariate analysis, high centrality was not found to be associated with worse recurrence-free and overall survival. CONCLUSION: Centrality significantly affected the surgical outcomes and treatment strategy for liver metastasis but did not influence the survival of the patients with colorectal cancer. Active efforts through surgical resections are important to treat liver metastasis of high centrality.

Safety and feasibility of pure laparoscopic extended cholecystectomy: comparison with the open technique in a propensity analysis at a single center.

BACKGROUND: The aim of this study was to validate the safety and feasibility of pure laparoscopic extended cholecystectomy (LEC) by comparing the outcome with that of open extended cholecystectomy (OEC). Moreover, on the basis of our experience, we also aimed to investigate the learning curve of pure LEC. METHODS: This single-center study enrolled patients who were diagnosed primary gallbladder cancer with pathologically confirmed and underwent R0 resection with curative intent between January 2016 and December 2019. A total of 31 patients who underwent OEC and 17 patients who underwent LEC were selected. Propensity score matching analysis was performed in a 1:1 ratio using the nearest-neighbor matching method, and clinical information was retrospectively collected from medical records and analyzed. RESULTS: The postoperative hospital stay was statistically shorter in the LEC group (7 days) than in the OEC group (12 days). The overall surgical complication rate did not differ between the two groups. The 1- and 3-year disease-free survival rates were 82.4% and 82.4% in the OEC group and 94.2% and 71.5% in the LEC group, respectively (P = 0.94). Considering the correlation between the number of cumulative cases and the operation time and between the number of cumulative cases and the number of retrieved lymph nodes in the LEC group, as the cases were accumulated, both the operation time and the number of retrieved lymph nodes had a statistically significant correlation with the number of cases. CONCLUSIONS: LEC showed a significant advantage in terms of achieving shorter postoperative hospital stay and similar results to OEC with respect to overall complications and pathological outcomes. The present results confirm that laparoscopy can be considered a safe treatment for primary gallbladder cancer in selected patients.

Should Lymph Nodes Be Retrieved in Patients with Intrahepatic Cholangiocarcinoma? A Collaborative Korea-Japan Study.

BACKGROUND: This study was performed to investigate the oncologic role of lymph node (LN) management and to propose a surgical strategy for treating intrahepatic cholangiocarcinoma (IHCC). METHODS: The medical records of patients with resected IHCC were retrospectively reviewed from multiple institutions in Korea and Japan. Short-term and long-term oncologic outcomes were analyzed according to lymph node metastasis (LNM). A nomogram to predict LNM in treating IHCC was established to propose a surgical strategy for managing IHCC. RESULTS: A total of 1138 patients were enrolled. Of these, 413 patients underwent LN management and 725 did not. A total of 293 patients were found to have LNM. The No. 12 lymph node (36%) was the most frequent metastatic node, and the No. 8 lymph node (21%) was the second most common. LNM showed adverse long-term oncologic impact in patients with resected IHCC (14 months, 95% CI (11.4-16.6) vs. 74 months, 95% CI (57.2-90.8), p < 0.001), and the number of LNM (0, 1-3, 4≤) was also significantly related to negative oncologic impacts in patients with resected IHCC (74 months, 95% CI (57.2-90.8) vs. 19 months, 95% CI (14.4-23.6) vs. 11 months, 95% CI (8.1-13.8)), p < 0.001). Surgical retrieval of more than four (≥4) LNs could improve the survival outcome in resected IHCC with LNM (13 months, 95% CI (10.4-15.6)) vs. 30 months, 95% CI (13.1-46.9), p = 0.045). Based on preoperatively detectable parameters, a nomogram was established to predict LNM according to the tumor location. The AUC was 0.748 (95% CI: 0.706-0.788), and the Hosmer and Lemeshow goodness of fit test showed p = 0.4904. CONCLUSION: Case-specific surgical retrieval of more than four LNs is required in patients highly suspected to have LNM, based on a preoperative detectable parameter-based nomogram. Further prospective research is needed to validate the present surgical strategy in resected IHCC.

Propensity score-matched analysis of internal stent vs external stent for pancreatojejunostomy during pancreaticoduodenectomy: Japanese-Korean cooperative project.

BACKGROUND: Several studies comparing internal and external stents have been conducted with the aim of reducing pancreatic fistula after PD. There is still no consensus, however, on the appropriate use of pancreatic stents for prevention of pancreatic fistula. This multicenter large cohort study aims to evaluate whether internal or external pancreatic stents are more effective in reduction of clinically relevant pancreatic fistula after pancreaticoduodenectomy (PD). METHODS: We reviewed 3149 patients (internal stent n = 1,311, external stent n = 1838) who underwent PD at 20 institutions in Japan and Korea between 2007 and 2013. Propensity score matched analysis was used to minimize bias from nonrandomized treatment assignment. The primary endpoint was the incidence of clinically relevant pancreatic fistula. This study was registered on the UMIN Clinical Trials Registry (UMIN000032402). RESULTS: After propensity score matched analysis, clinically relevant pancreatic fistula occurred in more patients in the external stents group (280 patients, 28.7%) than in patients in the internal stents group (126 patients, 12.9%) (OR 2.713 [95% CI, 2.139-3.455]; P < 0.001). In subset analysis of a high-risk group with soft pancreas and no dilatation of the pancreatic duct, clinically relevant pancreatic fistula occurred in 90 patients (18.8%) in internal stents group and 183 patients (35.4%) in external stents group. External stents were significantly associated with increased risk for clinically relevant pancreatic fistula (OR 2.366 [95% CI, 1.753-3.209]; P < 0.001). CONCLUSION: Propensity score matched analysis showed that, regarding clinically relevant pancreatic fistula after PD, internal stents are safer than external stents for pancreaticojejunostomy.

Clinicopathological Differences in T2 Gallbladder Cancer According to Tumor Location.

We aimed to identify clinicopathological differences and factors affecting survival outcomes of stage T2a and T2b gallbladder cancer (GBC) and validate the oncological benefits of regional lymphadenectomy and hepatic resection in these patients. This single-center study enrolled patients who were diagnosed with pathologically confirmed T2 GBC and underwent curative resection between January 1995 and December 2017. Eighty-two patients with T2a and 50 with T2b GBCs were identified, and clinical information was retrospectively collected from medical records and analyzed. Five-year overall survival rates were 96.8% and 80.7% in T2a and T2b groups, respectively (P = .007). Three- and 5-year survival rates among all patients with T2 GBC without and with lymph node metastasis were 97.2% and 94.4% and 81.3% and 81.3%, respectively (P = .029). There was no difference in survival rates between the 2 groups according to whether hepatic resection was performed (P = .320). However, in the T2b group, those who underwent hepatic resection demonstrated a better survival rate than those who did not (P = .029). The T2b group had more multiple recurrence patterns than the T2a group, and the lymph nodes were the most common site in both groups. Multivariate analysis revealed that lymph node metastasis, vascular invasion, and tumor location were significant independent prognostic factors. Hepatic resection was not always necessary in patients with peritoneal-side GBC. Considering clinicopathological features and recurrence patterns, a systematic treatment plan, including radical resection and adjuvant treatment, should be established for hepatic-side GBC.

Surgical Outcomes of Hepatocellular Carcinoma With Bile Duct Tumor Thrombus: A Korea-Japan Multicenter Study.

OBJECTIVE: To identify optimal surgical methods and the risk factors for long-term survival in patients with hepatocellular carcinoma accompanied by macroscopic bile duct tumor thrombus (BDTT). SUMMARY BACKGROUND DATA: Prognoses of patients with hepatocellular carcinoma accompanied by BDTT have been known to be poor. There have been significant controversies regarding optimal surgical approaches and risk factors because of the low incidence and small number of cases in previous reports. METHODS: Records of 257 patients from 32 centers in Korea and Japan (1992-2014) were analyzed for overall survival and recurrence rate using the Cox proportional hazard model. RESULTS: Curative surgery was performed in 244 (94.9%) patients with an operative mortality of 5.1%. Overall survival and recurrence rate at 5 years was 43.6% and 74.2%, respectively. TNM Stage (P < 0.001) and the presence of fibrosis/cirrhosis (P = 0.002) were independent predictors of long-term survival in the Cox proportional hazards regression model. Both performing liver resection equal to or greater than hemihepatectomy and combined bile duct resection significantly increased overall survival [hazard ratio, HR = 0.61 (0.38-0.99); P = 0.044 and HR = 0.51 (0.31-0.84); P = 0.008, respectively] and decreased recurrence rate [HR = 0.59 (0.38-0.91); P = 0.018 and HR = 0.61 (0.42-0.89); P = 0.009, respectively]. CONCLUSIONS: Clinical outcomes were mostly influenced by tumor stage and underlying liver function, and the impact of BDTT to survival seemed less prominent than vascular invasion. Therefore, an aggressive surgical approach, including major liver resection combined with bile duct resection, to increase the chance of R0 resection is strongly recommended.

Development and validation of novel scoring system for the prediction of disease recurrence following resection of colorectal liver metastasis.

BACKGROUND: The aim of this study was to identify predictive factors for the recurrence of colorectal cancer liver metastasis (CRLM) and then to develop a corresponding novel scoring system that should improve the sensitivity of predicting recurrence in patients with CRLM. METHODS: A total of 295 consecutive CRLM patients were enrolled in our institution between January 2002 and December 2015. Multivariate analyses were performed to identify the variables associated with disease recurrence and established the novel scoring system based on it. RESULTS: The scoring system considered seven variables: synchronosity, CA19-9 level, number of liver metastasis, largest size of liver metastasis, resection margin of hepatic lesion, neutrophil-to-lymphocyte ratio and prognostic nutritional index. The area under the curve of ROC was 0.824 (95% confidence interval 0.767-0.882); the sensitivity of our scoring system was 87.9%, specificity was 66.7%, positive predictive value was 20.6%, and negative predictive value was 20.9%. CONCLUSION: For patients with CRLM undergoing curative hepatic resection, our novel scoring system would improve the sensitivity for prediction of disease recurrence in Case of CRLM patients.

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 validation of scoring systems of postoperative pancreatic fistula after pancreatoduodenectomy: applicability to Eastern cohorts?

BACKGROUND: Although several prediction models for the occurrence of postoperative pancreatic fistula (POPF) after pancreatoduodenectomy (PD) exist, all were established using Western cohorts. Large-scale external validation studies in Eastern cohorts that consider demographic variables including lower body mass index (BMI) are scarce. The purpose of this study was to externally validate POPF prediction models using nationwide large-scale Korean cohorts. METHODS: Nine tertiary university hospitals in the Republic of Korea participated. Patients' preoperative characteristics, intraoperative factors, and pathologic findings were evaluated. POPF grades were determined according to the 2016 International Study Group on Pancreatic Surgery definition. Three POPF risk models (Callery, Roberts, and Mungroop) were selected for external validation. RESULTS: A total of 1,898 PD patients were enrolled. A non-pancreatic disease diagnosis [hazard ratio (HR), 1.856; 95% confidence interval (CI), 1.223-2.817; P=0.004), higher preoperative BMI (HR, 1.069; 95% CI, 1.019-1.121; P=0.006), and soft pancreatic texture (HR, 1.859; 95% CI, 1.264-2.735; P=0.002) were independent risk factors for clinically relevant POPF (CR-POPF). The area under the receiver operating characteristic curve (AUC) values were 0.61, 0.64, and 0.63 on the Callery, Roberts, and Mungroop models, respectively; all were lower than those published in each external validation study. CONCLUSIONS: Western POPF prediction models performed less well when applied to Korean cohorts. Thus, a large-scale Eastern-specific and externally validated POPF prediction model is needed.

Prognostic markers affecting the early recurrence of hepatocellular carcinoma with liver cirrhosis after curative resection.

BACKGROUND: Early recurrence is associated with poor prognosis after curative resection for hepatocellular carcinoma. Thus, we studied which factors, including this inflammation-based scoring system, affect disease recurrence in single hepatocellular carcinoma patients with liver cirrhosis. METHODS: A total of 430 consecutive hepatocellular carcinoma patients were enrolled in our institution between January 2002 and December 2015. Survival rate, univariate, and multivariate analyses were performed to identify the variables associated with recurrence and early recurrence especially. RESULTS: The overall survival rate was significantly lower in the early recurrence group than in the non-early recurrence group (P<0.001). According to the multivariate analysis, protein induced by vitamin K absence or antagonist (PIVKA) greater than 200 (P=0.035), neutrophil-to-lymphocyte ratio greater than 2.0 (P<0.001), elevated Glasgow prognostic score (P=0.003), tumor size greater than 5 cm (P=0.002), and the presence of lymphovascular invasion (P=0.002) were significantly different among the groups and affected the early recurrence of hepatocellular carcinoma. The patients were categorized into five levels of risk for early recurrence according to the number of independent risk factors, and patients with no risk factors were set as the reference group. CONCLUSION: Neutrophil-to-lymphocyte ratio, Glasgow prognostic score, and serum level of PIVKA offer significant prognostic information associated with early recurrence following single lesion hepatocellular carcinoma patients with liver cirrhosis after curative resection.

Prognostic impact of the combination of the neutrophil-to-lymphocyte ratio and serum carbohydrate antigen 19-9 in patients with pancreas head cancer.

BACKGROUND: This study aimed to evaluate the clinical value of the combination of a traditional prognostic factor with a systemic inflammation-based prognostic factor in patients undergoing curative resection for pancreas head cancer diagnosed as pancreatic ductal adenocarcinoma. METHODS: From January 2005 to December 2015, 198 patients were enrolled. Various clinicopathological factors potentially associated with survival and recurrence were evaluated in this study. RESULTS: The selected cut-off values for the test prognostic factors with sufficient sensitivity and specificity were 2.8 for the neutrophil-to-lymphocyte ratio (NLR) and 70 U/mL for serum carbohydrate antigen 19-9 (CA19-9). Kaplan-Meier survival analysis demonstrated that the 5-year survival rate in patients with a high NLR and CA19-9 was 21.8% compared with 79.8% for patients with a low NLR and CA19-9. The 5-year disease-free survival rate in patients with a high NLR and CA19-9 was 0% compared with 33.9% for patients with a low NLR and CA19-9. Patients with high NLRs and high CA19-9 were more likely to have an early recurrence and multiple relapse patterns. CONCLUSION: Preoperative NLR and serum CA19-9 offer significant prognostic information for survival following curative resection of pancreas head cancer diagnosed as pancreatic ductal adenocarcinoma.

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.