Quality Indicators of Endoscopic Retrograde Cholangiopancreatography in Korea.

Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure that requires significant experiences and skills and has various procedure-related complications, some of which can be severe and even result in the death of patients. Expanding ERCP availability has the advantage of increasing accessibility for patients. However, ERCP poses a substantial risk if performed without proper quality management. ERCP quality management is essential for both ensuring safe and successful procedures and meeting the social demands for enhanced healthcare competitiveness and quality assurance. To address these concerns, the Korean Pancreatobiliary Association established a task force to develop ERCP quality indicators (QIs) tailored to the Korean medical environment. Key questions for five pre-procedure, three intra-procedure, and four post-procedure measures were formulated based on a literature search related to ERCP QIs and a comprehensive clinical review conducted by experts. The statements and recommendations regarding each QI item were selected through peer review. The developed ERCP QIs were reviewed by external experts based on the latest available evidence at the time of development. These domestically tailored ERCP QIs are expected to contribute considerably to improving ERCP quality in Korea.

Initial experience of abdominal total mesorectal excision for rectal cancer using the da Vinci single port system.

From November 2021 to February 2022, 15 patients underwent total abdominal mesorectal excision for rectal cancer using the da Vinci single port system. The clinical and pathological results were analyzed retrospectively. All surgeries were performed without conversion. The mean distance from the tumor to the anal verge was 10 cm (range, 2-15 cm). The mean operative time was 191 minutes, the median docking time was 4 minutes (range, 2-10 minutes), and the estimated blood loss was 20 mL (range, 20-50 mL). The mean number of lymph nodes harvested was 16.5, the mean distal resection margin was 3.52 cm, and all patients had circumferential and distal tumor-free resection margins. One patient had minor anastomotic leakage. The mean length of hospital stay was 5.8 ± 2.5 days. Abdominal total mesorectal excision using the da Vinci single port system for rectal cancer is technically feasible and safe, with acceptable pathological and short-term clinical outcomes.

Outcomes of Palliative Chemotherapy for Ampulla of Vater Adenocarcinoma: A Multicenter Cohort Study.

Background/Aims: : Palliative chemotherapy (PC) is not standardized for patients with advanced ampulla of Vater adenocarcinoma (AA). This multicenter, retrospective study evaluated first-line PC outcomes in patients with AA. Methods: : Patients diagnosed with AA between January 2010 and December 2020 who underwent PC were enrolled from 10 institutions. Overall survival (OS) and progression-free survival (PFS) according to the chemotherapy regimen were analyzed. Results: : Of 255 patients (mean age, 64.0±10.0 years; male, 57.6%), 14 (5.5%) had locally advanced AA and 241 (94.5%) had metastatic AA. Gemcitabine plus cisplatin (GP) was administered as first-line chemotherapy to 192 patients (75.3%), whereas capecitabine plus oxaliplatin (CAPOX) was administered to 39 patients (15.3%). The median OS of all patients was 19.8 months (95% confidence interval [CI], 17.3 to 22.3), and that of patients who received GP and CAPOX was 20.4 months (95% CI, 17.2 to 23.6) and 16.0 months (95% CI, 11.2 to 20.7), respectively. The median PFS of GP and CAPOX patients were 8.4 months (95% CI, 7.1 to 9.7) and 5.1 months (95% CI, 2.5 to 7.8), respectively. PC for AA demonstrated improved median outcomes in both OS and PFS compared to conventional bile duct cancers that included AA. Conclusions: : While previous studies have shown mixed prognostic outcomes when AA was analyzed together with other biliary tract cancers, our study unveils a distinct clinical prognosis specific to AA on a large scale with systemic anticancer therapy. These findings suggest that AA is a distinct type of tumor, different from other biliary tract cancers, and AA itself could be expected to have a favorable response to PC.

The Awareness and Experience About Endoscopic Adverse Events Among South Korean Endoscopists.

BACKGROUND/AIMS: The number of endoscopic procedures and related adverse events is increasing. We investigated South Korean endoscopists' awareness and experience of endoscopic adverse events. MATERIALS AND METHODS: We used Google Forms to conduct an online questionnaire survey among South Korean endoscopists from December 11 to 29, 2020. The survey comprised 30 questions developed by members of the Quality Management Committee of the Korean Society of Gastrointestinal Endoscopy. RESULTS: In total, 475 endoscopists participated in the survey. Of these, 454 (95.6%) were board-certified gastroenterologists and 255 (53.7%) had >10 years of endoscopy experience. Most participants had experienced serious adverse events requiring hospitalization (80.4%, 382/475); however, only 100 (21.1%) were aware of programs for the prevention and management of adverse endoscopic events in their affiliated endoscopy centers. Most participants (98.5%, 468/475) agreed with the need for education on medical accidents for healthcare workers. Responses were inconsistent regarding the definition of adverse events formulated by the 2010 American Society for Gastrointestinal Endoscopy Workshop. Most participants were not aware of the minimal standard terminology (76.6%, 364/475) and had not used it when writing endoscopy reports (88.8%, 422/475). Responses were inconsistent regarding which events to record in endoscopy records. CONCLUSION: Further discussion on the nationwide adverse-event reporting system and education program for adverse events related to endoscopy is needed to ensure the safety of patients and endoscopists.

A comparative study on the short-term clinical outcomes of Da Vinci SP versus Da Vinci Xi for rectal cancer surgery.

PURPOSE: The Da Vinci SP robot system was recently introduced, but its safety and feasibility for rectal cancer compared with the currently used robot system have not been reported. METHODS: This was a single-centre retrospective study. Data from patients who underwent abdominal total mesorectal excision (TME) from October 2015 to October 2022 were analysed. After propensity score matching, the short-term outcomes were compared. RESULTS: A total of 56 patient data were analysed. Intersphincteric resection was more common in the SP group (7 cases (25%) vs. 0 case (0%), p = 0.001). The operation time was significantly shorter in SP (184 vs. 227.5 min, p < 0.0001), but the docking time was similar. The postoperative complications were similar. There were no differences in the postoperative pain score and length of hospital stay. CONCLUSION: The SP robotic system for abdominal TME has acceptable short-term and is safe and technically feasible.

Immunoglobulin G4-related Disease of the Small Bowel: A Case of Long-term Remission Achieved by Surgical Resection without Maintenance Therapy.

Immunoglobulin G4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory disease. IgG4-RD can affect any organ system, including the pancreas, bile ducts, salivary glands, mesentery, and retroperitoneum. On the other hand, small intestine involvement is extremely rare. This paper describes a case of IgG4-RD involving the small bowel, particularly at the distal ileum. An 81-year-old female was admitted to the authors' hospital complaining of abdominal pain, dyspepsia, and hematochezia. The laboratory tests, including tumor markers and IgG4, were within normal limits. A colonoscopy did not show any abnormal findings. Abdominal computed tomography revealed segmental aneurysmal dilatation and wall thickening at the distal ileum, suggesting malignant conditions, such as small bowel lymphoma. The patient underwent an exploratory laparoscopy and ileocecectomy to differentiate a malignancy. A histopathology examination revealed dense lymphoplasmacytic infiltration, storiform fibrosis, and IgG4-positive plasma cells (>50 per high power field). The patient was finally diagnosed with IgG4-RD. The patient was followed up in the outpatient clinic for five years without recurrence. This paper suggests that a radical resection without maintenance therapy can be a treatment option, particularly when the IgG4-RD manifests as a localized gastrointestinal tract lesion.

Short-term outcomes of Early versus conventional adjuvant chemotherapy in stage III colon cancer: randomized clinical trial.

BACKGROUND: Evidence is lacking regarding the earliest timing of initiating adjuvant chemotherapy to maximize its efficacy safely. A trial was designed and conducted to evaluate the safety and oncological efficacy of early adjuvant chemotherapy compared with conventional adjuvant chemotherapy. The short-term outcomes are reported here. METHODS: A multicentre, randomized (1 : 1), open-label, phase III trial was conducted comparing early adjuvant chemotherapy with conventional adjuvant chemotherapy in patients with stage III colon cancer. Patients who underwent radical surgery who had stage III colon cancer confirmed by histopathological assessment were screened and randomized into the early adjuvant chemotherapy arm or the conventional adjuvant chemotherapy arm. The primary endpoint was 3-year disease-free survival. The adjuvant chemotherapy with FOLFOX was delivered between postoperative day 10 and 14 in the early adjuvant chemotherapy arm, and between postoperative day 24 and 28 in the conventional adjuvant chemotherapy arm. Toxicity and quality of life were evaluated. RESULTS: Between 9 September 2011 and 6 March 2020, 443 patients consented to randomization at eight sites. The intention-to-treat population included 423 patients (209 in the early adjuvant chemotherapy arm and 214 in the conventional adjuvant chemotherapy arm), and the safety population included 380 patients (192 in the early adjuvant chemotherapy arm and 188 in the conventional adjuvant chemotherapy arm). There was no statistically significant difference in overall toxicity (28.1 per cent in the early adjuvant chemotherapy arm and 28.2 per cent in the conventional adjuvant chemotherapy arm, P = 0.244), surgical complications, and quality of life between the two arms. CONCLUSION: Adjuvant chemotherapy can be safely initiated 2 weeks after surgery with toxicity and quality of life comparable to conventional adjuvant chemotherapy for stage III colon cancer.

Immediate urinary catheter removal after colorectal surgery with the enhanced recovery after surgery protocol.

PURPOSE: The Enhanced Recovery After Surgery protocol for colorectal surgery recommends early urinary catheter (UC) removal after surgery. However, the optimal timing remains controversial. We aimed to evaluate the safety of immediate UC removal and risk factors of postoperative urinary retention (POUR) after colorectal cancer surgery. METHODS: From November 2019 and April 2022, patients who underwent elective colorectal cancer surgery at Seoul St. Mary's hospital were collected retrospectively. A UC was inserted in the operating room after general anesthesia and removed in the operating room immediately after surgery. The primary outcome was the occurrence of POUR following immediate UC removal after surgery, and the secondary outcomes were the identification of POUR-related risk factors and postoperative complications. RESULTS: Among 737 patients, 81 (10%) had POUR immediately after UC removal. No patient had urinary tract infection. The incidence of POUR was significantly higher in male and in those with a history of urinary disease. However, there were no significant differences in tumor location, surgical procedure, or approach. The mean operative time was significantly longer in the POUR group. Postoperative morbidity and mortality rates did not differ significantly between two groups. Multivariate analysis showed that risk factors for POUR were male, a history of urinary disease, and intrathecal morphine injection. CONCLUSIONS: Immediate removal of UC immediately after colorectal surgery is safe and feasible in the trend of ERAS. Male, a history of benign prostatic hyperplasia, and intrathecal morphine injection were risk factors for POUR.

Robotic Lateral Pelvic Lymph Node Dissection Could Harvest More Lateral Pelvic Lymph Nodes over Laparoscopic Approach for Mid-to-Low Rectal Cancer: A Multi-Institutional Retrospective Cohort Study.

Lateral pelvic lymph node dissection (LPND) is a technically demanding procedure. This study aimed to compare the short-term outcomes of laparoscopic and robotic LPNDs. This multi-institutional retrospective study included 108 consecutive patients who underwent laparoscopic or robotic total mesorectal excision with LPND for locally advanced rectal cancer. There were 74 patients in the laparoscopic and 34 in the robotic groups. The median operation time was longer in the robotic group than in the laparoscopic group (353 vs. 275 min, p < 0.001). No patients underwent conversion to open surgery in either group. Pathological LPN metastases were observed in 24 and 8 patients in the laparoscopic and robotic groups, respectively (p = 0.347). Although the number of harvested mesorectal lymph nodes was similar (15.5 vs. 15.0, p = 0.968), the number of harvested LPNs was higher in the robotic than in the laparoscopic group (7.0 vs. 5.0, p = 0.004). Postoperative complications and length of hospital stay were similar (robotic vs. laparoscopic, 35.3% and 7 days vs. 37.8% and 7 days, respectively). Both laparoscopic and robotic LPND are safe and feasible for locally advanced rectal cancers, but robotic LPND showed more harvested lateral lymph node than laparoscopic LPND.

Adjuvant Chemotherapy and Effect on Long-Term Survival in Ampullary Adenocarcinoma: A Multicenter Cohort Study.

BACKGROUND: The role of adjuvant chemotherapy (AC) in patients with ampullary adenocarcinoma (AA) remains controversial. This study aimed to determine if AC could improve the prognosis of patients with resected AA. STUDY DESIGN: This study enrolled patients diagnosed with AA at 9 tertiary teaching hospitals. Patients who did and did not receive AC were matched 1:1 using propensity score. The overall survival (OS) and recurrence-free survival (RFS) were compared between the 2 groups. RESULTS: Of the 1,057 patients with AA, 883 underwent curative-intent pancreaticoduodenectomy, and 255 received AC. Because patients with advanced-stage AA received AC more frequently, the no AC group unexpectedly had a longer OS (not reached vs 78.6 months; p < 0.001) and RFS (not reached vs 18.7 months; p < 0.001) than did the AC group in the unmatched cohort. In the propensity score-matched cohort (n = 296), no difference between the 2 groups in terms of OS (95.9 vs 89.8 months, p = 0.303) and RFS (not reached vs 25.5 months; p = 0.069) was found. By subgroup analysis, patients with advanced stage (pT4 or pN1-2) showed longer OS in the AC group than in the no AC group (not reached vs 15.7 months, p = 0.007: 89.8 vs 24.2 months, p = 0.006, respectively). There was no difference in RFS according to AC in the propensity score-matched cohort. CONCLUSIONS: Given its favorable long-term outcomes, AC can be recommended for patients with resected AA, especially those in the advanced stage (pT4 or pN1-2).

Effectiveness of personalized treatment stage-adjusted digital therapeutics in colorectal cancer: a randomized controlled trial.

BACKGROUND: Colorectal cancer survivors often experience decline in physical performance and poor quality of life after surgery and during adjuvant therapies. In these patients, preserving skeletal muscle mass and high-quality nourishment are essential to reduce postoperative complications and improve quality of life and cancer-specific survival. Digital therapeutics have emerged as an encouraging tool for cancer survivors. However, to the best of our knowledge, randomized clinical trials applying personalized mobile application and smart bands as a supportive tool to several colorectal patients remain to be conducted, intervening immediately after the surgical treatment. METHODS: This study is a prospective, multi-center, single-blinded, two-armed, randomized controlled trial. The study aims to recruit 324 patients from three hospitals. Patients will be randomly allocated to two groups for one year of rehabilitation, starting immediately after the operation: a digital healthcare system rehabilitation (intervention) group and a conventional education-based rehabilitation (control) group. The primary objective of this protocol is to clarify the effect of digital healthcare system rehabilitation on skeletal muscle mass increment in patients with colorectal cancer. The secondary outcomes would be the improvement in quality of life measured by EORTC QLQ C30 and CR29, enhanced physical fitness level measured by grip strength test, 30-sec chair stand test and 2-min walk test, increased physical activity measured by IPAQ-SF, alleviated pain intensity, decreased severity of the LARS, weight, and fat mass. These measurements will be held on enrollment and at 1, 3, 6 and 12 months thereafter. DISCUSSION: This study will compare the effect of personalized treatment stage-adjusted digital health interventions on immediate postoperative rehabilitation with that of conventional education-based rehabilitation in patients with colorectal cancer. This will be the first randomized clinical trial performing immediate postoperative rehabilitation in a large number of patients with colorectal cancer with a tailored digital health intervention, modified according to the treatment phase and patient condition. The study will add foundations for the application of comprehensive digital healthcare programs focusing on individuality in postoperative rehabilitation of patients with cancer. TRIAL REGISTRATION: NCT05046756. Registered on 11 May 2021.

Medical disputes related to advanced endoscopic procedures with endoscopic retrograde cholangiopancreatography or endoscopic ultrasonography for the management of pancreas and biliary tract diseases.

BACKGROUND/AIMS: This study aimed to evaluate the characteristics of endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasonography (EUS)-related adverse events (AEs) that eventually lead to medical disputes or claims on medical professional liability. METHODS: Medical disputes for ERCP/EUS-related AEs filed in the Korea Medical Dispute Mediation and Arbitration Agency between April 2012 and August 2020 were evaluated using corresponding medical records. AEs were categorized into three sections: procedure-related, sedation-related, and safety-related AEs. RESULTS: Among a total of 34 cases, procedure-related AEs were 26 (76.5%; 12 duodenal perforations, 7 post-ERCP pancreatitis, 5 bleedings, 2 perforations combined with post-ERCP pancreatitis); sedation-related AEs were 5 (14.7%; 4 cardiac arrests, 1 desaturation), and safety-related AEs were 5 (8.8%; 1 follow-up loss for stent removal, 1 asphyxia, 1 fall). Regarding clinical outcomes, 20 (58.8%) were fatal and eventually succumbed to AEs. For the types of medical institutions, 21 cases (61.8%) occurred at tertiary or academic hospitals, and 13 (38.2%) occurred at community hospitals. CONCLUSION: The ERCP/EUS-related AEs filed in Korea Medical Dispute Mediation and Arbitration Agency showed distinct features: duodenal perforation was the most frequent AE, and clinical outcomes were fatal, resulting in at least more than permanent physical impairment.

Reappraisal of the Lymphatic Drainage System of the Distal Rectum: Functional Lymphatic Flow into the Presacral Space and Its Clinical Implication in Rectal Cancer Treatment.

Understanding the source and route of pelvic metastasis is essential to developing an optimal strategy for controlling local and systemic diseases of rectal cancer. This study aims to delineate the distribution of lymphatic channels and flow from the distal rectum. In fresh-frozen cadaveric hemipelvis specimens, the ligamentous attachment of the distal rectum to the pelvic floor muscles and the presacral fascia were evaluated. Using indocyanine green (ICG) fluorescence imaging, we simultaneously evaluated the gross anatomy of the lymphatic communication of the distal rectum. We also investigated the lymphatic flow in the pelvic cavity intraoperatively in rectal cancer patients who underwent radical rectal resection with total mesorectal excision (TME). In fresh cadavers, multiple small perforating lymphovascular branches exist in the retrorectal space, posteriorly connecting the mesorectum to the presacral fascia. The lymphatic flow from the distal rectum drains directly into the presacral space through the branches. In patients who underwent TME for rectal cancer, intraoperative ICG fluorescence signals were seen in the pelvic sidewalls and the presacral space. This anatomical study demonstrated that the lymphatic flow from the distal rectum runs directly to the pelvic lateral sidewalls and the presacral space, suggesting a possible route of metastasis in distal rectal cancer.

Lateral Lymph Node Size and Tumor Distance From Anal Verge Accurately Predict Positive Lateral Pelvic Lymph Nodes in Rectal Cancer: A Multi-Institutional Retrospective Cohort Study.

BACKGROUND: Lateral pelvic lymph node dissection improves oncological outcomes in rectal cancer patients with suspected lateral pelvic lymph node metastasis. However, the indication for this procedure remains unclear. OBJECTIVE: This study aimed to identify the predictive factors for lateral lymph node metastasis and the indications for lateral pelvic lymph node dissection. DESIGN: A multi-institutional retrospective study. SETTINGS: This study was conducted at 3 university hospitals. PATIENTS: This study involved 105 patients with locally advanced mid/low rectal cancer and clinically suspected lateral pelvic lymph node metastasis who underwent total mesorectal excision with lateral pelvic lymph node dissection between 2015 and 2020. MAIN OUTCOME MEASURES: Indications were set using lateral pelvic lymph node metastasis-associated preoperative factors. RESULTS: Among 105 patients, 36 (34.3%) had pathologically confirmed lateral pelvic lymph node metastasis and 77 (73.3%) underwent preoperative chemoradiation. Tumors located within 5 cm distance from the anal verge ( p = 0.02) and initial node size ≥ 6 mm ( p = 0.001) were significant predictors of lateral pelvic lymph node metastasis. The sensitivity was 100% (36/36) with a cutoff of 6 mm for the initial node size and 94.4% (34/36) with a cutoff of 8 mm for the initial node size. When using initial node size cutoffs of 8 mm for anal verge-to-tumor distance of >5 cm and 6 mm for anal verge-to-tumor distance of ≤5 cm, the sensitivity of lateral pelvic lymph node metastasis was found to be 100%. LIMITATIONS: The retrospective design and small sample size were the limitations of this study. CONCLUSION: Initial node size and tumor height were significant predictors of lateral pelvic lymph node metastasis. This study proposed that an initial node size of ≥8 mm with an anal verge-to-tumor distance of >5 cm and ≥6 mm with an anal verge-to-tumor distance of ≤5 cm are optimal indications for lateral pelvic lymph node dissection in rectal cancer. See Video Abstract at http://links.lww.com/DCR/C101 . EL TAMAO DEL GANGLIO LINFTICO LATERAL Y LA DISTANCIA DEL TUMOR DESDE EL BORDE ANAL PREDICEN CON PRECISIN LOS GANGLIOS LINFTICOS PLVICOS LATERALES POSITIVOS EN EL CNCER DE RECTO UN ESTUDIO DE COHORTE RETROSPECTIVO MULTIINSTITUCIONAL: ANTECEDENTES:La disección de los ganglios linfáticos pélvicos laterales mejora los resultados oncológicos en pacientes con cáncer de recto con sospecha de metástasis en los ganglios linfáticos pélvicos laterales. Sin embargo, la indicación de este procedimiento sigue sin estar clara.OBJETIVO:Nuestro objetivo fue identificar los factores predictivos de la metástasis de los ganglios linfáticos laterales y las indicaciones para la disección de los ganglios linfáticos pélvicos laterales.DISEÑO:Estudio retrospectivo multiinstitucional.AJUSTES:Este estudio se realizó en tres hospitales universitarios.PACIENTES:Este estudio involucró a 105 pacientes con cáncer de recto medio/bajo localmente avanzado y sospecha clínica de metástasis en los ganglios linfáticos pélvicos laterales que se sometieron a una escisión mesorrectal total con disección de los ganglios linfáticos pélvicos laterales entre 2015 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Las indicaciones se establecieron utilizando los factores preoperatorios asociados con la metástasis de los ganglios linfáticos pélvicos laterales.RESULTADOS:Entre 105 pacientes, 36 (34,3%) tenían metástasis en los ganglios linfáticos pélvicos laterales confirmada patológicamente y 77 (73,3%) se sometieron a quimiorradiación preoperatoria. Los tumores ubicados dentro de los 5 cm desde el borde anal ( p = 0,02) y el tamaño inicial del ganglio ( p = 0,001) fueron predictores significativos de metástasis en los ganglios linfáticos pélvicos laterales. La sensibilidad fue del 100 % (36/36), con un punto de corte de 6 mm para el tamaño inicial del ganglio, seguido de 8 mm para el tamaño inicial del ganglio (94,4%, 34/36). Cuando se utilizó un tamaño de corte inicial del ganglio de 8 mm para una distancia entre el borde anal y el tumor >5 cm y 6 mm para una distancia entre el borde anal y el tumor ≤5 cm, la sensibilidad de la metástasis en los ganglios linfáticos pélvicos laterales fue del 100 %.LIMITACIONES:El diseño retrospectivo y el pequeño tamaño de la muestra.CONCLUSIONES:El tamaño inicial del ganglio y la altura del tumor fueron predictores significativos de metástasis en los ganglios linfáticos pélvicos laterales. Este estudio propuso que un tamaño de ganglio inicial de ≥8 mm con un tumor a >5 cm del margen anal y ≥6 mm con un tumor a ≤5 cm del margen anal son indicaciones óptimas para la disección de los ganglios linfáticos pélvicos laterales en el cáncer de recto. Consulte Video Resumen en http://links.lww.com/DCR/C101 . (Traducción-Dr. Yolanda Colorado ).

Long-term outcomes of endoscopic papillectomy for ampullary adenoma with high-grade dysplasia or adenocarcinoma: a propensity score-matched analysis.

BACKGROUND: Evidence of endoscopic papillectomy (EP) for ampullar adenoma with high-grade dysplasia (HGD) or adenocarcinoma is insufficient. Here we investigated the long-term outcomes of the advanced ampullary tumors treated by EP with careful surveillance comparing to subsequent surgery after EP. METHODS: Patients treated with EP for ampullary adenoma with HGD or adenocarcinoma from the multi-center retrospective Korean cohort of ampulla of Vater tumor were categorized into EP alone versus EP with subsequent surgery groups. The overall survival (OS) and recurrence-free survival (RFS) were analyzed for unmatched and matched cohorts using propensity score with nearest neighbor method. RESULTS: During a median 43.3 months of follow-up, 5-year OS was not significantly different between the EP alone and EP surgery groups (91.9% vs. 82.3%, P = 0.443 for unmatched cohort; 89.2% vs. 82.3%, P = 0.861 for matched cohort, respectively). Furthermore, 5-year RFS was not significantly different between the two groups (82.1% vs. 86.7%, P = 0.520 for unmatched cohort; 66.1% vs. 86.7%, P = 0.052 for matched cohort, respectively). However, the patients with positive both (lateral and deep) margins showed significantly poorer survival outcomes than those with negative margins within the EP alone group (P = 0.007). CONCLUSION: EP alone with careful surveillance showed comparable survival outcomes to those of EP with subsequent surgery for ampullar HGD or adenocarcinoma. Resection margin status could be a parameter to determine whether to perform subsequent radical surgery after EP.

National Survey Regarding the Management of Difficult Bile Duct Stones in South Korea.

Background/Aims: This study aimed to investigate the patterns of preferred endoscopic procedure types and techniques for managing difficult common bile duct (CBD) stones in South Korea. Methods: The Committee of Policy and Quality Management of Korean Pancreatobiliary Association (KPBA) conducted a survey containing 19 questions. Both paper and online surveys were carried out; with the paper survey being conducted during the 2019 Annual Congress of KPBA and the online survey being conducted through Google Forms from April 2020 to February 2021. Results: The response rate was approximately 41.3% (86/208). Sixty-two (73.0%) worked at tertiary hospitals or academic medical centers, and 60 (69.7%) had more than 5 years of endoscopic retrograde cholangiopancreatography experience. The preferred size criteria for large CBD stones were 15 mm (40.6%), 20 mm (31.3%), and 30 mm (4.6%). For managing of large CBD stones, endoscopic papillary large balloon dilation after endoscopic sphincterotomy was the most preferred technique (74.4%). When performing procedures in those with bleeding diathesis, 64 (74.4%) respondents favored endoscopic papillary balloon dilation (EPBD) alone or EPBD with small endoscopic sphincterotomy. Fifty-five respondents (63.9%) preferred the doubleguidewire technique when faced with difficult bile duct cannulation in patients with periampullary diverticulum. In surgically altered anatomies, cap-fitted forward viewing endoscopy (76.7%) and percutaneous transhepatic cholangioscopy (48.8%) were the preferred techniques for Billroth-II anastomosis and total gastrectomy with Roux-en-Y anastomosis, respectively. Conclusions: Most respondents showed unifying trends for the management of difficult CBD stones. The current practice patterns could be used as basic data for clinical quality improvements in the management of difficult CBD stones.

Increased incidence of indeterminate pancreatic cysts and changes of management pattern: Evidence from nationwide data.

BACKGROUND: Pancreatic cysts are common. However, most studies are based on data collected from individual centers. The present study aimed to evaluate the changes of management patterns for pancreatic cystic lesions (PCLs) by analyzing large epidemiologic data. METHODS: Between January 2007 and December 2018, information regarding pancreatic cystic lesions was acquired from the nationwide Health Insurance Review and Assessment Service database in Korea. RESULTS: The final number of patients with pancreatic cysts was 165 277 among the total claims for reimbursement of 855 983 associated with PCLs over 12 years. The total number of claims were increased from 19 453 in 2007 to 155 842 in 2018 and the prevalence increased from 0.04% to 0.23%. For 12 years, 2874 (1.7%) had pancreatic cancer and 8212 (5.0%) underwent surgery, and 36 had surgery for twice (total 8248 pancreatectomy). After ruling out claims from the first 3 years of washout period, the incidence increased from 9891 to 24 651 and the crude incidence rate of PCLs expanded from 19.96 per 100 000 to 47.77 per 100 000. Compared to specific neoplasm codes (D136 or D377), the use of pancreatic cyst code (K862) has been remarkably increased and the most common since 2010. The annual number of pancreatectomies increased from 518 to 861 between 2007 and 2012, and decreased to 596 until 2018. The percentage of pancreatic cancer in patients who received pancreatectomy increased from 5.6% in 2007 to 11.7% in 2018. CONCLUSIONS: The incidence of PCLs is rapidly increasing. Among PCLs, indeterminate cyst is increasing outstandingly. A trend of decreasing in the number of resections and increasing cancer rates among resected cysts may be attributed to the updated international guidelines.

Current Practice Patterns of Endoscopic Ultrasound-Guided Tissue Sampling for Pancreatic Solid Mass in Korea: Outcomes of a National Survey.

Background/Aims: Although endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) and fine needle biopsy (FNB) are widely used for tissue acquisition of pancreatic solid mass, the optimal strategy of this procedure has not been established yet. The aim of this nationwide study was to investigate the current practice patterns of EUS-FNA/FNB for pancreatic solid mass in Korea. Methods: The Policy-Quality Management of the Korean Pancreatobiliary Association (KPBA) developed a questionnaire containing 22 questions. An electronic survey consisting of the questionnaire was distributed by e-mail to members registered to the KPBA. Results: A total of 101 respondents completed the survey. Eighty respondents (79.2%) performed preoperative EUS-FNA/FNB for operable pancreatic solid mass. Acquire needles (60.4%) were used the most, followed by ProCore needles (47.5%). In terms of need size, most respondents (>80%) preferred 22-gauge needles regardless of the location of the mass. Negative suction with a 10-mL syringe (71.3%) as sampling technique was followed by stylet slow-pull (41.6%). More than three needle passes for EUS-FNA/FNB was performed by most respondents (>80%). The frequency of requiring repeated procedure was significantly higher in respondents with a low individual volume (<5 per month, p=0.001). Prophylactic antibiotics were routinely used in 39 respondents (38.6%); rapid on-site pathologic evaluation was used in 6.1%. Conclusions: According to this survey, practices of EUS-FNA/FNB for pancreatic solid mass varied substantially, some of which differed considerably from the recommendations present in existing guidelines. These results suggest that the development of evidence-based quality guidelines fitting Korean clinical practice is needed to establish the optimal strategy for this procedure.

Long-term outcomes after endoscopic versus surgical resection of T1 colorectal carcinoma.

BACKGROUND: The long-term outcomes of patients with T1 colorectal cancer (CRC) who undergo endoscopic and/or surgical treatment are not well understood. Invasive CRC confined to the colonic submucosa (T1 CRC) is challenging in terms of clinical decision-making. We compared the long-term outcomes of T1 CRC by treatment method. METHODS: We examined 370 patients with pathological T1 CRC treated between 2000 and 2015 at Seoul St. Mary's Hospital. In total, 93 patients underwent endoscopic resection (ER) only, 82 underwent additional surgery after ER, and 175 underwent surgical resection only. Patients who did not meet the curative criteria were defined as "high-risk." High-risk patients were classified into three groups according to the treatment modalities: ER only (Group A: 35 patients), additional surgery after ER (Group B: 72 patients), and surgical resection only (Group C: 133 patients). The recurrence-free and overall survival (OS) rates, and factors associated with recurrence and mortality, were analyzed. Factors associated with lymph node metastasis (LNM) were subjected to multivariate analysis. RESULTS: Of the 370 patients, 7 experienced recurrence and 7 died. All recurrences occurred in the high-risk group and two deaths were in the low-risk group. In high-risk groups, there was no significant group difference in recurrence-free survival (P = 0.511) or OS (P =0.657). Poor histology (P =0.042) was associated with recurrence, and vascular invasion (P =0.044) with mortality. LNMs were observed in 30 of 277 patients who underwent surgery either initially or secondarily. Lymphatic invasion was significantly associated with the incidence of LNM (P < 0.001). CONCLUSIONS: ER prior to surgery did not affect the prognosis of high-risk T1 CRC patients, and did not worsen the clinical outcomes of patients who required additional surgery. Lymphatic invasion was the most important predictor of LNM.