Predictors of Choledocholithiasis in Cholecystectomy Patients and Their Cutoff Values and Prediction Model in Korea in Comparison with the 2019 ASGE Guidelines.

Background/Aims: : In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) established clinical predictors for choledocholithiasis. Our study was designed to evaluate these predictors within the Korean clinical context, establish cutoff values, and develop a predictive model. Methods: : This retrospective study analyzed patients who underwent laparoscopic cholecystectomy. The relationships between choledocholithiasis and predictors including age, blood tests, and imaging findings were assessed through univariate and multivariate logistic regression analyses. We established Korean cutoff values for these predictors and developed a scoring system for choledocholithiasis using a multivariate logistic regression. The performance of this scoring system was then compared with that of the 2019 ASGE guidelines through a receiver operating characteristic curve. Results: : We established Korean cutoff values for age (>70 years), alanine aminotransferase (>26.5 U/L), aspartate aminotransferase (>28.5 U/L), gamma-glutamyl transferase (GGT; >82.5 U/L), alkaline phosphatase (ALP; >77.5 U/L), and total bilirubin (>0.95 mg/dL). In the multivariate analysis, only age >70 years, GGT >77.5 U/L, ALP >77.5 U/L, and common bile duct dilatation remained significant. We then developed a new Korean risk stratification model from the multivariate analysis, with an area under the curve of 0.777 (95% confidence interval, 0.75 to 0.81). Our model was stratified into the low-risk, intermediate-risk, and high-risk groups with the scores being <1.0, 1.0-5.5, and >5.5, respectively. Conclusions: : Predictors of choledocholithiasis in cholecystectomy patients and their cutoff values in Korean should be adjusted and further studies are needed to develop appropriate guidelines.

Perioperative textbook outcomes of minimally invasive pancreatoduodenectomy: a multicenter retrospective cohort analysis in a Korean minimally invasive pancreatic surgery registry.

BACKGROUND: The aim of this study is to investigate the perioperative composite textbook outcomes of pancreatic surgery after minimally invasive pancreatoduodenectomy (MIPD). MATERIALS AND METHODS: The cohort study was conducted across 10 institutions and included 1552 patients who underwent MIPD registered with the Korean Study Group on Minimally Invasive Pancreatic Surgery between May 2007 and April 2020. We analyzed perioperative textbook outcomes of pancreatic surgery after MIPD. Subgroup analyses were performed to assess outcomes based on the hospital volume of MIPD. RESULTS: Among all patients, 21.8% underwent robotic pancreatoduodenectomy. High-volume centers (performing >20 MIPD/year) performed 88.1% of the procedures. The incidence of clinically relevant postoperative pancreatic fistula was 11.5%. Severe complications (Clavien-Dindo grade ≥IIIa) occurred in 15.1% of the cases. The 90-day mortality rate was 0.8%. The mean hospital stay was 13.7 days. Textbook outcomes of pancreatic surgery success were achieved in 60.4% of patients, with higher rates observed in high-volume centers than in low-volume centers (62.2% vs. 44.7%, P<0.001). High-volume centers exhibited significantly lower conversion rates (5.4% vs. 12.5%, P=0.001), lower 90-day mortality (0.5% vs. 2.7%, P=0.001), and lower 90-day readmission rates (4.5% vs. 9.6%, P=0.006) than those low-volume centers. CONCLUSION: MIPD could be performed safely with permissible perioperative outcomes, including textbook outcomes of pancreatic surgery, particularly in experienced centers. The findings of this study provided valuable insights for guiding surgical treatment decisions in periampullary disease.

Single-incision versus conventional multiport laparoscopic cholecystectomy in acute cholecystitis according to disease severity: single center retrospective study in Korea.

Purpose: The safety of single-incision laparoscopic cholecystectomy (SILC) for acute cholecystitis (AC) has not yet been confirmed. Methods: This single-center retrospective study included patients who underwent laparoscopic cholecystectomy (LC) for AC between April 2010 and December 2020. Propensity scores were used to match patients who underwent SILC with those who underwent conventional multiport LC (CMLC) in the entire cohort and in the two subgroups. Results: A total of 1,876 patients underwent LC for AC, and 427 (22.8%) underwent SILC. In the propensity score-matched analysis of the entire cohort (404 patients in each group), the length of hospital stay (2.9 days vs. 3.5 days, p = 0.029) was shorter in the SILC group than in the CMLC group. No significant differences were observed in other surgical outcomes. In grade I AC (336 patients in each group), the SILC group showed poorer surgical outcomes than the CMLC group, regarding operation time (57.6 minutes vs. 52.4 minutes, p = 0.001) and estimated blood loss (22.9 mL vs. 13.1 mL, p = 0.006). In grade II/III AC (58 patients in each group), there were no significant differences in surgical outcomes between the two groups. Postoperative pain outcomes were also not significantly different in the two groups, regardless of severity. Conclusion: This study demonstrated that SILC had similar surgical and pain outcomes to CMLC in patients with AC; however, subgroup analysis showed that SILC was associated with poor surgical outcomes than CMLC in grade I AC. Therefore, SILC should be carefully performed in patients with AC by experienced hepatobiliary surgeons.

Acute cholecystitis in old adults: the impact of advanced age on the clinical characteristics of the disease and on the surgical outcomes of laparoscopic cholecystectomy.

BACKGROUND: Impact of advanced age on disease characteristics of acute cholecystitis (AC), and surgical outcomes after laparoscopic cholecystectomy (LC) has not been established. METHODS: This single-center retrospective study included patients who underwent LC for AC between April 2010 and December 2020. We analyzed the disease characteristics and surgical outcomes according to age: Group 1 (age < 60 years), Group 2 (60 ≤ age < 80 years), and Group 3 (age ≥ 80 years). Risk factors for complications were assessed using logistic regression analysis. RESULTS: Of the 1,876 patients (809 [43.1%] women), 723 were in Group 1, 867 in Group 2, and 286 in Group 3. With increasing age, the severity of AC and combined common bile duct stones increased. Group 3 demonstrated significantly worse surgical outcomes when compared to Group 1 and 2 for overall (4.0 vs. 9.1 vs. 18.9%, p < 0.001) and serious complications (1.2 vs. 4.2 vs. 8.0%, p < 0.001), length of hospital stay (2.78 vs. 3.72 vs. 5.87 days, p < 0.001), and open conversion (0.1 vs. 1.0 vs. 2.1%, p = 0.007). Incidental gallbladder cancer was also the most common in Group 3 (0.3 vs. 1.5 vs. 3.1%, p = 0.001). In the multivariate analysis, body mass index < 18.5, moderate/severe AC, and albumin < 2.5 g/dL were significant risk factors for serious complications in Group 3. CONCLUSION: Advanced age was associated with severe AC, worse surgical outcomes, and a higher rate of incidental gallbladder cancer following LC. Therefore, in patients over 80 years of age with AC, especially those with poor nutritional status and high severity grading, urgent surgery should be avoided, and surgery should be performed after sufficient supportive care to restore nutritional status before LC.

Robotic single-site cholecystectomy is better in reducing postoperative pain than single-incision and conventional multiport laparoscopic cholecystectomy.

BACKGROUND: To compare the short-term outcomes of robotic single-site cholecystectomy (RSSC) with single-incision laparoscopic cholecystectomy (SILC) and conventional multiport laparoscopic cholecystectomy (CMLC), focusing on postoperative pain outcomes. METHODS: This single-center retrospective study included consecutive patients with benign gallbladder disease who underwent cholecystectomy by a single surgeon between June 2019 and December 2021. Exclusion criteria were acute cholecystitis (AC) and other combined surgeries. One-to-one propensity score matching was performed between the RSSC and SILC or CMLC. RESULTS: Of the 157 patients included, 39 (24.8%) underwent RSSC, 32 (20.4%) underwent SILC, and 86 (54.8%) underwent CMLC. In a propensity score-matched cohort between RSSC and SILC (32 patients in each group), the number of additional analgesic injections was significantly lower in the RSSC group than in the SILC group (0.7 vs. 1.3, p = 0.002), and postoperative pain scores were also significantly lower at 6 h (2.8 vs. 3.6, p = 0.004) and 24 h (2.6 vs. 3.3, p = 0.021) after surgery in the RSSC group than in the SILC group. In a propensity score-matched cohort between RSSC and CMLC (23 patients in each group), the number of additional analgesic injections was significantly lower in the RSSC group than in the CMLC group (0.7 vs. 1.3, p = 0.005), and postoperative pain scores were also significantly lower at 6 h after surgery (2.9 vs. 3.7, p = 0.025) in the RSSC group than in the CMLC group. CONCLUSION: This study demonstrated that RSSC is helpful in reducing postoperative pain and the use of additional analgesics compared to both SILC and CMLC.

Conversion to pancreaticogastrostomy for salvage of disrupted pancreaticojejunostomy following pancreaticoduodenectomy.

Purpose: This study aimed to report on a pancreas-preserving strategy consisting of the conversion to pancreaticogastrostomy (PG) for the salvage of disrupted pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD). Methods: This single-center retrospective study included 188 patients who underwent PD between March 2000 and June 2021. Conversion to PG was performed by placing the pancreatic stump with an internal stent in the stomach through the posterior gastrostomy and suturing the wound in 2 layers through the anterior gastrostomy. Results: A total of 181 patients underwent PJ, while 7 underwent PG. Of all patients, 6 had International Study Group on Pancreatic Fistula grade C postoperative pancreatic fistulae (POPF; 3.3%) and 23 had grade B POPF (12.7%). Two of the 6 grade C patients underwent completion pancreatectomy and died of liver failure after common hepatic artery embolization due to pseudoaneurysm. Conversion to PG was performed in 4, all of whom survived and experienced no long-term pancreatic fistulae, remnant pancreatic atrophy, or newly developed diabetes after a median follow-up period of 11.5 months. Conclusion: Conversion to PG for the salvage of disrupted PJ following PD is safe and effective in selected patients that can lower mortality rates while maintaining pancreatic function.

The role of postoperative neutrophil-to-lymphocyte ratio as a predictor of postoperative major complications following total gastrectomy for gastric cancer.

Purpose: This study was performed to investigate the role of the perioperative neutrophil-to-lymphocyte ratio (NLR) as an early predictor of major postoperative complications after total gastrectomy for gastric cancer. Methods: This single-center, retrospective study reviewed consecutive patients with gastric cancer who underwent total gastrectomy at a single institution from March 2009 to March 2021. The postoperative complications were graded according to the Clavien-Dindo classification. We analyzed the patient demographics and surgical outcomes according to the grade of postoperative complications in the major complications group (≥grade III) and the no major complications group (

Optimal indication of single-incision laparoscopic cholecystectomy using Konyang Standard Method in benign gallbladder diseases.

Purpose: The optimal indications for single-incision laparoscopic cholecystectomy (SILC) have not yet been established. Methods: This single-center retrospective study included consecutive patients who underwent SILC between April 2010 and June 2020. Difficult surgery (DS) (conversion to multiport or open cholecystectomy, adjacent organ injury, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL) and poor postoperative outcome (PPO) (postoperative hospital stay ≥ 7 days or Clavien-Dindo grade ≥ II postoperative complications) were defined to comprehensively evaluate surgical difficulty and postoperative outcomes, respectively. Results: Of 1,405 patients (mean age, 51.2 years; 802 female [57.1%]), 427 (grade I, n = 358; grade II/III, n = 69) underwent SILC for acute cholecystitis (AC), 34 (2.4%) needed conversion to multiport (n = 33) or open cholecystectomy (n = 1), 7 (0.5%) had adjacent organ injury during surgery, and 49 (3.5%) developed postoperative complications. Of the patients, 89 and 52 had DS and PPO, respectively. In the multivariate analysis, grade I AC, grade II/III AC, and body mass index of ≥30 kg/m2 were significant predictors of DS. Age of ≥70 years and DS were significant predictors of PPO. In a subgroup analysis of patients with AC, DS (9.5% vs. 27.5%, p < 0.001) and PPO (5.0% vs. 15.9%, p = 0.001) were more frequent in patients with grade II/III AC than in those with grade I AC. Conclusion: SILC is not recommended in patients with grade II/III AC and should be carefully performed by experienced and well-trained surgeons.

Optimal drain management following complicated laparoscopic cholecystectomy for acute cholecystitis: a propensity-matched comparative study.

Purpose: This study was performed to investigate the effect of drain placement on complicated laparoscopic cholecystectomy (cLC) for acute cholecystitis (AC). Methods: This single-center retrospective study reviewed patients with AC who underwent cLC between January 2010 and December 2020. cLC was defined as open conversion, subtotal cholecystectomy, adjacent organ injury during surgery, operation time of ≥90 minutes, or estimated blood loss of ≥100 mL. One-to-one propensity score matching was performed to compare the surgical outcomes between patients with and without drain on cLC. Results: A total of 216 patients (mean age, 65.8 years; 75 female patients [34.7%]) underwent cLC, and 126 (58.3%) underwent intraoperative abdominal drainage. In the propensity score-matched cohort (61 patients in each group), early drain removal (≤postoperative day 3) was performed in 42 patients (68.9%). The overall rate of surgical site infection (SSI) was 10.7%. Late drain removal demonstrated significantly worse surgical outcomes than no drain placement and early drain removal for overall complications (13.1% vs. 21.4% vs. 47.4%, p = 0.006), postoperative hospital stay (3.8 days vs. 4.4 days vs. 12.7 days, p < 0.001), and SSI (4.9% vs. 11.9% vs. 31.6%, p = 0.006). In the multivariate analysis, late drain removal was the most significant risk factor for organ space SSI. Conclusion: This study demonstrated that drain placement is not routinely recommended, even after cLC for AC. When placing a drain, early drain removal is recommended because late drain removal is associated with a higher risk of organ space SSI.

Comparison of oncologic outcomes between open and laparoscopic distal pancreatectomy for pancreatic ductal adenocarcinoma using data from the KOTUS-BP national database: overcoming selection bias and the necessity of definite indications.

BACKGROUND: Despite the lack of high-level evidence, laparoscopic distal pancreatectomy (LDP) is frequently performed in patients with pancreatic ductal adenocarcinoma (PDAC) owing to advancements in surgical techniques. The aim of this study was to investigate the long-term oncologic outcomes of LDP in patients with PDAC via propensity score matching (PSM) analysis using data from a large-scale national database. METHODS: A total of 1202 patients who were treated for PDAC via distal pancreatectomy across 16 hospitals were included in the Korean Tumor Registry System-Biliary Pancreas. The 5-year overall (5YOSR) and disease-free (5YDFSR) survival rates were compared between LDP and open DP (ODP). RESULTS: ODP and LDP were performed in 846 and 356 patients, respectively. The ODP group included more aggressive surgeries with higher pathologic stage, R0 resection rate, and number of retrieved lymph nodes. After PSM, the 5YOSRs for ODP and LDP were 37.3% and 41.4% (p = 0.150), while the 5YDFSRs were 23.4% and 27.2% (p = 0.332), respectively. Prognostic factors for 5YOSR included R status, T stage, N stage, differentiation, and lymphovascular invasion. CONCLUSION: LDP was performed in a selected group of patients with PDAC. Within this group, long-term oncologic outcomes were comparable to those observed following ODP.

Comparison of one-stage laparoscopic common bile duct exploration plus cholecystectomy and two-stage endoscopic sphincterotomy plus laparoscopic cholecystectomy for concomitant gallbladder and common bile duct stones in patients over 80 years old.

Purpose: This study was performed to compare the safety and efficacy of one-stage laparoscopic common bile duct exploration (LCBDE) plus laparoscopic cholecystectomy (LC) with those of endoscopic sphincterotomy (EST) plus LC for concomitant gallbladder (GB) and common bile duct (CBD) stones in elderly patients. Methods: This single-center retrospective study reviewed the medical records of patients aged >80 years who were diagnosed with concomitant GB and CBD stones between January 2010 and December 2020. Results: Of the 137 patients included in this study, 46 underwent one-stage LCBDE + LC and 91 underwent two-stage EST + LC. The frequency of previous gastrectomy (23.9% vs. 5.5%, p = 0.002) and multiple stones (76.1% vs. 49.5%, p = 0.003) was higher in the LCBDE + LC group than in the EST + LC group. Further, patients in LCBDE + LC group had larger CBD stones (11.9 mm vs. 6.0 mm, p < 0.001). There were no significant differences in the clearance (91.3% vs. 95.6%, p = 0.311) and recurrence (4.3% vs. 8.8%, p = 0.345) rates between the groups. The incidence of posttreatment overall complications (17.4% vs. 22.0%, p = 0.530) and total hospital stay (12.7 days vs. 11.7 days, p = 0.339) were similar in the two groups. Conclusion: One-stage LCBDE + LC is a safe and effective treatment for concomitant GB and CBD stones, even in elderly patients, and may be considered as the first treatment option in elderly patients with previous gastrectomy, multiple large (≥ 15 mm) CBD stones, or inability to cooperate with endoscopic procedures.

Is Laparoscopic Common Bile Duct Exploration Safe for the Oldest Old Patients?

BACKGROUND: This study aimed to identify the risk factors for postoperative complications of laparoscopic common bile duct exploration (LCBDE) in the oldest old patients aged 80 years or older. METHODS: From March 2001 to October 2020, 363 patients underwent LCBDE with stone removal. Based on their ages, they were divided into two groups, those younger than 80 years (n=240) and those 80 years old or older (n=123). We compared patient demographics, disease characteristics, surgical outcomes, and postoperative complications based on these groups. RESULTS: The older group had a higher proportion of patients with a Charlson Comorbidity Index ≥5 (p<0.001) and the American Society of Anesthesiologist (ASA) physical status classification ≥3 (p<0.001). In addition, the older group had longer postoperative hospital stays than younger group (7.5±6.1 days vs. 6.2±3.9 days, p=0.013). However, there were no significant differences between groups according to the postoperative complications (13.8% vs. 20.3%, p=0.130). According to multivariate analysis, the risk factors for postoperative complications were Charlson Comorbidity Index ≥5 (odds ratio [OR]=2.307; 95% confidence interval [CI], 1.162-4.579; p=0.017) and operative time >2 hours (OR=3.204; 95% CI, 1.802-5.695; p<0.001). CONCLUSION: In patients with Charlson Comorbidity Index <5 and operation time <2 hours, LCDBE with stone removal can be considered safe for the oldest old patients.

Optimal timing of percutaneous transhepatic gallbladder drainage and subsequent laparoscopic cholecystectomy according to the severity of acute cholecystitis.

Backgrounds/Aims: The optimal timing of percutaneous transhepatic gallbladder drainage (PTGBD) and subsequent laparoscopic cholecystectomy (LC) according to the severity of acute cholecystitis (AC) has not been established yet. Methods: This single-center, retrospective study included 695 patients with grade I or II AC without common bile duct stones who underwent PTGBD and subsequent LC between January 2010 and December 2019. Difficult surgery (DS) (open conversion, subtotal cholecystectomy, adjacent organ injury, transfusion, operation time ≥ 90 minutes, or estimated blood loss ≥ 100 mL) and poor postoperative outcome (PPO) (postoperative hospital stay ≥ 7 days or Clavien-Dindo grade ≥ II postoperative complication) were defined to comprehensively evaluate intraoperative and postoperative outcomes, respectively. Results: Of 695 patients, 403 had grade I AC and 292 had grade II AC. According to the receiver operating characteristic curve and multivariate logistic regression analyses, an interval from symptom onset to PTGBD of > 3.5 days and an interval from PTGBD to LC of > 7.5 days were significant predictors of DS and PPO, respectively, in grade I AC. In grade II AC, the timing of PTGBD and subsequent LC were not statistically related to DS or PPO. Conclusions: In grade I AC, performing PTGBD within 3.5 days after symptom onset can reduce surgical difficulties and subsequently performing LC within 7.5 days after PTGBD can improve postoperative outcomes. In grade II AC, early PTGBD cannot improve the surgical difficulty. In addition, the timing of subsequent LC is not correlated with surgical difficulties or postoperative outcomes.

Optimal treatment for concomitant gallbladder stones with common bile duct stones and predictors for recurrence of common bile duct stones.

BACKGROUND: The optimal treatment for concomitant gallbladder (GB) stones with common bile duct (CBD) stones and predictors for recurrence of CBD stones are not established. METHODS: This single-center, retrospective study reviewed 466 patients diagnosed with a first event of concomitant GB stones with CBD stones from January 2010 to December 2018. RESULTS: 92 patients underwent single-stage laparoscopic CBD exploration (LCBDE) and laparoscopic cholecystectomy (LC) (group1), 108 underwent LCBDE + LC after endoscopic stone extraction (ESE) failure (group2), and 266 underwent ESE + LC (group3). Clearance (95.7 vs. 99.1 vs. 97.0%, p = 0.324) and recurrence rates (5.4 vs. 13.0 vs. 7.9%, p = 0.138) did not differ between groups. Group1 had fewer procedures (p < 0.001), lower post-treatment complication rates (7.6 vs. 18.5 vs. 13.9%, p = 0.082), and shorter hospital stay after the first procedure (5.7 vs 13.0 vs 9.8 days, p < 0.001). 40 patients (8.6%) had recurrence of CBD stones at mean follow-up of 17.1 months, of which 29 (72.5%) occurred within 24 months. In multivariate analysis, a CBD diameter > 8 mm, combined type-1 periampullary diverticulum, and age > 70 years were significant predictors of recurrence. CONCLUSION: Single-stage LCBDE + LC is a safe and effective treatment for concomitant GB stones with CBD stones compared to ESE + LC. LCBDE should be considered in patients with a high risk of ESE failure. Careful follow-up is recommended for patients at high risk of recurrence of CBD stones, especially within 24 months after surgical or endoscopic treatment.

Completion of single-incision laparoscopic cholecystectomy using the modified Konyang standard method.

BACKGROUND: To date, a surgical method for single-incision laparoscopic cholecystectomy (SILC) has not been standardized. Therefore, this study aimed to introduce a standardized surgical method for SILC, in addition to reporting our experience over 10 years. METHODS: Patients who underwent SILC at a single institution between April 2010 and December 2019 were included in this study. We analyzed the patient demographics and surgical outcomes according to the surgical method used: phase 1 (Konyang standard method, KSM) comprising initial 3-channel SILC, phase 2 (modified KSM, mKSM) comprising 4-channel SILC with a snake retractor, and phase 3 (commercial mKSM, C-mKSM) using a commercial 4-channel port. RESULTS: Of 1372 patients (mean age, 51.3 years; 781 [56.9%] women), 418 (30.5%) surgeries were performed for acute cholecystitis (AC), 33 (2.4%) were converted to multiport or open cholecystectomy, and 49 (3.6%) developed postoperative complications. The mean operation time (OT) and length of postoperative hospital stay (LOS) were 51.9 min and 2.6 days, respectively. Overall, 325 patients underwent SILC with the KSM, 660 with the mKSM, and 387 with the C-mKSM. In the C-mKSM group, the number of patients with AC was the lowest (26.8% vs. 38.2% vs. 20.4%, p < 0.001) and the OT (51.7 min vs. 55.4 min vs. 46.1 min, p < 0.001), estimated blood loss (24.5 mL vs. 15.5 mL vs. 6.1 mL, p < 0.001), and LOS (2.8 days vs. 2.5 days vs. 2.3 days, p = 0.001) were significantly improved. The surgical outcomes were better in the non-AC group than in the AC group. CONCLUSION: Based on our 10 year experience, C-mKSM is a safe and feasible method of SILC in selected patients, although there were lower percentage of patients with AC compared to other groups.

Elective Laparoscopic Cholecystectomy Is Better than Conservative Treatment in Elderly Patients with Acute Cholecystitis After Percutaneous Transhepatic Gallbladder Drainage.

BACKGROUND: It is unclear whether cholecystectomy is beneficial after percutaneous transhepatic gallbladder drainage (PTGBD) in elderly patients with acute cholecystitis (AC). METHODS: This single-center, retrospective study included 202 patients aged >80 years with AC without common bile duct (CBD) stones who underwent PTGBD between January 2010 and December 2019. RESULTS: One hundred and forty-two patients underwent elective laparoscopic cholecystectomy (ELC), and 60 underwent conservative treatment, specifically PTGBD removal (PTGBD-R) in 36 patients and PTGBD maintained (PTGBD-M) in 24 patients. The postoperative major complication (POMC) rate in the ELC group was 8.5%. The cumulative incidence for recurrence of biliary events (BE) in the PTGBD-R group was 22.2%. The cumulative incidence for PTGBD-related complication in the PTGBD-M group was 70.8%. Mortality after initial treatment was not significantly different between the three groups (2.8% vs. 2.8% vs. 8.3%, p=0.381). In multivariate analysis, a Charlson age comorbidity index ≥6 and body mass index ≤19 were significant risk factors for POMC after ELC, and a closed cystic duct was a significant risk factor for recurrent BE after PTGBD-R. CONCLUSION: ELC is recommended in AC after PTGBD for selected patients aged >80 years without CBD stones due to the high recurrence rate of BE after PTGBD-R and the difficulty associated with PTGBD-M.

A comparative study of postoperative outcomes between minimally invasive living donor hepatectomy and open living donor hepatectomy: The Korean organ transplantation registry.

BACKGROUND: This study evaluated the safety and effectiveness of minimally invasive living donor hepatectomy in comparison with the open procedure, using Korean Organ Transplantation Registry data. METHODS: We reviewed the prospectively collected data of all 1,694 living liver donors (1,071 men, 623 women) who underwent donor hepatectomy between April 2014 and December 2017. The donors were grouped on the basis of procedure type to the minimally invasive procedure group (n = 304) or to the open procedure group (n = 1,390) and analyzed the relationships between clinical data and complications. RESULTS: No donors died after the procedure. The overall complication rates after operation in the minimally invasive procedure group and the open procedure group were 6.2% and 3.5%, respectively. Biliary complications were the most frequent events in both groups (minimally invasive procedure group, 2.4%; open procedure group, 1.6%). The majority of complications occurred within 7 days after surgery in both groups. The duration of hospitalization was shorter in the minimally invasive procedure group than in the open procedure group (9.04 ± 3.78 days versus 10.29 ± 4.01 days; P < .05). CONCLUSION: Based on its similar outcomes in our study, minimally invasive donor hepatectomy cannot be an alternative option compared with the open procedure method. To overcome this, we need to ensure better surgical safety, such as lower complication rate and shorter duration of hospitalization.

Efficacy of sentinel lymph node biopsy with radioisotope alone and the prediction of sentinel node status using PET-CT in breast cancer.

Purpose: Sentinel lymph node biopsy (SLNB) using both a radioactive isotope (RI) and blue dye is considered highly effective; however, there were limitations with the use of both agents in some hospitals, and blue dye has been shown to have some adverse effects. Additionally, preoperative prediction of sentinel lymph node (SLN) status using the maximum standardized uptake value (SUVmax) on positron emission tomography-computed tomography (PET-CT) can help avoid unnecessary axillary dissection or SLNB. Thus, we evaluated the efficacy and oncologic safety of SLNB using an RI alone in terms of long-term outcomes and determined the association between SLN metastasis and SUVmax of the primary tumor. Methods: This retrospective study was conducted at Konyang University Hospital between March 2011 and May 2018. Overall, 142 patients with breast cancer who underwent SLNB using an RI alone were enrolled. Data on identification and false-negative rates were collected. The SUVmax of primary tumors on PET-CT were analyzed for their association with SLN metastasis. Results: The identification and false-negative rates were 98.6% and 0%, respectively. There was no axillary local recurrence in patients with negative SLN findings. The correlation between the SUVmax of the primary tumor and SLN status was significant (r=0.249, P=0.005); the cutoff value for negative SLN metastasis was <2.15. Conclusion: The single agent method using an RI is not inferior to other methods and serves as a feasible option for SLNB. And the number of excised SLNs could be minimized when the SUVmax of primary tumor is extremely low.

The chronological change of indications and outcomes for single-incision laparoscopic cholecystectomy: a Korean multicenter study.

BACKGROUND: Although single-incision laparoscopic cholecystectomy (SILC) is a common procedure, the change in its surgical indications and perioperative outcomes has not been analyzed. METHODS: We collected the clinical data of patients who underwent pure SILC in 9 centers between 2009 and 2018 and compared the perioperative outcomes. RESULTS: In this period, 6497 patients underwent SILC. Of these, 2583 were for gallbladder (GB) stone (39.7%), 774 were for GB polyp (11.9%), 994 were for chronic cholecystitis (15.3%), and 1492 were for acute cholecystitis (AC) (23%). 162 patients (2.5%) experienced complication, including 20 patients (0.2%) suffering from biliary leakage. The number of patients who underwent SILC for AC increased over time (p = 0.028), leading to an accumulation of experience (27.4 vs 23.7%, p = 0.002). The patients in late period were more likely to have undergone a previous laparotomy (29.5 vs 20.2%, p = 0.006), and to have a shorter operation time (47.0 vs 58.8 min, p < 0.001). Male (odds ratio [OR]; 1.673, 95% confidence interval [CI] 1.090-2.569, p = 0.019) and moderate or severe acute cholecystitis (OR; 2.602, 95% CI 1.677-4.037, p < 0.001) were independent predictive factors for gallbladder perforation during surgery, and open conversion (OR; 5.793, 95% CI 3.130-10.721, p < 0.001) and pathologically proven acute cholecystitis or empyema (OR; 4.107, 95% CI 2.461-6.854, p < 0.001) were related with intraoperative gallbladder perforation CONCLUSION: SILC has expanded indication in late period. In this period, the patients had shorter operation times and a similar rate of severe complications, despite there being more numerous patients with AC.

New-onset diabetes after adult liver transplantation in the Korean Organ Transplantation Registry (KOTRY) study.

BACKGROUND: New-onset diabetes after transplantation (NODAT) is a serious complication following liver transplantation (LT). The present study aimed to investigate the incidence of and risk factors for NODAT using the Korean Organ Transplantation Registry (KOTRY) database. METHODS: Patients with history of pediatric transplantation (age ≤18 years), re-transplantation, multi-organ transplantation, or pre-existing diabetes mellitus were excluded. A total of 1,919 non-diabetic adult patients who underwent a primary LT between May 2014 and December 2017 were included. Risk factors were identified using Cox regression analysis. RESULTS: NODAT occurred in 19.7% (n=377) of adult liver transplant recipients. Multivariate analysis showed steroid use, increased age, and high body mass index (BMI) in recipients, and implantation of a left-side liver graft was closely associated with NODAT in adult LT. In living donor liver transplant (LDLT) patients (n=1,473), open donor hepatectomy in the living donors, steroid use, small for size liver graft (graft to recipient weight ratio ≤0.8), increased age, and high BMI in the recipient were predictive factors for NODAT. The use of antimetabolite and basiliximab induction reduced the incidence of NODAT in adult LT and in adult LDLT. CONCLUSIONS: Basiliximab induction, early steroid withdrawal, and antimetabolite therapy may prevent NODAT after adult LT. High BMI or advanced age in liver recipients, open donor hepatectomy in living donors, and small size liver graft can predict the occurrence of NODAT after adult LT or LDLT.