Laparoscopic left hepatectomy in patients with intrahepatic duct stones and recurrent pyogenic cholangitis

Sunjong Han,Insang Song,Kwangsik Chun 한국간담췌외과학회 2012 한국간담췌외과학회지 Vol.16 No.3

Backgrounds/Aims: Recently many studies have been reported the early results of a hepatectomy for various intrahepatic lesions. Also various types of laparoscopic hepatectomies are being performed in many centers. Some reports about the safety of laparoscopic parenchymal dissection of the liver have been published. In this study, we reported our experiences of laparoscopic left hepatectomies in patients with an intrahepatic duct (IHD) stone with recurrent pyogenic cholangitis (RPC), and investigated whether the total laparoscopic parenchymal dissection is as safe as open surgery. Methods: From April 2008 to December 2010, 25 patients had been admitted for left IHD stones with RPC. Preoperatively, the type of surgery was decided with the intention of treating each patient. Initially 10 patients underwent a laparoscopy-assisted left hepatectomy and the next 15 patients underwent total laparoscopic left hepatectomy as our experience grew. Demographics, peri- and postoperative results were collected and analyzed comparatively. Results: The mean age, gender ratio, preoperative American Society of Anesthesiologists (ASA) score, accompanied acute cholangitis and biliary pancreatitis, and the number of preoperative percutaneous transhepatic biliary drainage (PTBD) inserted cases were not different between the two groups who had undergone laparoscopy-assisted and totally laparoscopic left hepatectomy. The operation time, intraoperative transfusions and postoperative complications also showed no difference between them. The postoperative hospital stay did not show a significant difference statistically. Conclusions: In this study, we concluded that a laparoscopic left hepatectomy can be adapted to the patients with a left IHD stone with RPC. Also laparoscopic parenchymal dissection is safe and equivalent to an open procedure.

Clinical significance of revised microscopic positive resection margin status in ductal adenocarcinoma of pancreatic head

유영훈,Dong Wook Choi,Jin Seok Heo,In Woong Han,Seong Ho Choi,Kee-Taek Jang,Sunjong Han,Sang Hyup Han 대한외과학회 2019 Annals of Surgical Treatment and Research(ASRT) Vol.96 No.1

Purpose: Recent studies have suggested microscopic positive resection margin should be revised according to the presence of tumor cells within 1mm of the margin surface in resected specimens of pancreatic cancer. However, the clinical meaning of this revised margin status for R1 resection margin was not fully clarified. Methods: From July 2012 to December 2014, the medical records of 194 consecutive patients who underwent pancreaticoduodenectomy for ductal adenocarcinoma of the pancreatic head were analyzed retrospectively. They were divided into 3 groups on margin status; revised microscopic negative margin (rR0) – tumor exists more than 1 mm from surgical margin, revised microscopic positive margin (rR1) – tumor present within less than 1 mm from surgical margin, classic microscopic positive margin (cR1) – tumor is exposed to surgical margin. Results: There were 76 rR0 (39.2%), 100 rR1 (51.5%), and 18 cR1 (9.3%). There was significant difference in disease-free survival rates between cR1 vs. rR1 (8.4 months vs. 24.0 months, P = 0.013). Margin status correlated with local recurrence rate (17.1% in rR0, 26.0% in rR1, and 44.4% in cR1, P = 0.048). There is significant difference in recurrence at tumor bed (11.8% in rR0 vs. 23.0 in rR1, P = 0.050). Of rR1, adjuvant treatment was found to be an independent risk factor for local recurrence (hazard ratio, 0.297; 95% confidence interval, 0.127–0.693, P = 0.005). Conclusion: Revised R1 resection margin (rR1) affects recurrence at the tumor bed. Adjuvant treatment significantly reduced local recurrence of rR1. Accordingly, adjuvant chemoradiation for rR1 group should be taken into account.

Long-term clinical outcomes after endovascular management of ruptured pseudoaneurysm in patients undergoing pancreaticoduodenectomy

유영훈,Seong Ho Choi,Dong Wook Choi,Jin Seok Heo,In Woong Han,Sunjong Han,Sung Wook Shin,Kwang Bo Park,Hong Suk Park,Sung Ki Cho,Sang Hyup Han 대한외과학회 2019 Annals of Surgical Treatment and Research(ASRT) Vol.96 No.5

Purpose: Recent studies have analyzed the short-term clinical outcomes of ndovascular management. However, the long-term outcomes are unknown. This study aimed to investigate clinical outcomes after endovascular management for ruptured pseudoaneurysm in patients after pancreaticoduodenectomy (PD). Methods: The medical records of 2,783 patients who underwent PD were retrospectively reviewed at a single center. Of 62 patients who received intervention after pseudonaeurysm rupture, 57 patients (91.9%) experienced eventual success of hemostasis. The patients were composed as follows: (embolization only [EMB], n = 30), (stent-graft placement only [STENT], n = 19) and (both embolization and stent-graft placement simultaneously or different times [EMB + STENT], n = 8). Longterm complications were defined as events that occur more than 30 days after the last successful endovascular treatment. Results: Among 57 patients, short-term stent-graft related complications developed in 3 patients (5.3%) and clinical complication developed in 18 patients (31.5%). Nine (15.8%) had long-term stent-graft related complications, which involved partial thrombosis in 5 cases, occlusion in 3 cases and migration in 1 case. Except for 1 death, the remaining 8 cases did not experience clinical complications. The stent graft primary patency rate was 88.9% after 1 month, 84.2% after 1 year, and 63.2% after 2 years. Of 57 patients, 30 days mortality occurred in 8 patients (14.0%). Conclusion: After recovery from initial complication, most of patients did not experience fatal clinical complication during long-term follow-up. Endovascular management is an effective and safe management of pseudoaneurysm rupture after PD in terms of long-term safety.

Effect of Sarcopenic Obesity on Postoperative Pancreatic Fistula after Pancreaticoduodenectomy in Patients with Pancreas Head Cancer

( Youngju Ryu ),( In Woong Han ),( Dong Wook Choi ),( Seong Ho Choi ),( Jin Seok Heo ),( Yung Hun You ),( Sunjong Han ),( Dae Joon Park ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Preoperative nutritional status may reflect outcomes after pancreatoduodenectomy(PD) in patients with pancreas head cancer(PHC). Recently, several studies have reported that preoperative sarcopenic obesity(SO), which is a high visceral adipose tissue-to-skeletal muscle ratio, could worsen postoperative complications in patients with various periampullary diseases. The purpose of this study is to evaluate the effect of preoperative SO on POPF following PD. Methods: Preoperative SO was assessed in 548 patients undergoing PD for PDAC at Samsung Medical Center between 2007 and 2016. The visceral adipose tissue-to-skeletal muscle ratio was calculated from cross-sectional visceral fat and muscle area on preoperative CT imaging at the third lumbar vertebra level and normalized for height by an automatic calculation program. Overall survival(OS) and the rate of POPF with ISGPF grade B or C among postoperative complications were extracted from prospectively maintained databases. Results: Preoperative SO was present in 202(36.9%) of the patients. After multivariate analysis, the presence of SO was the only independent risk factor for developing POPF(HR:2.561, 95%CI:1.179-5.564, P=0.018). Age over 63 years(HR:1.465, 95%CI:1.154-1.859, P=0.002), poorly differentiated carcinoma(HR:2.175, 95%CI:1.709-2.769, P<0.001), nodal metastasis(HR:2.127, 95%CI:1.604-2.819, P<0.001), portal vein invasion(HR:1.488, 95%CI:1.143-1.936, P=0.003), and absence of adjuvant treatment(HR:2.454, 95%CI:1.933-3.116, P<0.001) were identified as independent risk factors for OS, but preoperative SO was not significantly associated with decreased OS. Conclusions: Preoperative SO is the only predictive factor for CR-POPF after PD in patients with PHC. Preoperative SO measures may stratify patients into risk categories for developing POPF. For evaluation of the effect of SO on survival after PD, more observational studies will be needed.

Comparison analysis of left-side versus right-side resection in bismuth type III hilar cholangiocarcinoma

YouJin Lee,DongWook Choi,Sunjong Han,In Woong Han,Jin Seok Heo,Seong Ho Choi 한국간담췌외과학회 2018 Annals of hepato-biliary-pancreatic surgery Vol.22 No.4

Backgrounds/Aims: Several studies report worse prognosis after left-side compared to right-side liver resection in patients with perihilar cholangiocarcinoma. In this study, we compared outcomes of left-side and right-side resections for Bismuth type III hilar cholangiocarcinoma and analyzed factors affecting survival. Methods: From May 1995 to December 2012, 179 patients underwent surgery at Samsung Medical Center for type III hilar cholangiocarcinoma. Among these patients, 138 received hepatectomies for adenocarcinoma with curative intent: 103 had right-side resections (IIIa group) and 35 had left-side resections (IIIb group). Perioperative demographics, morbidity, mortality, and overall and disease-free survival rates were compared between the groups. Results: BMI was higher in the IIIa group (24±2.6 kg/m2 versus 22.7±2.8 kg/m2; p=0.012). Preoperative portal vein embolization was done in 23.3% of patients in the IIIa group and none in the IIIb group. R0 rate was 82.5% in the IIIa group and 85.7% in the IIIb group (p=0.796) and 3a complications by Clavien-Dindo classification were significantly different between groups (10.7% for IIIa versus 23.3% for IIIb; p=0.002). The 5-year overall survival rate was 33% in the IIIa group and 35% in the IIIb group (p=0.983). The 5-year disease-free survival rate was 28% in the IIIa group and 29% in the IIIb group (p=0.706). Advanced T-stages 3 and 4 and LN metastasis were independent prognostic factors for survival and recurrence by multivariate analysis. Conclusions: No significant differences were seen in outcomes by lesion side in patients receiving curative surgery for Bismuth type III hilar cholangiocarcinoma.

Validation of Original Fistula Risk Score and Alternative Fistula Risk Score in Postoperative Pancreatic Fistula

( Youngju Ryu ),( In Woong Han ),( Dong Wook Choi ),( Seong Ho Choi ),( Jin Seok Heo ),( Yung Hun You ),( Sunjong Han ),( Dae Joon Park ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Postoperative pancreatic fistula(POPF) is the most serious surgical complication after pancreaticoduodenectomy(PD). In 2013, Fistula Risk Score(FRS) was developed to assess the risk of clinically relevant postoperative pancreatic fistula(CR-POPF). In 2017, the alternative Fistula Risk Score(a-FRS) was proposed. In this study, we validate the o-FRS and a-FRS to assess statistical significances following PD. Methods: From 2007 to 2016, a total of 1771 patients underwent PD for primary periampullary cancers. POPF was defined and classified according to the International Study Group for Pancreatic Fistula(ISGPF), 2016. All data were reviewed retrospectively. Results: Pathologic diagnosis other than ductal adenocarcinoma(P<0.001), pancreas duct diameter(P<0.001) and BMI(P<0.001) were independent risk factors of CR-POPF by multivariate analysis. However, pancreas texture(P=0.534) and intraoperative blood loss volume(P=0.827) were not associated with CR-POPF. According to o-FRS, the CR-POPF incidence increased as the o-FRS score increased(P<0.001). Within o-FRS groups, incidence of CR-POPF was 2.3%, 8%, 14.2% and 17.5% in the no risk group, low risk group, moderate risk group and high risk group(P<0.001). By comparison, according to a-FRS, CR-POPF occurred in 6.7%, 13.4% and 21.6% of patients in the low risk group, intermediate risk group and high risk group(P<0.001). However, discrimination with area under curve (AUC) was only 0.629(95%CI:0.593-0.665) in o-FRS and 0.622(95%CI:0.585-0.660) in a-FRS. Conclusions: o-FRS and a-FRS could reflect the incidence of CR-POPF to some extent, but some risk factors were considered to have no or low statistical significance. These measures are also of low value as predictive models, and further research is needed to modify and revise the FRS.

Prognostic factors of non-functioning pancreatic neuroendocrine tumor revisited

Jiyoung Bu,Sangmin Youn,Wooil Kwon,Kee Taek Jang,Sanghyup Han,Sunjong Han,Younghun You,Jin Seok Heo,Seong Ho Choi,Dong Wook Choi 한국간담췌외과학회 2018 Annals of hepato-biliary-pancreatic surgery Vol.22 No.1

Backgrounds/Aims: Various factors have been reported as prognostic factors of non-functional pancreatic neuroendocrine tumors (NF-pNETs). There remains some controversy as to the factors which might actually serve to successfully prognosticate future manifestation and diagnosis of NF-pNETs. As well, consensus regarding management strategy has never been achieved. The aim of this study is to further investigate potential prognostic factors using a large single-center cohort to help determine the management strategy of NF-pNETs. Methods: During the time period 1995 through 2013, 166 patients with NF-pNETs who underwent surgery in Samsung Medical Center were entered in a prospective database, and those factors thought to represent predictors of prognosis were tested in uni- and multivariate models. Results: The median follow-up time was 46.5 months; there was a maximum follow-up period of 217 months. The five-year overall survival and disease-free survival rates were 88.5% and 77.0%, respectively. The 2010 WHO classification was found to be the only prognostic factor which affects overall survival and disease-free survival in multivariate analysis. Also, pathologic tumor size and preoperative image tumor size correlated strongly with the WHO grades (p<0.001, and p<0.001). Conclusions: Our study demonstrates that 2010 WHO classification represents a valuable prognostic factor of NF-pNETs and tumor size on preoperative image correlated with WHO grade. In view of the foregoing, the preoperative image size is thought to represent a reasonable reference with regard to determination and development of treatment strategy of NF-pNETs.

Laparoscopic Liver Resection Versus Open Liver Resection for Intrahepatic Cholangiocarcinoma: 3-Year Outcomes of a Cohort Study

So Hyun Kang,YoungRok Choi,Woohyung Lee,Ho-Seong Han,Yoo-Seok Yoon,Jai Young Cho,Kilhwan Kim,In-Gun Hyun,Sunjong HAN 대한외과학회 2018 대한외과학회 학술대회 초록집 Vol.2018 No.11

Comparison of Long-Term Outcomes between Laparoscopic and Open Liver Resection in Combined Hepatocellular Carcinoma and Intrahepatic Cholangiocarcinoma

So Hyun Kang,YoungRok Choi,Woohyung Lee,Ho-Seong Han,Yoo-Seok Yoon,Jai Young Cho,Kilhwan Kim,In-Gun Hyun,Sunjong HAN 대한외과학회 2018 대한외과학회 학술대회 초록집 Vol.2018 No.11

Long-term outcome of intraoperative radiofrequency ablation for hepatocellular carcinoma and its efficacy as a primary treatment

Jongduk Kwon,Kwang-Sik Chun,In-Sang Song,Seok-Hwan Kim,Sunjong Han 한국간담췌외과학회 2020 Annals of hepato-biliary-pancreatic surgery Vol.24 No.1

Backgrounds/Aims: We conducted this study to identify long-term outcomes following intraoperative radiofrequency ablation (IO-RFA) for hepatocellular carcinoma (HCC) and to reveal independent prognostic factors for survival. Methods: From December 1998 to February 2019, 183 patients underwent IO-RFA for HCC. These patients were divided into two groups according to whether RFA was done as a first-line (1-RFA group, n=106) or secondary-line (2-RFA group, n=77) treatment. Furthermore, we compared the survival outcomes between the 1-RFA and 2-RFA groups. Results: There were no significant differences in type of surgical approaches between the two groups (p=0.079). The number of tumors and largest tumor size were not significantly different between the two groups. Overall recurrence rate was 53%, and the 2-RFA group showed a higher recurrence rate (46.2% in 1-RFA group versus 62.3% in 2-RFA group; p=0.031). The 5-year overall survival (OS) and disease-free survival (DFS) rates of all the patients were 75.2% and 27.9%, respectively. The OS and DFS rates were significantly higher in the 1-RFA group. The 5-year OS rates were 83.6% and 64.9% in the 1-RFA and 2-RFA groups, respectively (p=0.010), whereas the 5-year DFS rates were 32.2% and 21.6%, respectively (p=0.012). On multivariate analysis, HBV-LC, 2-RFA, recurrence, and postoperative complications were independent predictive factors for survival. Conclusions: Therapeutic outcomes of IO-RFA were comparable to those of surgical resection. Additionally, 1-RFA might be an alternative treatment for naïve HCC in patients with uncompensated liver function and severe comorbidities.