Browse the corpus

oviden, Mansfield, MA, USA) for traction and dissection, and a suction-hook bovies (Endopath Probe Plus II Pistol Grip handle, Ethicon, Bridgewater, NJ, USA) for irrigation and coagulation. We ligated cystic duct and artery using 5-, 10-mm hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC, USA) (Fig. 1) Method Patient was placed in reverse Trendelenburg position (15°-30°) and rotated right up. The surgeon stood on the left side of the patient. The first assistant who played the role of scopist stood below the surgeon and the second assistant who was to help with insertion and angulation of instruments stood on the right of the patient. All instruments were inserted by right side of the telescope. Surgeon used right hand for traction, left hand for main surgery. (Fig. 2) Traction Cephalic traction on the fundus of the gallbladder by right hand (grasper) and lateral traction on the infundibulum of the gallbladder by left hand (dissector) is the best way for identification of the cystic duct. After identification of the cystic duct at its junction with the gallbladder, lateral traction of the gallbladder by right hand place the cystic duct perpendicular to the common bile duct (CBD) (Fig. 3).

INTRODUCTION Thyroid cancer is the most common cancer and breast cancer is the second-most common cancer in Korean women [1]. Many studies have evaluated the association between these cancers, which are both more common in women. Furthermore, the incidence of autoimmune thyroiditis, including Hashimoto's thyroiditis, is several fold higher in breast cancer patients than in control subjects [2,3,4, 5]. Hashimoto's thyroiditis was reported in 13.7% of breast cancer patients and in 2% of controls [3]. In another study, the odds ratio (OR) of autoimmune thyroiditis was 2.92 (95% confidence interval [CI], 2.13-4.01) in breast cancer patients, and the OR of the presence of antithyroid antibodies was 2.02 (95% CI, 1.63-2.50) [5]. In the same study, the risk of developing thyroid goiter was twofold higher in breast cancer patients than normal controls (OR, 2.26; 95% CI, 1.39-3.69) [5]. Epidemiologic studies have shown breast cancer patients have an elevated risk of developing thyroid cancer and vice versa [6,7,8,9]. The risk of thyroid cancer following breast cancer was increased by 31%-73% and that of breast cancer following thyroid cancer by 21%-89% [6,7,8]. Furthermore, the presence of breast cancer in thyroid cancer patients aged 40-50 years was found to be three times more likely than in age-matched controls [9]. In addition, a study that evaluated relations between the risk factors of breast cancer and thyroid cancer showed the incidence of thyroid cancer was 2.5 folds higher in women weighing over 60 kg [10].

in thyroid cancer patients aged 40-50 years was found to be three times more likely than in age-matched controls [9]. In addition, a study that evaluated relations between the risk factors of breast cancer and thyroid cancer showed the incidence of thyroid cancer was 2.5 folds higher in women weighing over 60 kg [10]. A relationship between thyroid cancer and breast cancer was first postulated over 30 years ago, and thus, we considered an investigation of the characteristics of thyroid cancers occurring in breast cancer patients would aid prognostic predictions and treatment options. Accordingly, we investigated the clinicopathologic characteristics of thyroid cancer in breast cancer patients and compared these characteristics with those of thyroid cancer patients without breast cancer with respect to prognosis and treatment methods. METHODS One hundred and one patients diagnosed with breast cancer and thyroid cancer between January 1993 and September 2012 (the BT group) were enrolled in this retrospective comparative study. The patients received a diagnosis of thyroid cancer between August 1998 and September 2012 and of breast cancer between January 1993 and July 2012. These patients underwent a breast cancer operation in our institute or another hospital, but all were followed at our institute. Thyroid cancer was diagnosed before, after, or at the same time as breast cancer. All thyroid cancer operations were performed at our institute.

ast cancer between January 1993 and July 2012. These patients underwent a breast cancer operation in our institute or another hospital, but all were followed at our institute. Thyroid cancer was diagnosed before, after, or at the same time as breast cancer. All thyroid cancer operations were performed at our institute. The control group (the oT group) was composed of 193 female patients that underwent a thyroid cancer operation between January 2008 and December 2008 at our institute. This timing was chosen because 2008 was the median time of thyroid operations in the BT group (from August 1998 to September 2012). Thyroid lobectomy and isthmectomy with ipsilateral central lymph node (LN) dissection were performed for unilateral thyroid tumors (<1 cm in maximum diameter) suggestive of malignancy by fine-needle aspiration cytology when there was no suspicion of a nodule in the contralateral lobe. We also performed total thyroidectomy with bilateral central LN dissection. Levels II-V were routinely dissected during lateral neck LN dissection in thyroid cancer patients.

The postoperative hospital stays were longer in the nutritional risk group (8.9 ± 4.2 days) than in the no risk group (7.8 ± 3.5 days) (P = 0.019). Results of analysis of the relationship between risk factors for postoperative complication and duration of hospital stays are detailed in Table 3. The relationship between malnutrition and each complication are shown in Table 4. Malnutrition was an independent risk factor for anastomotic leakage (P = 0.027) and wound infection (P = 0.01). DISCUSSION In this study, the overall morbidity rate was 27.0% and the mortality rate was 0.3% after elective surgery for colorectal cancer. This study supports the finding that measurements of nutritional risk can predict postoperative outcomes. NRS 2002 was a statistically significant predictor of morbidity. Similar to the present findings, a recent prospective study demonstrated that the NRS 2002 was successful in predicting postoperative complications in 186 patients undergoing elective surgery for colorectal cancer (OR, 2.43) [10]. The authors reported a nutritional risk prevalence of 39.2% in patients with NRS 2002, was higher to the data here.

maximum diameter) suggestive of malignancy by fine-needle aspiration cytology when there was no suspicion of a nodule in the contralateral lobe. We also performed total thyroidectomy with bilateral central LN dissection. Levels II-V were routinely dissected during lateral neck LN dissection in thyroid cancer patients. In patients with a tumor size of <1 cm, endoscopic thyroid surgery was performed using an axillary approach for patients that requested an endoscopic operation. Postoperative radioactive iodine (RAI) ablation was planned for patients with LN metastasis, distant metastasis, or TNM stage T3/T4, with consent. Follow-up studies comprised routine cervical ultrasonography (USG), a thyroid function test, CT, and positron emission tomography, if needed. At six months and one year postoperatively, cervical USG and a thyroid function test were performed, and subsequently, a semiannual thyroid function test and annual cervical USG were performed. Our Institutional Review Board approved this retrospective study before the patient list was retrieved from the hospital database. Medical records, pathology reports, operation records, and radiological findings suggestive of recurrence or disease-related mortality were retrospectively evaluated. Pearson chi-square test, Fisher exact test, and the independent t-test were used to evaluate differences between the BT and oT groups. In addition, Cox regression analysis and multivariate logistic regression analysis were performed. Statistical significance was accepted for P values of <0.05.

Our Institutional Review Board approved this retrospective study before the patient list was retrieved from the hospital database. Medical records, pathology reports, operation records, and radiological findings suggestive of recurrence or disease-related mortality were retrospectively evaluated. Pearson chi-square test, Fisher exact test, and the independent t-test were used to evaluate differences between the BT and oT groups. In addition, Cox regression analysis and multivariate logistic regression analysis were performed. Statistical significance was accepted for P values of <0.05. RESULTS Clinicopathologic results for the 294 study subjects and the 101 thyroid cancer patients with breast cancer The clinicopathologic characteristics of the 294 study subjects are summarized in Table 1. Mean patient age was 48.6 years and papillary thyroid cancer (PTC) was the most common. Mean tumor size was 1.27 ± 1.03 cm, and the mean number of malignant thyroid tumors per patient was 1.47 (range, 1-11). Total thyroidectomy was performed in 76.9% of patients, and lateral LN dissection in 6.8%. Conventional open thyroidectomy was performed in 268 cases (91.2%) and endoscopic thyroid surgery in 26 (8.8%). The mean antithyroid peroxidase antibody level was 8.21 units/mL (range, 0.02-78.73 units/mL), and the mean antithyroglobulin antibody level was 9.50 units/mL (range, 0.01-102.29 units/mL). Mean follow-up duration was 40.78 ± 22.09 months.

was performed in 268 cases (91.2%) and endoscopic thyroid surgery in 26 (8.8%). The mean antithyroid peroxidase antibody level was 8.21 units/mL (range, 0.02-78.73 units/mL), and the mean antithyroglobulin antibody level was 9.50 units/mL (range, 0.01-102.29 units/mL). Mean follow-up duration was 40.78 ± 22.09 months. In the BT group, mean age at thyroid cancer diagnosis was 51.4 years and mean age at breast cancer diagnosis was 48.7. Breast cancer was diagnosed before thyroid cancer in 83 patients (82.2%) and 14 patients (13.9%) were simultaneously diagnosed with thyroid and breast cancer. Mean time elapsed between the two operations was 35.53 ± 37.91 months (range, 0-207 months). In cases in which the primary disease was breast cancer, the interval between the two operations was 41.17 ± 38.41 months (range, 1-207 months), and in cases in which the primary disease was thyroid cancer, the interval between the two operations was 43.00 ± 26.92 months (range, 6-67 months). Breast conserving surgery was performed in 56/101 (55.4%) and modified radical mastectomy was performed in 45/101 (44.6%). Endoscopic thyroid surgery was performed in 13 cases (12.9%).

in which the primary disease was thyroid cancer, the interval between the two operations was 43.00 ± 26.92 months (range, 6-67 months). Breast conserving surgery was performed in 56/101 (55.4%) and modified radical mastectomy was performed in 45/101 (44.6%). Endoscopic thyroid surgery was performed in 13 cases (12.9%). Differences between the clinicopathologic characteristics of patients in the BT and oT groups Table 2 summarizes differences between the BT and oT groups. Mean tumor size was smaller in the BT group, and extrathyroidal extension was observed less often in the BT group. Mean age at thyroid cancer diagnosis was greater in the BT group. T stage was earlier and LN metastasis was less frequent in the BT group than in the oT group. The frequency of postoperative RAI ablation was analyzed in athyroid patients with follicular cell-derived cancer, and postoperative RAI ablation was performed significantly less often in the BT group (P < 0.001).

he BT group. T stage was earlier and LN metastasis was less frequent in the BT group than in the oT group. The frequency of postoperative RAI ablation was analyzed in athyroid patients with follicular cell-derived cancer, and postoperative RAI ablation was performed significantly less often in the BT group (P < 0.001). Evaluation of prognosis in the BT group and the oT group Of the 294 study subjects, local recurrence (cervical LN or contralateral lobe recurrence) occurred in 12 patients (4.1%), distant metastasis occurred in 1 (0.3%), and one patient died from anaplastic thyroid cancer. In the BT group, no local recurrence or distant metastasis of thyroid cancer was observed. To reduce the possibility of confounding the analysis, we excluded non-PTC patients, which reduced the cohort to 281 patients. Thyroid cancer recurrence or thyroid cancer-related mortality occurred only in the oT group (0.0% vs. 6.1%, P = 0.009) (Table 3). Chi-square analysis showed that the presence of breast cancer, age, extrathyroidal extension, T/N stage, and follow-up duration were significantly related to recurrence. However, Cox regression analysis failed to identify any variable (including BT/oT group) significantly related to recurrence (data were not shown).

). Chi-square analysis showed that the presence of breast cancer, age, extrathyroidal extension, T/N stage, and follow-up duration were significantly related to recurrence. However, Cox regression analysis failed to identify any variable (including BT/oT group) significantly related to recurrence (data were not shown). Factors affecting the performance of postoperative RAI ablation Of the 227 athyroid patients with follicular cell-derived cancer, we excluded 3 patients that underwent breast surgery more than 6 months after thyroid surgery. Therefore, we analyzed the performance of RAI ablation in 224 patients. 146 patients were treated by postoperative RAI ablation (Table 4). In the BT group, postoperative RAI ablation was performed less often than in the oT group. In univariate analyses, RAI ablation was associated with younger age and larger and more invasive tumors. Multifocality, bilaterality, T stage, N stage, and TNM Stage were associated with the adoption of postoperative RAI ablation. Multivariate analysis indicated that the presence of breast cancer and N stage were associated with the adoption of RAI ablation. The OR of LN metastasis following postoperative RAI ablation was 11.851, and the OR of breast cancer in patients treated by RAI ablation postoperatively was 0.235.

ostoperative RAI ablation. Multivariate analysis indicated that the presence of breast cancer and N stage were associated with the adoption of RAI ablation. The OR of LN metastasis following postoperative RAI ablation was 11.851, and the OR of breast cancer in patients treated by RAI ablation postoperatively was 0.235. DISCUSSION Many studies have been performed to evaluate the relationship between breast cancer and thyroid cancer. Estrogen probably influences the physiology and pathology of thyroid glands, and 17β-estradiol is a potent mitogen of benign and malignant thyroid tumor cells [11,12,13]. Sodium/iodide symporter (NIS), which is located on the basolateral membrane in normal thyroid and lactating mammary glands, mediates iodide uptake by the thyroid gland and lactating breasts. Furthermore, basal NIS gene expression is detected in approximately 80% of breast cancer specimens, although the fraction exhibiting functional iodide transport is relatively low [14]. Moreover, abundant TSH receptors are present in breast tissue [15,16], although the role of TSH in the regulation of NIS in breast cells remains controversial [3,17]. Radiation therapy has been considered to contribute to the development of breast and thyroid cancer. Based on an analysis of data obtained from the National Cancer Institute's Surveillance, Epidemiology and End Results database, Chen et al. [18] reported that women with a history of thyroid carcinoma, particularly premenopausal white women, have a greater than expected risk of developing breast carcinoma, and suggested that RAI therapy for thyroid cancer potently contributes to breast cancer development. Rubino et al. [19] suggested that high radiation doses increase the risk of second malignancies, including thyroid cancer, slightly after breast cancer treatment.

eater than expected risk of developing breast carcinoma, and suggested that RAI therapy for thyroid cancer potently contributes to breast cancer development. Rubino et al. [19] suggested that high radiation doses increase the risk of second malignancies, including thyroid cancer, slightly after breast cancer treatment. However, Huang et al. [20] concluded that women administered external beam radiation therapy for breast cancer, are not at increased risk of developing thyroid cancer. In fact, after a 10-year follow-up, the relative risk of radiation-associated thyroid cancer after initial external beam radiation therapy for breast cancer was 1.0 (95% CI, 0.7-1.5). In another study that evaluated the influence of external beam radiation therapy for breast cancer on thyroid cancer development, and the influence of RAI therapy for thyroid cancer on breast cancer development, no relationship was found between radiation dose and the risk of thyroid cancer after radiation therapy in breast cancer patients or vice-versa [21]. Therefore, although radiation therapy has been considered to contribute to the development of thyroid cancer or breast cancer after external beam radiation therapy or RAI therapy, no reliable data is available on the topic.

the risk of thyroid cancer after radiation therapy in breast cancer patients or vice-versa [21]. Therefore, although radiation therapy has been considered to contribute to the development of thyroid cancer or breast cancer after external beam radiation therapy or RAI therapy, no reliable data is available on the topic. The correlation between breast cancer and thyroid cancer may not indicate causality, because the increase in the observed incidence of thyroid cancer may be the result of increased medical surveillance for breast cancer [22]. However, Park et al. [23] reported that 518 patients with breast cancer showed a relatively high (2.5%) incidence of thyroid cancer. In another report, the same authors compared incidences of thyroid cancer in breast cancer and routine screening patients. Thyroid cancer was diagnosed in 1.9% of breast cancer patients (13/685) and in 0.6% of routine screening patients (29/4864), which represented a significant difference (P < 0.05). Thus, it was concluded that breast cancer patients might have some internal factors that influence thyroid cancer development [24].

atients. Thyroid cancer was diagnosed in 1.9% of breast cancer patients (13/685) and in 0.6% of routine screening patients (29/4864), which represented a significant difference (P < 0.05). Thus, it was concluded that breast cancer patients might have some internal factors that influence thyroid cancer development [24]. Few studies have been conducted on the characteristics of thyroid cancer in breast cancer patients. Park et al. [24] reported different features for thyroid cancer in patients with or without breast cancer. In particular, LN metastasis was more prevalent in thyroid cancer patients without (13/29, 44.8%) than in those with breast cancer (2/13, 15.4%). Shin et al. [25] performed a study on the characteristics of thyroid cancer with or without breast cancer; almost all breast cancer patients with thyroid cancer were diagnosed with PTC. The authors found that tumor size was significantly smaller in patients in thyroid cancer patients with breast cancer than in thyroid cancer patients. In our series, the BT group had a smaller mean tumor size and a lower prevalence of LN metastasis, which concurs with previously published data. In addition, extrathyroidal extension was less prevalent and T stage was less advanced in the BT group. Furthermore, all patients in the BT group were diagnosed with PTC. Although we could not conclude what is the exact cause of earlier status in BT group, we considered that it was because of medical surveillance.

ata. In addition, extrathyroidal extension was less prevalent and T stage was less advanced in the BT group. Furthermore, all patients in the BT group were diagnosed with PTC. Although we could not conclude what is the exact cause of earlier status in BT group, we considered that it was because of medical surveillance. To our knowledge, this is the first study to evaluate the prognosis of thyroid cancer in breast cancer patients. Initially, we expected that BT group would be found to show a more favorable prognosis than oT group due to an early disease status at diagnosis. The chi-square test showed that the BT group showed a more favorable prognosis than the oT group, as neither recurrence nor thyroid cancer-related mortality were observed in the BT group. The other factors related to prognosis were age, extrathyroidal extension, and T/N stage, which are known prognostic factors in thyroid cancer. However, Cox regression analysis failed to reveal any factors significantly related to recurrence in our series, which we believe was due to different follow-up durations and the small number of patients that experienced recurrence. If in fact, the prognosis of thyroid cancer in patients with breast cancer is more favorable than in patients without breast cancer, thyroid USG would be helpful to identify second malignancy in breast cancer patients, as the early detection of thyroid cancer improves prognosis.

of patients that experienced recurrence. If in fact, the prognosis of thyroid cancer in patients with breast cancer is more favorable than in patients without breast cancer, thyroid USG would be helpful to identify second malignancy in breast cancer patients, as the early detection of thyroid cancer improves prognosis. This is the first series to investigate treatment method in thyroid cancer patients with breast cancer. Interestingly, postoperative RAI ablation was performed less often in the BT group than in the oT group. Our comparison of group characteristics (Table 2) showed that in the BT group, 41.9% of patients received postoperative RAI ablation, whereas in the oT group 75.2% of patients were treated with RAI. Although we believed this difference might be related to an earlier T stage and less LN metastasis, this analysis revealed a factor not previously associated with the performance of postoperative RAI ablation. Finally, the presence of breast cancer and N stage were found to be positively associated with the performance of RAI ablation.

ved this difference might be related to an earlier T stage and less LN metastasis, this analysis revealed a factor not previously associated with the performance of postoperative RAI ablation. Finally, the presence of breast cancer and N stage were found to be positively associated with the performance of RAI ablation. The OR of the BT group versus the oT group for postoperative RAI ablation was 0.235. This reduced usage of RAI ablation in the BT group was ascribed to the following. First, breast cancer patients treated with chemotherapy or radiotherapy sometimes refuse to undergo RAI ablation. Second, thyroid cancer is treated as a less grave disease than breast cancer by doctors and patients. Third, doctors try to avoid patient suffering caused by additional treatment. Forth, chemotherapy and radiotherapy can both prevent the administration of RAI at optimal ablation times. Although RAI ablation was not found to be a significant prognostic factor for thyroid cancer in our series, this result is interesting.

Third, doctors try to avoid patient suffering caused by additional treatment. Forth, chemotherapy and radiotherapy can both prevent the administration of RAI at optimal ablation times. Although RAI ablation was not found to be a significant prognostic factor for thyroid cancer in our series, this result is interesting. We have found that endoscopic thyroid surgery can be used to treat patients with breast operation scars, who are commonly reluctant to have another scar in the neck area. Our patients were operated on using an axillary approach for endoscopic thyroid surgery; however, a bilateral axillo-breast approach can also be used. Both of these endoscopic surgeries are performed through the subcutaneous layer in the anterior chest and do not affect breast tissue. When the bilateral axillo-breast approach is used for endoscopic thyroid surgery, breast tissue can be used as a buffer during instrument manipulation. Furthermore, because endoscopic thyroid surgery can be performed in male patients using a bilateral axillo-breast approach, thyroid cancer patients who have undergone mastectomy can also be operated on using endoscopic thyroid surgery.

yroid surgery, breast tissue can be used as a buffer during instrument manipulation. Furthermore, because endoscopic thyroid surgery can be performed in male patients using a bilateral axillo-breast approach, thyroid cancer patients who have undergone mastectomy can also be operated on using endoscopic thyroid surgery. In conclusion, thyroid cancer patients with breast cancer had smaller tumors, and less frequently had extrathyroidal extension or LN metastasis. However, no significant prognostic difference, including recurrence and mortality, was observed between the BT and oT groups, which we presume was due to different follow-up durations and small numbers of recurred patients. Thus, we believe that a study with a longer follow-up duration and a large number of patients should be conducted to determine whether the prognoses of thyroid cancer patients with or without breast cancer differ. Furthermore, the study shows thyroid cancer patients with breast cancer underwent RAI ablation less often, and demonstrates that endoscopic thyroid surgery can be used to treat these patients. No potential conflict of interest relevant to this article was reported. This study was presented at 64th Annual Congress of the Korean Surgical Society on November 30th, 2012 in Coex, Seoul, Korea. Table 1 Clinicopathologic characteristics of 294 thyroid cancer patients Values are presented as mean (range) or number (%).

In conclusion, thyroid cancer patients with breast cancer had smaller tumors, and less frequently had extrathyroidal extension or LN metastasis. However, no significant prognostic difference, including recurrence and mortality, was observed between the BT and oT groups, which we presume was due to different follow-up durations and small numbers of recurred patients. Thus, we believe that a study with a longer follow-up duration and a large number of patients should be conducted to determine whether the prognoses of thyroid cancer patients with or without breast cancer differ. Furthermore, the study shows thyroid cancer patients with breast cancer underwent RAI ablation less often, and demonstrates that endoscopic thyroid surgery can be used to treat these patients. No potential conflict of interest relevant to this article was reported. This study was presented at 64th Annual Congress of the Korean Surgical Society on November 30th, 2012 in Coex, Seoul, Korea. Table 1 Clinicopathologic characteristics of 294 thyroid cancer patients Values are presented as mean (range) or number (%). ETE, extrathyroidal extension; LV, lymphovascular; PTC, papillary thyroid cancer; FV, follicular variant; FTC, follicular thyroid cancer; HCC, hürthle cell cancer; MTC, medullary thyroid cancer; ATC, anaplastic thyroid cancer; LND, lateral neck dissection. Table 2 Comparison between breast + thyroid (BT) and ordinary thyroid (oT) cancer patients Values are presented as mean ± standard deviation or number (%).

ETE, extrathyroidal extension; LV, lymphovascular; PTC, papillary thyroid cancer; FV, follicular variant; FTC, follicular thyroid cancer; HCC, hürthle cell cancer; MTC, medullary thyroid cancer; ATC, anaplastic thyroid cancer; LND, lateral neck dissection. Table 2 Comparison between breast + thyroid (BT) and ordinary thyroid (oT) cancer patients Values are presented as mean ± standard deviation or number (%). ETE, extrathyroidal extension; LV, lymphovascular; PTC, papillary thyroid cancer; FV, follicular variant; FTC, follicular thyroid cancer; HCC, hürthle cell cancer; MTC, medullary thyroid cancer; ATC, anaplastic thyroid cancer; Lb, lobectomy; CT, completion thyroidectomy; ST, subtotal thyroidectomy; TT, total thyroidectomy; LND, lateral neck dissection; FU, follow-up; RAI, radioactive iodine. a)Total thyroidectomy status patients having follicular cell derived cancer only, n = 74 in BT, n = 153 in oT. Table 3 Last follow-up status of thyroid cancer between breast + thyroid (BT) and ordinary thyroid (oT) cancer patients Values are presented as number (%). a)P = 0.009. Table 4 Last follow-up status of thyroid cancer between breast + thyroid (BT) and ordinary thyroid (oT) cancer patients Values are presented as mean ± standard deviation or number (%). RAI, radioactive iodine; OR, odds ratio; CI, confidence interval; BT, breast + thyroid cancer patients; oT, ordinary thyroid cancer patients; ETE, extrathyroidal extension; PTC, papillary thyroid cancer; FTC, follicular thyroid cancer; HCC, hürthle cell cancer; PTMC, papillary microcarcinoma; NA, not assessed. a)Univariate analysis. b)Multivariate analysis.

INTRODUCTION Laparoscopic surgery has been progressing with the development of surgical instruments and techniques. Since the introduction of laparoscopic surgery, multiport laparoscopic cholecystectomy has been recognized as the gold standard for treatment of benign gallbladder disease [1]. Many surgeons have attempted to reduce the size and the number of incisions [2], and several types of single incision procedures have been performed by general surgeons. Single incision laparoscopic surgery was described as early as in 1992 by Pelosi and Pelosi 3rd [3] who performed single-puncture laparoscopic appendectomy, and in 1997, by Navarra et al. [4] who performed laparoscopic cholecystectomy via two transumbilical trocars and three transabdominal gallbladder stay sutures. Furthermore, several reports have been demonstrated the advantages of single port laparoscopic surgery in different patients and clinical situations [5], therefore attracting many surgeons to single incision laparoscopic cholecystectomy (SILC).

o transumbilical trocars and three transabdominal gallbladder stay sutures. Furthermore, several reports have been demonstrated the advantages of single port laparoscopic surgery in different patients and clinical situations [5], therefore attracting many surgeons to single incision laparoscopic cholecystectomy (SILC). In the last few years, many centers in the world have reported successful attempts at performing SILC. Results have indicated reduced postoperative pain, early return to work, improve cosmetic outcomes [6], and in several studies, SILC reduced the risk of trocar-related complication such as incisional hernia or infection [7]. However, with the exception of the obvious cosmetic result, several benefits of SILC are not quite clear. Also, many reports have only recommended SILC for symptomatic cholelithiasis cases which excluded complicated gallbladder disease, because of operative difficulties and lack of adapted instruments. And, so far there is no standard method for the SILC. Therefore, in this study, we evaluated an adequacy and feasibility of SILC using Konyang Standard Method.

ded SILC for symptomatic cholelithiasis cases which excluded complicated gallbladder disease, because of operative difficulties and lack of adapted instruments. And, so far there is no standard method for the SILC. Therefore, in this study, we evaluated an adequacy and feasibility of SILC using Konyang Standard Method. METHODS We retrospectively reviewed our series of 307 SILC performed between April 2010 and August 2012. All patients underwent surgery after obtaining an informed consent. Initially we excluded the patients who with age greater than 70, cardiologic or pulmonologic problems, cystic duct abnormalities and complications of acute cholecystitis. After 50 cases, as our experience with technique improved, the inclusion criteria of SILC evolved to include all patients who would typically be considered for conventional laparoscopic cholecystectomy (CLC). Therefore, the only exclusion criterion was; suspicion of malignancy. We performed SILC by Konyang Standard Method using three-trocar single port (hand-made) and long articulated instruments. Surgical technique The standardized procedure is called "Konyang Standard Method" which is composed of traction, dissection, isolation, ligation, and dissection from gall bladder (GB) bed.

METHODS We retrospectively reviewed our series of 307 SILC performed between April 2010 and August 2012. All patients underwent surgery after obtaining an informed consent. Initially we excluded the patients who with age greater than 70, cardiologic or pulmonologic problems, cystic duct abnormalities and complications of acute cholecystitis. After 50 cases, as our experience with technique improved, the inclusion criteria of SILC evolved to include all patients who would typically be considered for conventional laparoscopic cholecystectomy (CLC). Therefore, the only exclusion criterion was; suspicion of malignancy. We performed SILC by Konyang Standard Method using three-trocar single port (hand-made) and long articulated instruments. Surgical technique The standardized procedure is called "Konyang Standard Method" which is composed of traction, dissection, isolation, ligation, and dissection from gall bladder (GB) bed. Instruments & port Hand-made port was constructed from a 10-mm size ALEXIS wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) and a size-7 sterile glove in which three or two 5-mm ports and one 10-mm port (Laport, Sejong Medical, Paju, Korea) were prepared on the tip of fingers to create a working channel for the laparoscopic instruments. The wound retractor was introduced through the transumbilical incision. The surgical glove was fixed to the outer ring of the wound retractor, then the CO2 pipe was connected to 10-mm port, and then pneumoperitoneum was made. We used a flexible telescope (Olympus, Tokyo, Japan), a long articulated Endo-Roticulator (Coviden, Mansfield, MA, USA) for traction and dissection, and a suction-hook bovies (Endopath Probe Plus II Pistol Grip handle, Ethicon, Bridgewater, NJ, USA) for irrigation and coagulation. We ligated cystic duct and artery using 5-, 10-mm hem-o-lok clips (Weck Closure Systems, Research Triangle Park, NC, USA) (Fig. 1)

the infundibulum of the gallbladder by left hand (dissector) is the best way for identification of the cystic duct. After identification of the cystic duct at its junction with the gallbladder, lateral traction of the gallbladder by right hand place the cystic duct perpendicular to the common bile duct (CBD) (Fig. 3). Dissection Anterior peritoneum is dissected by the left hand using a dissector. After that, the left hand performed the cephalic traction of the infundibulum and exposure posterior peritoneum of the cystic duct, and then the right hand grasper carried out the posterior peritoneal dissection. Cystic duct and artery are dissected free of the underlying fat and connective tissue (Fig. 4). Isolation and division After dissection of posterior peritoneum of the cystic duct, lateral traction of the gallbladder by the right hand was performed to place the cystic duct perpendicular to the CBD. Isolation of the cystic duct and artery using 30°-50° angulated dissectors on the left hand was performed. After isolation, the cystic duct and artery are clipped using 5-mm hem-o-lok on the left hand and the cystic duct and artery were divided using scissors on the left hand (Fig. 5). Dissection of GB bed After cystic artery and duct being divided, The GB was pulled in cephalic way using grasper held in the right hand and then GB was dissected from GB bed by suction-hook bovie on the left hand. After cholecystectomy, irrigation was done by the right hand using the suction-hook bovie (Fig. 6).

Isolation and division After dissection of posterior peritoneum of the cystic duct, lateral traction of the gallbladder by the right hand was performed to place the cystic duct perpendicular to the CBD. Isolation of the cystic duct and artery using 30°-50° angulated dissectors on the left hand was performed. After isolation, the cystic duct and artery are clipped using 5-mm hem-o-lok on the left hand and the cystic duct and artery were divided using scissors on the left hand (Fig. 5). Dissection of GB bed After cystic artery and duct being divided, The GB was pulled in cephalic way using grasper held in the right hand and then GB was dissected from GB bed by suction-hook bovie on the left hand. After cholecystectomy, irrigation was done by the right hand using the suction-hook bovie (Fig. 6). RESULTS Preoperative clinical characteristics The patient's preoperative clinical characteristics of undergoing SILC are shown in Table 1. Three hundred and seven patients were underwent SILC during this study period, consisting of 131 male patients and 176 female patients. Mean age was 51.6 ± 13.7 years old and mean body mass index (BMI) was 24.8 ± 3.6 kg/m2. Ninety-three patients had a history of previous abdominal surgery. Among the 93 patients, 6 (6.5%) underwent upper abdominal surgery. Pathologic data were available for all patients. Among the study group, 247 patients (80.5%) had chronic cholecystitis, 30 patients (9.8%) had acute cholecystitis, 24 patients (7.8%) had gallbladder polyp, 6 patients (2%) had GB empyema.

ominal surgery. Among the 93 patients, 6 (6.5%) underwent upper abdominal surgery. Pathologic data were available for all patients. Among the study group, 247 patients (80.5%) had chronic cholecystitis, 30 patients (9.8%) had acute cholecystitis, 24 patients (7.8%) had gallbladder polyp, 6 patients (2%) had GB empyema. Operative and postoperative outcomes Mean operating time was 53.1 ± 25.4 minutes, average length of hospital stay was 2.9 days, and average blood loss was 25 mL (Table 2). There were four conversions to three (3 cases) or four (1 case) port, because of cystic artery bleeding. There was no open conversion. In five cases (1.6%), Hemo-vac drain was placed in subhepatic space.

e was 53.1 ± 25.4 minutes, average length of hospital stay was 2.9 days, and average blood loss was 25 mL (Table 2). There were four conversions to three (3 cases) or four (1 case) port, because of cystic artery bleeding. There was no open conversion. In five cases (1.6%), Hemo-vac drain was placed in subhepatic space. Postoperative complications There were 5 patients with postoperative complications (Table 3). Wound infection in 2 cases, bile duct injury in 1 case, duodenal perforation in 1 case, incisional hernia in 1 case. However, there was no mortality. Among those who developed complications, one patient with severe GB inflammation had major bile duct injury (Strasberg's classification type E [8]) which was recognized at the second postoperative day and hepaticojejunostomy was performed. In addition, duodenal perforation occurred in one patient that had undergone subtotal gastrectomy previously. We suspect that the complication could have occurred from dissection of duodenum attached to the liver. The patient underwent reoperation due to peritonitis at the second operative day. Reoperation was performed with laparoscopic primary repair of duodenal perforation site. In addition, there were two cases of surgical wound infection. Among these patients, one patient developed incisional hernia after three months, which was corrected by herniorrhaphy.

due to peritonitis at the second operative day. Reoperation was performed with laparoscopic primary repair of duodenal perforation site. In addition, there were two cases of surgical wound infection. Among these patients, one patient developed incisional hernia after three months, which was corrected by herniorrhaphy. DISCUSSION Laparoscopic surgery is a well-established alternative to open surgery. Many surgeons consider laparoscopic cholecystectomy to be the standard treatment for patients with benign gallbladder disease [1]. The result of laparoscopic cholecystectomy compare favorably to those for open cholecystectomy, because of decreased pain, shorter hospital stay and better cosmetic outcomes [9]. In an attempt to achieve better outcomes, surgeons have been successful in decreasing the number of ports for laparoscopic cholecystectomy. Many technical developments have been proposed to achieve further improvement in postoperative outcomes by reducing the port size and number. In recent year, many centers have published reports about their experiences with SILC. The SILC can predict better cosmetic outcome, reduce postoperative pain due to less operative trauma and quick recovery [10]. However, the superiority of the SILC compared to the CLC is still controversial.

the port size and number. In recent year, many centers have published reports about their experiences with SILC. The SILC can predict better cosmetic outcome, reduce postoperative pain due to less operative trauma and quick recovery [10]. However, the superiority of the SILC compared to the CLC is still controversial. Han et al. [11] reported SILC to be feasible and safe in selected patients with uncomplicated gallstone disease or gallbladder polyp [11]. And because of relatively high conversion rate to CLC, increased complications (bile leak by GB rupture, wound infection, bile duct injury), and prolonged operating time, SILC was not recommended in patients who have a high BMI or acute cholecystitis with complication (GB empyema, GB perforation) [12]. Erbella and Bunch [13] thought that patients with a lower BMI, early disease or no previous abdominal surgery would be ideal candidates for SILC. And Han et al. [11] demonstrated that SILC could be excluded patients with acute cholecystitis, previous upper abdominal surgery, suspected presence of CBD or intrahepaticduct stones, and suspected gallbladder malignancy. Initially, the inclusion criteria of SILC limited eligible subjects to favorable surgical candidates who are young women with minimal signs of inflammation of GB. However, by accumulation of our experiences and standardization of the method, the inclusion criteria evolved to include all patients who would typically be considered for CLC. Therefore, it was shown that SILC can be carried out even in patients with serious medical problems or complications of acute cholecystitis such as GB empyema. However, GB perforation in CLC was 3.5% (noncomplicated) and GB perforation in SILC occurred in 9.6%. SILC may have inadvertently increased the chance of GB perforation [14]. So we propose that patients who suspected malignancy were performed by CLC. In many studies, SILC was contraindicated in patients had been underwent abdominal surgery. But we performed SILC in 93 patients who had been underwent abdominal surgery, including upper abdominal surgery in six patients. If operative field could be secured through umbilical incision, SILC could be applied to these select patients.

es, SILC was contraindicated in patients had been underwent abdominal surgery. But we performed SILC in 93 patients who had been underwent abdominal surgery, including upper abdominal surgery in six patients. If operative field could be secured through umbilical incision, SILC could be applied to these select patients. Many centers have introduced various procedures and instruments of SILC. Podolsky et al. [15] demonstrated single port access cholecystectomy, which was performed through a single umbilical incision within the umbilicus. Then three trocars and a rigid grasper were inserted through separate fascial sites within the same skin incision to perform the procedure. Ceci et al. [16] used a SILC port (Covidien) and traditional laparoscopic instrument in all cases, where as in our center we performed SILC by hand-made port that have several advantages. It is easy to use and can be simply accommodated to the abdominal wall. Many commercial ports have three or four working channel, whereas 4 or 5 channel port is made for liver traction with snake retractor or for ligation of thick cystic duct with 10-mm hem-o-lok clip. In addition, a wide axis of movements is possible, so the instruments can be used apart, easily crossed or rotated as required in any situation. However, the hand-made port requires a long time to be made during operation, and there is some inconvenience during insertion of instruments through umbilical incision. The using of articulated instruments and flexible telescope is important, which would avoid the interference with each other and help to perform more meticulous dissection of cystic duct and artery.

to be made during operation, and there is some inconvenience during insertion of instruments through umbilical incision. The using of articulated instruments and flexible telescope is important, which would avoid the interference with each other and help to perform more meticulous dissection of cystic duct and artery. If SILC become the gold standard of procedure, it is not only better cosmetics, shorter hospital stay, decreased pain, but also lower incidence in bile leakage, duct injury, incisional hernia and organ damage. However, there is no available study including accurate incidence of complications, especially of bile duct injury. Unfortunately, the widespread application of LC has led to concurrent rise in the incidence of bile duct injuries. Compared with open cholecystectomy, the incidence of biliary injuries in CLC has doubled from 0.2% to 0.4% and remained constant despite the advances in knowledge, technique and technology [17, 18, 19]. To prevent bile duct injury, Hugh [20] recommends identifying Rouviere's sulcus. Also, Hunter [21] and Troidl [22] have proposed several techniques to prevent the injury: a 30' telescope, avoidance of approach close to the common hepatic duct, dissection close to the gallbladder-cystic duct-common hepatic duct junction, and conversion to an open approach when uncertain. We had one case of bile duct injury which was occurred by failure to identify location of cystic duct due to severe inflammation of gallbladder. Recently, traction of liver by snake retractor which is inserted through a 4-channel port can prevent bile duct injury and provide proper exposure of cystic duct and artery. Therefore, it can minimize bile duct injury and be used for extensive indications of SILC.

cystic duct due to severe inflammation of gallbladder. Recently, traction of liver by snake retractor which is inserted through a 4-channel port can prevent bile duct injury and provide proper exposure of cystic duct and artery. Therefore, it can minimize bile duct injury and be used for extensive indications of SILC. Several published reports have focused on postoperative herniation in laparoscopic surgery. The consensus is that an incision located in midline with larger size has a higher risk of herniation, especially in the perinavel area [23]. In our experience, there was one incisional hernia after 3 months. The suture of incisional site could also be a concern, and sterile techniques should be strictly practiced to prevent wound infection. Sasaki et al. [24] demonstrated that SILC required additional ports for acute cholecystitis compare to chronic calculous cholecystitis. Also, Rao et al. [25] thought that SILS would be possible to start as a single port procedure and add extra needles or ports for retraction as needed. In our experience, of the 307 cases of SILC, four cases were converted to CLC. The main reason for conversion to CLC was cystic artery bleeding. Therefore, the cystic artery was first exposed, then separately clipped with a 5-mm hem-o-lok clip and divided with scissors. After that, cystic duct was dissected and divided. We thought that cystic artery bleeding could be prevented by this method. After accumulation of our experience, SILC is becoming the standard of care for most of our elective patients with benign gallbladder disease.

ith a 5-mm hem-o-lok clip and divided with scissors. After that, cystic duct was dissected and divided. We thought that cystic artery bleeding could be prevented by this method. After accumulation of our experience, SILC is becoming the standard of care for most of our elective patients with benign gallbladder disease. In conclusion, with the accumulation of experience and the development of instruments, SILC may be recognized as an alternative for CLC in almost all benign gallbladder diseases. We documented the feasibility and the safety of SILC. There seems to be no typical limitation and there are no potential increased complication and operating time with SILC compared to CLC. It is likely to gain popularity among patients and surgeons alike due to its benefits (less scar, minimal pain, lower incidence of port-related complications etc.). Therefore, almost all benign disease of gallbladder can be applied to the SILC using Konyang Standard Method. ACKNOWLEDGEMENTS This work was supported (in part) by Konyang University Myunggok Research Fund of 2010. No potential conflict of interest relevant to this article was reported. Fig. 1 Hand-made port and the long articulated Endo-roticulator. Fig. 2 Schematic diagram of single incision laparoscopic cholecystectomy. Fig. 3 "Cephalic traction" on the fundus and "lateral traction" on the infundibulum of the gallbladder. Fig. 4 Exposure of the Calot's Triangle. (A) Anterior dissection, (B) posterior dissection of peritoneum of cystic duct.

Fig. 1 Hand-made port and the long articulated Endo-roticulator. Fig. 2 Schematic diagram of single incision laparoscopic cholecystectomy. Fig. 3 "Cephalic traction" on the fundus and "lateral traction" on the infundibulum of the gallbladder. Fig. 4 Exposure of the Calot's Triangle. (A) Anterior dissection, (B) posterior dissection of peritoneum of cystic duct. Fig. 5 Isolation and division of cystic duct and artery. (A) Isolation of the cystic duct and artery using 30°-50° angulated dissector, (B) division of the cystic duct and artery. Fig. 6 Dissection of the gallbladder off the liver bed using suction-hook bovie divices. Table 1 Preoperative clinical characteristics of all patients undergoing SILC (n = 307) Values are presented as mean ± standard deviation (range) or number (%). SILC, single incision laparoscopic cholecystectomy; OP, operation; PTGBD, percutaneous transhepatic gallbladder drainage. Table 2 Operative and postoperative outcomes of all patients undergoing SILC (n = 307) Values are presented as number (%) or mean ± standard deviation (range). SILC, single incision laparoscopic cholecystectomy. Table 3 Postoperative complication of all patients undergoing SILC (n = 307) Values are presented as number (%). SILC, single incision laparoscopic cholecystectomy.

INTRODUCTION Since the first report of human liver transplantation in 1963, patient and graft survival rates have continuously improved. However, organ shortage has been considered as one of the major obstacles of this treatment option and has resulted in the need for donor pool expansion [1,2]. Living donor liver transplantation (LDLT), an alternative to classic deceased donor liver transplantation (DDLT), has become the mainstream treatment in East Asia because of the scarcity of cadaveric liver grafts. Furthermore, the proportion of aged donors in LDLT has gradually increased to meet this requirement [3,4]. In cadaveric liver transplantation, commonly known donor risk factors include old age, hypotension duration, use of vasoactive agents, and the degree of steatosis [5,6], among which age is generally considered as one of the most significant risk factors that negatively impact graft and patient survival [7,8,9]. The morphological and functional problems surrounding elderly donor livers have been well described. The representative morphological changes include a reduction in overall liver weight and size, as well as in the number of hepatocytes. It is known that these changes are attributable to an annually decreased hepatic blood flow of 0.3%-0.5%; by age 65 years, the liver volume reaches 40%-45% of its peak volume. However, no significant decrease in synthetic function occurs [6,10].

in overall liver weight and size, as well as in the number of hepatocytes. It is known that these changes are attributable to an annually decreased hepatic blood flow of 0.3%-0.5%; by age 65 years, the liver volume reaches 40%-45% of its peak volume. However, no significant decrease in synthetic function occurs [6,10]. Decreased clearance and increased sensitivity to certain drugs, especially warfarin, occurs because of decreasing microsomal oxidation rates with increasing age along with an increased incidence of cholelithiasis and related diseases [11]. Moreover, some studies have stated that the prevalence of hepatic artery thrombosis after liver transplantation increases with the increase in donor ages [7,8]. Several studies have analyzed the impact of donor age on liver transplantation but have shown contradictory results [5,9,12,13,14,15]. Moreover, LDLT has been the sole focus of only a few studies. The aims of this study were to retrospectively evaluate the differences in survival length of recipients of liver transplants from elderly living donors and review their complications and causes of death. METHODS We retrospectively reviewed the medical records of 604 LDLT recipients who underwent the procedure using a right liver graft between May 1999 and September 2012 in the Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea. This study was approved by the Institutional Review Board of The Catholic University of Korea.

dings, a recent prospective study demonstrated that the NRS 2002 was successful in predicting postoperative complications in 186 patients undergoing elective surgery for colorectal cancer (OR, 2.43) [10]. The authors reported a nutritional risk prevalence of 39.2% in patients with NRS 2002, was higher to the data here. Hendry et al. [11] reported that morbidity was related to ASA III-IV (P = 0.004), male sex (P = 0.023) and rectal surgery (P = 0.002) in which 1,035 patients underwent colorectal surgery. And, this study demonstrated that low BMI is not an independent risk factor. However, there are clear limitations to the use of BMI for screening nutritional status. Some patients weigh less than is usual for their height but are otherwise fit and healthy, and a normal BMI does not exclude the presence of malnutrition.

d the medical records of 604 LDLT recipients who underwent the procedure using a right liver graft between May 1999 and September 2012 in the Department of Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea. This study was approved by the Institutional Review Board of The Catholic University of Korea. We defined elderly donors as those ≥55 years of age [16,17,18]. The recipients were divided into two groups: group A included those recipients whose donors were elderly (≥55 years of age), and group B included those recipients whose donors were not elderly (<55 years of age). Preoperative evaluation Donor age, sex, and the degree of hepatosteatosis were compared between the groups. Recipient age, sex, body mass index (BMI), and transplantation indications were also compared between the two groups. We measured the recipients' Child-Turcotte-Pugh (CTP) and Model for End-stage Liver disease (MELD) scores in both groups to compare the preoperative disease severity. The patients of high-urgency were listed using United Network for Organ Sharing classification system, including status I and IIA. The length of hospital stay, use of a T-tube, in-hospital mortality, and overall mortality were compared between the two groups to evaluate surgical outcomes. Postoperative complications were compared according to arterial, biliary, and portal vein complications; hepatocellular carcinoma recurrence; and the development of infection. The median follow-up period was 58.5 months (6-143 months).

The length of hospital stay, use of a T-tube, in-hospital mortality, and overall mortality were compared between the two groups to evaluate surgical outcomes. Postoperative complications were compared according to arterial, biliary, and portal vein complications; hepatocellular carcinoma recurrence; and the development of infection. The median follow-up period was 58.5 months (6-143 months). Donor evaluation Although the general donor age recommendation in our institution is 16-55 years of age, the donors in this study were 16-67 years old. None of the donors had substantial medical conditions, and almost all were family members of the recipients. After the surgery was scheduled, all the candidates reconfirmed their voluntary participation with social workers and transplantation coordinators. Furthermore, all the donor candidates (with the exception of those participating in emergency operations) underwent psychiatric evaluations by psychiatrists at the beginning of the donor evaluation. The anatomical structure of the vasculature and biliary tree and liver consistency were evaluated using abdominal CT, ultrasonography, and magnetic resonance cholangiopancreatography (MRCP). In cases of suspicious fatty liver of more than a moderate degree on preoperative ultrasonography, a preoperative percutaneous liver biopsy was performed. A degree of hepatosteatosis up to 30% was considered optimal.

evaluated using abdominal CT, ultrasonography, and magnetic resonance cholangiopancreatography (MRCP). In cases of suspicious fatty liver of more than a moderate degree on preoperative ultrasonography, a preoperative percutaneous liver biopsy was performed. A degree of hepatosteatosis up to 30% was considered optimal. All the patients were evaluated by preoperative CT volumetry to calculate the remnant liver volume after an imaginary right hepatectomy. We considered an estimated remnant liver volume >35% to be optimal. If the remnant left liver volume was estimated to be <35%, we shifted the procedure of a hepatic parenchymal cutting line 1 or 2 cm on the right lateral side to a conventional right hepatectomy procedure to ensure greater remnant liver volume in the donor. Donor candidates whose estimated remnant liver volume was <30% were excluded from the operation. Technical aspects A frozen section liver biopsy to evaluate the degree of hepatosteatosis was performed in all of the donors during the operation. All of the hepatic grafts were perfused and preserved with iced Histidine-Triptophan-Ketoglutalate solution (Custodiol, JeniceParm, Seoul, Korea) through the portal vein and hepatic artery. The amount of perfusion solution used was at least three times that of the graft volume.

Technical aspects A frozen section liver biopsy to evaluate the degree of hepatosteatosis was performed in all of the donors during the operation. All of the hepatic grafts were perfused and preserved with iced Histidine-Triptophan-Ketoglutalate solution (Custodiol, JeniceParm, Seoul, Korea) through the portal vein and hepatic artery. The amount of perfusion solution used was at least three times that of the graft volume. Until December 2004, T-tube insertion into the bile duct had been a routine procedure; however, since then, duct-to-duct biliary reconstruction without a stent became the standard technique, except in a few cases of expected stricture or leakage at the biliary anastomosis site such as multiple preoperative transarterial chemoembolization (attempted >10 times) for hepatocellular carcinoma treatment and retransplantation or previous Roux-en-Y hepaticodochojejunostomy.

t a stent became the standard technique, except in a few cases of expected stricture or leakage at the biliary anastomosis site such as multiple preoperative transarterial chemoembolization (attempted >10 times) for hepatocellular carcinoma treatment and retransplantation or previous Roux-en-Y hepaticodochojejunostomy. Postoperative care of the recipient All of the recipients were managed using a standardized postoperative treatment protocol. Doppler ultrasonography was routinely performed to evaluate vascular structure patency and confirm bile duct dilatation on the first, third, and fifth postoperative days. On the 7th and 20th day after surgery, follow-up abdominal CT scans were performed to evaluate intra-abdominal statuses of vascular patency, liver regeneration status and the other intra-abdominal condition. On the 20th postoperative day, MRCP was performed to examine the status of the biliary system. CT scans with volumetry were performed regularly after discharge. If abnormal findings were suspected, then angiography, endoscopic retrograde cholangiopancreatography, or percutaneous transhepatic cholangiography was also performed, and an immediate interventional procedure was performed if indicated.

biliary system. CT scans with volumetry were performed regularly after discharge. If abnormal findings were suspected, then angiography, endoscopic retrograde cholangiopancreatography, or percutaneous transhepatic cholangiography was also performed, and an immediate interventional procedure was performed if indicated. Immunosuppression Immunosuppression regimens were composed of a calcineurin inhibitor such as tacrolimus or cyclosporine, mycophenolate mofetil (MMF), and prednisolone. The dose of tacrolimus was adjusted to maintain serum levels of 7-10 ng/mL for the first month after surgery and 5-7 ng/mL thereafter. The dose of cyclosporine was adjusted to maintain serum levels of 100-150 ng/mL for the first month after surgery and 50-100 ng/mL thereafter. Withdrawal of steroids was generally completed at the first month after surgery, and MMF was discontinued between 3 and 6 months after surgery. An interleukin-2 receptor blocker was administered on the day of surgery prior to the operation and on the fourth day after surgery. Statistical analysis Mean and standard deviation were used as numeric variables. Continuous variables were compared using the Student t-test, whereas categorical variables were analyzed using the chi-square test. Survival data were analyzed using the Kaplan-Meier method to analyze graft and patient survival rates. The survival time distribution between groups was analyzed using the log-rank test. A P-value less than 0.05 was considered statistically significant.

Statistical analysis Mean and standard deviation were used as numeric variables. Continuous variables were compared using the Student t-test, whereas categorical variables were analyzed using the chi-square test. Survival data were analyzed using the Kaplan-Meier method to analyze graft and patient survival rates. The survival time distribution between groups was analyzed using the log-rank test. A P-value less than 0.05 was considered statistically significant. RESULTS Donor A total of 604 cases were included in this study. Of the patients, 26 were recipients whose donors were ≥55 years of age (group A), whereas the remaining 578 patients had donors who were <55 years of age (group B). The mean donor age was 59.4 ± 2.9 years (55-67 years) and 32.3 ± 9.9 years (16-54 years) in groups A and B, respectively. There was no statistically significant difference in the donor sex ratio between the groups (P = 0.406). The BMI score was 23.8 ± 2.5 kg/m2 in group A and 23.3 ± 3.7 kg/m2 in group B (P = 0.476). The degree of graft hepatosteatosis did not different statistically (7.9% ± 7.6% in group A vs. 5.2% ± 7.1% in group B, P = 0.061). The mean donor length of hospital stay was 12.9 ± 4.5 and 12.4 ± 3.2 days in groups A and B, respectively (P = 0.403). The mean graft liver volume was not significantly different between the groups (828.2 ± 234.5 mL vs. 870.0 ± 200.7 mL, respectively, P = 0.303), nor was the mean remnant liver volume of the donors (38.1% ± 5.1% vs. 37.7% ± 4.8%, respectively, P = 0.675). And then, the postoperative complication rate of donors in each groups was compared. In group A, there were 3 cases of liver dysfunction (11.5%), 2 cases of pleural effusion (7.7%) and 1 case of postoperative ileus (3.8%). There was no case of biliary complication and vascular complication in elderly donor group. All of the liver dysfunction was temporary, pleural effusion and postoperative ileus was spontaneously improved with conservative care. There was no statistically significantly difference in postoperative complication rate between two groups (P = 0.340) (Table 1).

ation and vascular complication in elderly donor group. All of the liver dysfunction was temporary, pleural effusion and postoperative ileus was spontaneously improved with conservative care. There was no statistically significantly difference in postoperative complication rate between two groups (P = 0.340) (Table 1). Recipients The recipients' characteristics and posttransplantation outcomes are presented in Table 2. There were no statistically significant differences in age, BMI, CTP score, MELD score, or proportion of the high urgency patients. There was also no significant difference in anatomic variation such as portal vein thrombosis and biliary variation that could affect the postoperative surgical complication rate (P = 0.466). However, the sex ratio of the recipients between the groups did differ significantly as follows: in group B, 418 patients (72.7%) were male, whereas in group A, 13 patients (50%) were male (P = 0.023). A T-tube was used during bile duct anastomosis in 5 cases (19.2%) in group A and 138 cases (23.9%) in group B (P = 0.586). The overall lengths of hospital and intensive care unit stays did not differ between the groups (33.3 ± 16.9 days vs. 30.3 ± 21.7 days, respectively, P = 0.481; 7.1 ± 1.2 days vs. 7.3 ± 5.4 days, respectively, P = 0.821). The most common indication for liver transplantation in both groups was liver cirrhosis due to HBV infection (88.5% vs. 70.3%, respectively, P = 0.048), followed by hepatocellular carcinoma (HCC: 53.8% vs. 41.1%, respectively, P = 0.225). The mean AFP level in all the patients and that in the patients with HCC did not differ significantly between the groups (64.3 ± 135.8 ng/mL vs. 67.9 ± 218.8 ng/mL, P = 0.933; 67.1 ± 133.6 ng/mL vs. 115.1 ± 07.0 ng/mL, P = 0.562, respectively). Among the patients with HCC, 2 patients (14.3%) in group A and 40 patients (16.8%) in group B experienced recurrence during the follow-up period. And then, the postoperative complication rate of recipient in each groups was compared. There were 8 cases of postoperative complication cases in group A. The most common postoperative complication was biliary complication (39.3%), there were 2 cases (25.0%) in group A and 79 cases (39.9%) in group B. However, there was no significant difference in overall complication rate between two groups (P = 0.637) (Table 3).

8 cases of postoperative complication cases in group A. The most common postoperative complication was biliary complication (39.3%), there were 2 cases (25.0%) in group A and 79 cases (39.9%) in group B. However, there was no significant difference in overall complication rate between two groups (P = 0.637) (Table 3). Although there was no significant difference in hospital mortality rate between the groups (7.7% vs. 7.4%, respectively, P = 0.955), the overall mortality rate was significantly higher in group A than in group B (46.2% vs. 18.1%, P = 0.004). A total of 12 patients in group A and 106 patients in group B died during the follow-up period. The causes of death in group A were biliary complications (n = 5, 41.7%), arterial complications (n = 2, 16.7%), HCC recurrence (n = 2, 16.7%), portal vein complications (n = 1, 8.3%), sepsis (n = 1, 8.3%), and other causes (n = 1, 8.3%). In group B, the causes of death included HCC recurrence (n = 31, 29.2%), sepsis (n = 23, 21.7%), biliary complications (n = 10, 9.4%), portal vein complications (n = 9, 8.5%), arterial complications (n = 5, 5.7%), and other causes (n = 27, 25.5%) (Table 4). The overall survival length was 31.2 ± 31.3 months in group A and 51.4 ± 40.8 months in group B (P = 0.013). The 1-, 3-, and 5-year posttransplantation survival rates were respectively 63.4%, 58.5%, and 44.6% in group A and 86.9%, 84.3%, and 80.7% in group B (P < 0.001) (Fig. 1).

And, this study demonstrated that low BMI is not an independent risk factor. However, there are clear limitations to the use of BMI for screening nutritional status. Some patients weigh less than is usual for their height but are otherwise fit and healthy, and a normal BMI does not exclude the presence of malnutrition. The largest prospective randomized trial of preoperative total parenteral nutrition (TPN) was a multiinstitutional study conducted by the Veterans Administration [12]. Only in severely malnourished patients, significantly fewer nonseptic complications (e.g., anastomotic leaks, bronchopleural fistulas) occurred in patients receiving TPN (5% vs. 43%, P = 0.03). Shukla et al. [13] studied 110 patients with benign or malignant gastrointestinal, breast, or oropharyngeal disease by comparing preoperative enteral nutrition with standard oral diets in patients undergoing major surgical procedures. Control patients received a standard oral diet and were compared to patients receiving 10 days of nasogastric enteral nutrition. Major complications were reduced from 30% in the control group to 10% in the enteral nutrient group in this study.

other causes (n = 27, 25.5%) (Table 4). The overall survival length was 31.2 ± 31.3 months in group A and 51.4 ± 40.8 months in group B (P = 0.013). The 1-, 3-, and 5-year posttransplantation survival rates were respectively 63.4%, 58.5%, and 44.6% in group A and 86.9%, 84.3%, and 80.7% in group B (P < 0.001) (Fig. 1). DISCUSSION The use of elderly donor livers for LDLT remains controversial. Some studies reported favorable results [5,13,15], but others reported significantly increased risks of initial graft non function, and low graft and patient survival rates. However, almost all of the earlier studies were of DDLT [12,14,19,20], and only one report was of LDLT [4]. Liver transplantation for end-stage liver disease and HCC seems to provide better results than other treatment modalities, but the scarcity of graft donors remains its major obstacle. Furthermore, there have been low numbers of brain death liver donors due to cultural customs, especially in Far East Asia. As such, family members would be the most promising source of liver grafts for LDLT in these areas. Therefore, we have no choice but to use the limited supplies of available liver grafts, meaning that we cannot deny elderly LDLT donor volunteers unless they are medically compromised. In this study, we tried to use of medically uncompromised donor graft and there was no significant difference in the post-operative complication rate of donors between usual and elderly group (P = 0.340).

able liver grafts, meaning that we cannot deny elderly LDLT donor volunteers unless they are medically compromised. In this study, we tried to use of medically uncompromised donor graft and there was no significant difference in the post-operative complication rate of donors between usual and elderly group (P = 0.340). Earlier studies stated that the cold ischemic time in DDLT negatively influences graft patency and is the major problem in grafts from elderly patients. However, this problem can be overcome in LDLT as demonstrated by the lack of cases of primary liver graft non function in the present study. Despite this, several complications other than primary liver graft non function occurred. Therefore, older donor age with or without other complications could negatively influence graft patency [21]. Our study showed that the outcomes including overall mortality rate and mean survival length in recipients of liver grafts from elderly living donors was significantly poorer than those of nonelderly donors (46.2% vs. 18.1%, P = 0.004). Nevertheless, the 5 year overall survival rate was 79.5% in the elderly group and 81.5% in the nonelderly group. This is a promising result compared with those of earlier reports that revealed 60%-80% survival rates [22,23]. Moreover, there was no case of primary liver graft non function, a concern in DDLT using elderly donor grafts, and no other severe acute complications in our study. In addition, the hospital mortality rates did not differ significantly between the groups (7.7% vs. 7.4%, P = 0.955).

ealed 60%-80% survival rates [22,23]. Moreover, there was no case of primary liver graft non function, a concern in DDLT using elderly donor grafts, and no other severe acute complications in our study. In addition, the hospital mortality rates did not differ significantly between the groups (7.7% vs. 7.4%, P = 0.955). Some authors described that preoperative biliary and vascular anomaly was related with postoperative complication and eventually, could affect mortality rate [24,25]. In this study, there was no significant difference in anatomic variation between two groups (P = 0.466) and the postoperative complication rate was not so different between groups (P = 0.637). Furthermore, there was also no statistically significant difference in terms of age, CTP score, MELD score, proportion of the high urgency patients, or other preoperative medical conditions between the recipient groups. Therefore, donor age might be the sole risk factor for reduced recipient survival rate in our study. Woodhouse and Wynne [10] described that liver age itself may be associated with a loss in proliferative response and regeneration. This causes increased susceptibility to irreversible damage such as viral infection, ischemic injury, and impaired hepatic blood flow despite the appearance of well-maintained liver graft function.

e and Wynne [10] described that liver age itself may be associated with a loss in proliferative response and regeneration. This causes increased susceptibility to irreversible damage such as viral infection, ischemic injury, and impaired hepatic blood flow despite the appearance of well-maintained liver graft function. Mutimer et al. [20] and other several investigators [6,26] described that the use of elderly donors for HCV-infected recipients promotes HCV recurrence and hepatic fibrosis or even cirrhosis. This could explain the poor outcome of recipients of liver donations of elderly patients; however, it cannot explain our results because there were no patients with HCV in group A (recipients whose donors were ≥55 years of age). On the other hand, Lake [27] described that donor age was not related with disease recurrence or graft loss in patients with HBV. Some investigators have suggested that the degree of hepatosteatosis of donor liver increases with age as a result of reduced protein synthesis, prolonged cholestasis, and delayed capacity for regeneration and described that with donor age, it was one of the most important risk factors for decreased graft and patient survival [10,28]. In our study, the degree of hepatosteatosis of group A seemed to be higher than that of group B (7.9% ± 7.6% vs. 5.2% ± 7.1%), but the difference was not statistically significant (P = 0.061).

described that with donor age, it was one of the most important risk factors for decreased graft and patient survival [10,28]. In our study, the degree of hepatosteatosis of group A seemed to be higher than that of group B (7.9% ± 7.6% vs. 5.2% ± 7.1%), but the difference was not statistically significant (P = 0.061). In group A, the most common cause of death was biliary complications (41.7%), followed by hepatic artery thrombosis and recurrent HCC. Most of the biliary complications arose from biliary anastomotic strictures. Its prevalence is similar or slightly higher than those described by others [29,30]. Biliary complications are considered the most common problem after LDLT, but there have been no definite measurements for that without careful preoperative evaluation and the use of a meticulous surgical technique. Several studies have described that biliary complications, especially anastomotic and nonanastomotic strictures, are closely related to arterial complications, mainly hepatic artery thrombosis [7,8]. Due to increasing the disparity between donors and recipients, expansion of the donor pool has become a serious issue. As the mean life expectancy continues to increase, increasing demands for elderly donors are emerging. However, our study shows a higher overall mortality rate in the group using elderly living donor livers (≥55 years of age) than in the group using younger living donor livers (<55 years of age).

ecome a serious issue. As the mean life expectancy continues to increase, increasing demands for elderly donors are emerging. However, our study shows a higher overall mortality rate in the group using elderly living donor livers (≥55 years of age) than in the group using younger living donor livers (<55 years of age). Our study showed conflicting results compared with that of Li et al. [3] in which the use of older donors in LDLT had no negative influence on donor or recipient outcomes. However, that study had some limitation. First, there were fewer enrolled elderly donors (21 vs. 26) and much fewer younger donors (108 vs. 578) than in our study. Decisively, the criteria used by that study to distinguish elderly donors (≥50 years of age) was more generous than those used in our study (≥55 years of age), which followed those of earlier reports [16,17,18] and many other transplant centers. Furthermore, the mean age of the recipients in that study who received livers from the elderly donors was much younger than that in our study (41.10 ± 10.26 years vs. 55.2 ± 11.8 years), which would influence the result to be more favorable than ours. The limitation of this study was that it was not controlled or prospective; rather, it was a retrospective study. It also recruited a relatively small number of patients, especially in the elderly group. Because of the small number of cases, a multivariate analysis of the cause of death was not possible. As such, we think that a large and multicenter analysis of LDLT using elderly donor livers is required.

s a retrospective study. It also recruited a relatively small number of patients, especially in the elderly group. Because of the small number of cases, a multivariate analysis of the cause of death was not possible. As such, we think that a large and multicenter analysis of LDLT using elderly donor livers is required. In conclusion, based on our results, we believe that LDLT using elderly donors (≥55 years of age) could induce more serious complications such as biliary strictures or hepatic artery thrombosis and could cause higher morbidity and mortality rates than LDLT using younger donors. As such, the selection of elderly donor livers should be made carefully. No potential conflict of interest relevant to this article was reported. Fig. 1 Kaplan-Meier survival curves of the recipients (P < 0.001) in living donor liver transplantation. Group A, recipients of livers from elderly donors (≥55 years of age); group B, recipients of livers from younger donors (<55 years of age). Table 1 Donor characteristics in the comparison study using elderly donors and younger donors in the living donor liver transplantation Values are presented as mean ± standard deviation or number (%) unless otherwise indicated. Group A, recipients of livers from elderly donors (≥55 years of age); group B, recipients of livers from younger donors (<55 years of age). a)Remnant donor liver volume, b)Postoperative complications. c)Mean ± standard deviation (range).

Values are presented as mean ± standard deviation or number (%) unless otherwise indicated. Group A, recipients of livers from elderly donors (≥55 years of age); group B, recipients of livers from younger donors (<55 years of age). a)Remnant donor liver volume, b)Postoperative complications. c)Mean ± standard deviation (range). Table 2 Recipient characteristics and posttransplantation outcomes in the comparison study using elderly donors and younger donors in the living donor liver transplantation Values are presented as mean ± standard deviation or number (%). Group A, recipients of livers from elderly donors (≥55 years of age); group B, recipients of livers from younger donors (<55 years of age); BMI, body mass index; CTP, Child-Turcotte-Pugh; MELD, model for end stage liver disease; ICU, intensive care unit; HCC, hepatocellular carcinoma; PV, portal vein; Alc., alcohol. a)High urgency included United Network for Organ Sharing status I and IIA. Table 3 Comparison of the postoperative complications between two groups Values are presented as number (%). Group A, recipients of livers from elderly donors (≥55 years of age); group B, recipients of livers from younger donors (<55 years of age). Table 4 Cause of recipient death in the comparison study using elderly donors and younger donors in the living donor liver transplantation Values are presented as number (%). Group A, recipients of livers from elderly donors (≥55 years of age); group B, recipients of livers from younger donors (<55 years of age); HCC, hepatocellular carcinoma.

INTRODUCTION Mycophenolate mofetil (MMF) (Cellcept, Roche Pharmaceuticals AG, Basel, Switzerland) is used routinely as a combination immunosuppressant with calcineurin inhibitors (CNIs) after liver transplantation. MMF significantly decreases the rate of biopsy-proven acute rejection (BPAR) as compared with either placebo or azathioprine at 6 months after transplantation [1,2]. However, a high proportion of MMF-treated recipients suffer from gastrointestinal (GI) complications, such as watery diarrhea or abdominal pain. GI symptoms contribute significantly to the deterioration of health-related quality of life (HRQoL) in transplant recipients [3]. High proportions of patients receiving MMF require dose reductions or discontinue MMF treatment because of adverse GI events [4]. MMF dose reduction or discontinuation has a significant impact on transplant outcomes and is associated with a significantly higher incidence of acute rejection within the first posttransplant year, resulting in decreased 3-year graft survival [5].

ductions or discontinue MMF treatment because of adverse GI events [4]. MMF dose reduction or discontinuation has a significant impact on transplant outcomes and is associated with a significantly higher incidence of acute rejection within the first posttransplant year, resulting in decreased 3-year graft survival [5]. The importance of generic versions of immunosuppressive agents has been recently studied [6,7]. As generic drugs do not require expensive drug development programs, their price is often considerably lower than that of the innovator product. Generic substitution is generally accepted and promoted by healthcare providers, health insurance companies and government agencies [8]. Unbranded and branded generic drugs accounted for 65.6% and 8.6%, respectively, of all drugs dispensed in the United States in 2009, revealing that 74.2% of all drugs dispensed are generic products [6].

n is generally accepted and promoted by healthcare providers, health insurance companies and government agencies [8]. Unbranded and branded generic drugs accounted for 65.6% and 8.6%, respectively, of all drugs dispensed in the United States in 2009, revealing that 74.2% of all drugs dispensed are generic products [6]. In 2009, the Korea Food and Drug Administration (KFDA) approved the first generic formulation of MMF (My-rept), manufactured by Chong Kun Dang Pharmaceutical Co. (Seoul, Korea). The KFDA accepts two products as bioequivalent if tests of the generic product against the reference product have a 90% confidence interval within 80%-125% for relative mean maximum blood concentration (Cmax) and area under the plasma concentration-versus-time curve (AUC [0-t] or AUC [0-∞]). A typical bioequivalence study employs a single-dose, two-way crossover design in 24-40 healthy subjects, depending on the pharmacokinetic variability of the test compound, and data in the intended patient population are not required. However, transplant patients are vastly different from healthy subjects because they are subject to multiple comorbidities and concomitant pharmacotherapy that can influence drug disposition.

depending on the pharmacokinetic variability of the test compound, and data in the intended patient population are not required. However, transplant patients are vastly different from healthy subjects because they are subject to multiple comorbidities and concomitant pharmacotherapy that can influence drug disposition. The use of generic MMF in the setting of liver transplantation is still a subject of discussion because bioequivalence to MMF has not been demonstrated and interference with CNI absorption and triggering of acute rejection are possible because of the retarded intestinal absorption of MMF. Additionally, there has been no investigation of one-way conversion from brand-name MMF to generic MMF published in the literature, so the tolerability and safety of MMF and its effects on patient quality of life are unknown. Data describing conversion to generic MMF formulation in adult liver transplant recipients are scarce. This six-month, multicenter, single-arm, open-label study in maintenance liver transplant recipients aimed to investigate the efficacy, safety and tolerability of converting stable maintenance liver transplant patients from brand-name MMF to generic MMF.

MMF formulation in adult liver transplant recipients are scarce. This six-month, multicenter, single-arm, open-label study in maintenance liver transplant recipients aimed to investigate the efficacy, safety and tolerability of converting stable maintenance liver transplant patients from brand-name MMF to generic MMF. METHODS Study design This study was a prospective trial conducted at four transplant centers between January 2010 and December 2012. Institutional Review Board (IRB) approval was obtained at each center (Samsung Medical Center IRB no. 9405, Seoul National University Hospital IRB no. 2009-P-000381/1, Konkuk University Hospital IRB no. 0912006049, Chonbuk University Hospital IRB no. 2009-P-000979/1). Each center used its own criteria to determine which patients to convert and when patients had stable graft function. Once a patient converted from brand to generic MMF (My-rept), all centers followed a plan of treatment consistent with other liver transplant recipients. Written informed consent was obtained prior to participation.

sed its own criteria to determine which patients to convert and when patients had stable graft function. Once a patient converted from brand to generic MMF (My-rept), all centers followed a plan of treatment consistent with other liver transplant recipients. Written informed consent was obtained prior to participation. Inclusion criteria Patients of either gender, aged 19 to 70 years, who received a primary or secondary liver transplant from a deceased or living donor and who were at least six months posttransplant were eligible. Patients were required to have received CNI and MMF for at least two months as part of their immunosuppressive regimen. Additionally, patients were to be in stable condition in terms of graft function, which was defined as within twice the upper limit for serum total bilirubin, AST, ALT at screening and baseline, have had no changes in immunosuppressive regimen due to graft dysfunction, and have no known clinically significant laboratory changes for at least two months before enrollment. Women of childbearing potential were required to have a negative pregnancy test.

or serum total bilirubin, AST, ALT at screening and baseline, have had no changes in immunosuppressive regimen due to graft dysfunction, and have no known clinically significant laboratory changes for at least two months before enrollment. Women of childbearing potential were required to have a negative pregnancy test. Exclusion criteria Patients were excluded if they were multiorgan recipients or had a previous transplant with any organ other than a liver. Additional exclusion criteria included evidence of graft rejection or treatment for acute rejection within three months prior to screening, leukopenia (<2,500/mm3) and/or serum creatinine >2.0 mg/dL prior to enrollment, use of any other investigational drug within two weeks before screening, malignancy (other than local basal or squamous cell carcinoma of the skin) within the last five years or after liver transplantation, clinically significant infection requiring continued therapy, presence of severe GI complications such as diarrhea or severe peptic ulcer disease at screening, more than two discontinuations of MMF prior to screening, detection of recurrent hepatitis B virus infection (defined as positive hepatitis B surface antigen), receipt of antiviral therapy for HCV reinfection, positive HIV status, or evidence of drug or alcohol abuse. Women of childbearing potential who were unwilling to use an effective form of contraception for the duration of the study and for six weeks following study drug discontinuation and women who were pregnant or lactating were also excluded.

y for HCV reinfection, positive HIV status, or evidence of drug or alcohol abuse. Women of childbearing potential who were unwilling to use an effective form of contraception for the duration of the study and for six weeks following study drug discontinuation and women who were pregnant or lactating were also excluded. Monitoring All participants received care in the outpatient transplant clinic where weight, height, total bilirubin, albumin, serum creatinine, ALP, AST, ALT, gamma glutamyltranspeptidase (γ-GT) and graft rejection status were routinely monitored. A 1:1 dose conversion was applied in switching from the reference to the generic drug. Evaluations were performed at baseline (day of conversion to generic drug), 2, 4, and 6 months after conversion. Data were collected as planned for analysis. This trial was monitored internally and externally during the study period. Safety evaluations Evaluation of safety criteria included monitoring and recording all infections and adverse events, defined as any newly occurring condition or disability or worsening of a condition observed at baseline. Routine blood analysis, blood chemistry, vital signs, and physical examinations were performed regularly.

valuations Evaluation of safety criteria included monitoring and recording all infections and adverse events, defined as any newly occurring condition or disability or worsening of a condition observed at baseline. Routine blood analysis, blood chemistry, vital signs, and physical examinations were performed regularly. Efficacy evaluations Efficacy was measured by rate of treatment failure, such as BPAR, liver graft loss, or death within six months of conversion to study medication. Liver graft function was assessed via liver function tests such as total bilirubin, albumin, ALP, AST, ALT, and γ-GT. All data were collected by the investigators, monitored by independent external personnel, and transferred to a database. Rejection Acute rejection episodes were proven with core biopsies before or within 24 hours following commencement of antirejection therapy and assessed according to the Banff classification [9]. Methylprednisolone was administered intravenously at 500 mg/day for three days. Study medication was not interrupted during antirejection therapy. Quality of life assessment Three questionnaires were used to examine patient' conditions: (1) Gastrointestinal Symptom Rating Scale (GSRS), (2) Gastrointestinal Quality-of-Life Index (GIQLI), and (3) Patient Overall Treatment Effect (P-OTE) and Investigator Overall Treatment Effect (I-OTE).

Rejection Acute rejection episodes were proven with core biopsies before or within 24 hours following commencement of antirejection therapy and assessed according to the Banff classification [9]. Methylprednisolone was administered intravenously at 500 mg/day for three days. Study medication was not interrupted during antirejection therapy. Quality of life assessment Three questionnaires were used to examine patient' conditions: (1) Gastrointestinal Symptom Rating Scale (GSRS), (2) Gastrointestinal Quality-of-Life Index (GIQLI), and (3) Patient Overall Treatment Effect (P-OTE) and Investigator Overall Treatment Effect (I-OTE). The GSRS is a 15-item instrument designed to assess symptoms associated with common GI disorders [10]. The GSRS consists of five subscales (reflux, diarrhea, constipation, abdominal pain, and indigestion) producing a mean subscale score ranging from 0 (no discomfort) to 6 (very severe discomfort). The GIQLI is a 36-item questionnaire that assesses the impact of GI disease on daily life [11]. The GIQLI has five subscales (GI symptoms, emotional status, physical functions, social functions, and stress of medical treatment) within the total score of 36 items. Lower scores represent greater dysfunction [10]. The OTE assesses changes in symptoms or HRQoL since the previous visit [12]. Respondents indicate the degree of improvement or worsening on a seven-point scale. Patients completed the GSRS and GIQLI at visits 1 (baseline) and 4 (after 24 weeks on generic drug treatment). The OTE was administered only at visit 4. Patients completed OTE questionnaires for symptoms and for HRQoL and physicians completed an OTE questionnaire for symptoms.

ement or worsening on a seven-point scale. Patients completed the GSRS and GIQLI at visits 1 (baseline) and 4 (after 24 weeks on generic drug treatment). The OTE was administered only at visit 4. Patients completed OTE questionnaires for symptoms and for HRQoL and physicians completed an OTE questionnaire for symptoms. Statistical analyses The safety population included all patients who received at least one dose of study medication and underwent at least one safety assessment following trial medication. The study was exploratory in nature and a control group was not included in the protocol. Continuous variables are presented as mean ± standard deviations and compared using the paired t-test or analysis of variance. Data are summarized for demographic and baseline characteristics. Assessment of safety was based on the frequency of adverse events and the number of laboratory values outside of predetermined ranges. P < 0.05 was considered significant. Analysis was performed using IBM SPSS ver. 21.0 (IBM Co., Armonk, NY, USA).

iance. Data are summarized for demographic and baseline characteristics. Assessment of safety was based on the frequency of adverse events and the number of laboratory values outside of predetermined ranges. P < 0.05 was considered significant. Analysis was performed using IBM SPSS ver. 21.0 (IBM Co., Armonk, NY, USA). RESULTS Patients Patients undergoing liver transplantation from living or deceased donors were enrolled at four transplantation centers in South Korea between January 2010 and December 2012. A total of 154 patients (mean age, 53.8 years; men:women, 116:38) were screened and enrolled. Among the 154 enrolled patients, six were immediately excluded, and 140 patients completed the trial with eight drop-outs for violation of inclusion or exclusion criteria (n = 4), violation of study program (n = 3), or use of prohibited drugs (n = 1). Patient demographic information is presented in Table 1. The mean time since liver transplantation was 47.7 months; 33.1% of participants received a liver from a deceased donor and 66.9% from a living donor; 89.6% (n = 138) were treated with tacrolimus as concomitant immunosuppressive therapy, and 10.4% (n = 16) with cyclosporine. One hundred forty patients fulfilled the criteria for inclusion in per-protocol (PP) analysis, with 14 showing at least one major deviation from the protocol (Fig. 1).

66.9% from a living donor; 89.6% (n = 138) were treated with tacrolimus as concomitant immunosuppressive therapy, and 10.4% (n = 16) with cyclosporine. One hundred forty patients fulfilled the criteria for inclusion in per-protocol (PP) analysis, with 14 showing at least one major deviation from the protocol (Fig. 1). Adverse events After conversion, the overall incidence of adverse events (AEs) was 48.1% (112 cases in 74 patients). Infections accounted for 27.7% (31/112) of all incidence, particularly upper respiratory tract infections (24 cases). GI events accounted for 21.4% (24 cases in 21 patients) including abdominal pain (5 cases), diarrhea (4 cases) and gastritis (3 cases). The incidence of hematologic AEs was 0.7% (one case of neutropenia). No patient discontinued the study medication due to an AE. Drug-related AEs occurred in nine cases in eight patients (Table 2), with nine cases of severe AEs in six patients (Table 3). All patients with serous AEs recovered. Only two patients (1.4%) experienced acute rejection during the study period and no episodes of death or graft loss occurred. No neoplasias or lymphomas were reported. During the six-month follow-up, no appreciable change was observed after conversion in biochemical indices of liver function such as total bilirubin, albumin, ALP, ALT, AST, or γ-GT (Table 4).

te rejection during the study period and no episodes of death or graft loss occurred. No neoplasias or lymphomas were reported. During the six-month follow-up, no appreciable change was observed after conversion in biochemical indices of liver function such as total bilirubin, albumin, ALP, ALT, AST, or γ-GT (Table 4). Gastrointestinal complications and quality of life Mean GSRS score increased from 8.9 ± 9.3 at baseline (visit 1) to 10.4 ± 11.8 at visit 4. However, GIQLI score decreased from 125.6 ± 13.9 at baseline (visit 1) to 123.1 ± 16.0 at visit 4. No significant differences were observed in GSRS or GIQLI score between visit 1 (baseline) and visit 4 (last visit) (P = 0.060 for GSRS and P = 0.261 for GIQLI) (Fig. 2). P-OTE revealed that 90.3% of patients in the total PP population felt "about the same" with regard to participant-reported GI symptoms and quality of life after switching from brand-name to generic MMF. I-OTE showed that 94.4% of patients had the same GI symptoms and quality of life after conversion (Fig. 3). DISCUSSION The use of generic medications is widespread and represents a viable cost-saving opportunity in the face of rising health care costs [13]. However, while economics is a driving force behind utilization of generic drug products, patient welfare must remain the principal consideration. Prior to this study, data related to the safety and efficacy of switching liver transplant patients from the reference MMF to the recently available generic formulation had not been reported.

onomics is a driving force behind utilization of generic drug products, patient welfare must remain the principal consideration. Prior to this study, data related to the safety and efficacy of switching liver transplant patients from the reference MMF to the recently available generic formulation had not been reported. In this study, the impact of generic substitution of MMF on indices of liver function was investigated in clinically stable liver transplant recipients. Also investigated was the impact of the use of the generic version of MMF on general and GI-specific HRQoL in the study population after medication conversion. Maintenance of immunosuppressive balance is critical for allograft patency and minimization of adverse effects, and is ultimately implicated in the long-term survival of solid organ transplant recipients [14]. The degree of immunosuppression required to prevent allograft rejection is substantial in many patients, particularly in the immediate posttransplantation period. Moreover, a change in the immunosuppressive drug could predispose patients to episodes of toxicity, infection, or allograft rejection [15].

recipients [14]. The degree of immunosuppression required to prevent allograft rejection is substantial in many patients, particularly in the immediate posttransplantation period. Moreover, a change in the immunosuppressive drug could predispose patients to episodes of toxicity, infection, or allograft rejection [15]. In this study, two cases (1.4%) of acute rejection were reported, with no reports of severe GI intolerance, life-threatening infection, graft loss or death. Patients showed only slight changes from baseline in the questionnaires that were used; neither GSRS nor GIQLI score varied significantly after conversion. Furthermore, OTE evaluated by physicians and patients remained about the same. Because stable patients reported considerably better overall well-being at baseline in the evaluation questionnaires, changes in this group were not expected to be as pronounced as in patients suffering from generic drug conversion. The conversion from the brand-name MMF formulation to a generic MMF formulation at equimolar doses seemed to provide clinically effective immunosuppressant management for maintenance of liver transplant recipients, and the results supported existing data on similar efficacy maintained in other patients. Thus, we conclude that conversion from the brand-name MMF formulation to a generic MMF formulation was safe and well-tolerated, without causing GI complaints in patients.

management for maintenance of liver transplant recipients, and the results supported existing data on similar efficacy maintained in other patients. Thus, we conclude that conversion from the brand-name MMF formulation to a generic MMF formulation was safe and well-tolerated, without causing GI complaints in patients. Substitution of brand-name MMF for generic MMF (My-rept) in stable liver transplant recipients resulted in similar safety, GI complications, adverse effects, and quality of life as before conversion from the brand-name MMF product (Cellcept). Generic drugs can have the same therapeutic efficacy at a substantially lower price than brand-name drugs and are important for controlling healthcare costs. The use of generic immunosuppressive drugs could therefore generate significant cost savings in the long-term treatment of transplant recipients [8]. Generic immunosuppressants can be safely used as long as two main requirements are met: patients must consistently receive the same product, and patients and providers must be aware of transition points. Thus, outcomes research in generic immunosuppression is critically needed to assess the clinical and therapeutic equivalence of new generic immunosuppression formulations. In addition, pharmacoeconomic analyses of the transition from innovator to generic, and generic to generic formulations are needed. Currently, the true cost of generic substitution for solid organ transplant recipients is not known. Appropriate clinical decisions about the use of generic drugs must balance therapeutic outcomes, patient quality of life, and associated financial burden.

ator to generic, and generic to generic formulations are needed. Currently, the true cost of generic substitution for solid organ transplant recipients is not known. Appropriate clinical decisions about the use of generic drugs must balance therapeutic outcomes, patient quality of life, and associated financial burden. This study had several limitations. First, it lacked a control group so statistical comparisons of patients remaining on the brand-name formulation with patients switched to the generic formulation could not be performed. As a result, the data were descriptive and the analysis was exploratory. Conclusions from this study are observational and should only be compared to results from randomized control trials performed around the same time. Nevertheless, the observations of this study are clinically important and relevant to clinicians in Korea because data on generic MMF are relatively scarce. Second, the study population was outpatients, and compliance with the MMF regimen was not directly assessed. Third, long-term follow-up data are lacking. In conclusion, this study demonstrated that, in maintenance liver transplant patients, generic MMF was a safe and effective alternative to brand-name MMF. This study was sponsored by a grant from Chong Kun Dang Pharmaceutical Co., Korea. Fig. 1 Study population. Fig. 2 Changes in GSRS (A) and GIQLI (B) scores between visit 1 (baseline) and visit 4. GSRS, Gastrointestinal Symptom Rating Scale; GIQLI, Gastrointestinal Quality-of-Life Index.

In conclusion, this study demonstrated that, in maintenance liver transplant patients, generic MMF was a safe and effective alternative to brand-name MMF. This study was sponsored by a grant from Chong Kun Dang Pharmaceutical Co., Korea. Fig. 1 Study population. Fig. 2 Changes in GSRS (A) and GIQLI (B) scores between visit 1 (baseline) and visit 4. GSRS, Gastrointestinal Symptom Rating Scale; GIQLI, Gastrointestinal Quality-of-Life Index. Fig. 3 Patient-reported and investigator-reported overall treatment effect on quality of life. P-OTE, patient overall treatment effect; I-OTE, investigator overall treatment effect. Table 1 Baseline participant characteristics HCC, hepatocellular carcinoma. Table 2 Adverse events Table 3 Serious adverse events LFT, liver function test; IVC, inferior vena cava. Table 4 Laboratory results by visit Values are presented as mean ± standard deviation. γ-GT, gamma glutamyltranspeptidase.

INTRODUCTION Standard treatment for gastroduodenal SMTs is surgical resection due to difficulties in pathologic confirmation before operation [1]. Several surgical approaches are recommended according to their size and locations [2]. Among them, laparoscopic wedge resection is most widely performed for gastric SMTs and has become a main treatment option for small to medium size gastric SMTs [3,4]. However, treatment controversies still exist, from observation to surgical resection, especially for the small sized SMTs. Additionally, location near esophagogastric junction (EGJ) and pylorus can be a challenging issue for laparoscopic resection. Herein we aimed to show experience of laparoscopic surgery for gastroduodenal SMTs to evaluate and introduce the safety and efficacy of laparoscopic resection with reasonable treatment strategies for the small to medium sized gastroduodenal SMTs, especially located near EGJ and pylorus.

ssue for laparoscopic resection. Herein we aimed to show experience of laparoscopic surgery for gastroduodenal SMTs to evaluate and introduce the safety and efficacy of laparoscopic resection with reasonable treatment strategies for the small to medium sized gastroduodenal SMTs, especially located near EGJ and pylorus. METHODS We reviewed the prospectively collected data of 137 consecutive patients who underwent surgical resection for the gastric submucosal tumors from August 2004 until March 2013 at Yeouido St. Mary's Hospital, The Catholic University of Korea. Current study protocol was reviewed and approved by the Catholic University of Korea Institutional Review Board. We excluded 12 cases including 7 epithelial origin tumors (6 inflammatory fibroid polyps and 1 hyperplastic polyp), 2 GISTs treated by conventional open method due to large size and perforated state and 2 duodenal SMTs located at duodenal 2nd and 3rd portion. In this study, we analyzed patients' demographics, tumor locations, tumor morphologic characteristics, operation types, operative results, and perioperative outcomes. Tumor location was differentiated into duodenal bulb, antrum, body, cardia, and fundus. Cardia was defined from EGJ to 3-cm distal from EGJ. To evaluate the efficacy and appropriateness of applying laparoscopic resection for the SMTs located near EGJ and pylorus, we divided all lesions into three area according to surgical concerns; area I, cardiac SMTs; area II, SMTs located no more than 3 cm from pylorus including duodenal bulb; area III, else area except area I or area II. We classified the locations in to areas I and II with the nearest margin of the tumor. In case of GIST, recurrence and survival analysis were performed.

to surgical concerns; area I, cardiac SMTs; area II, SMTs located no more than 3 cm from pylorus including duodenal bulb; area III, else area except area I or area II. We classified the locations in to areas I and II with the nearest margin of the tumor. In case of GIST, recurrence and survival analysis were performed. Statistic analyses were performed using SPSS ver. 17.0 (SPSS Inc., Chicago, IL, USA). All continuous variables were expressed as mean ± standard deviation. Continuous variables were compared with unpaired Student t-test and nominal variables were compared with chi-square test. Correlation between size and mitotic figure of GISTs was estimated with linear regression analysis. Survival analysis was done with Kaplan-Meier and log-rank test. Null hypotheses of no difference were rejected if P-values were less than 0.05.

red Student t-test and nominal variables were compared with chi-square test. Correlation between size and mitotic figure of GISTs was estimated with linear regression analysis. Survival analysis was done with Kaplan-Meier and log-rank test. Null hypotheses of no difference were rejected if P-values were less than 0.05. Surgical techniques for laparoscopic wedge resection A day before surgery, endoscopic clipping was performed in cases of small endophytic SMTs less than 2 cm, for accurate tumor localization during operation. Each patient was placed in the reverse Trendelenburg position. A carbon dioxide pneumoperitoneum was performed from the umbilical port with pressure maintenance between 12-14 mmHg. Usually 4 trocars (10 mm for scope, 5 mm and 12 mm for operator, 5 mm for assistant) were placed. Easily detected exophytic or dumb-bell shape tumors were resected by laparoscopic wedge resection using linear staplers with exogastric approach. In cases of small, endophytic, posterior wall intraluminal lesions were explored through anterior gastrotomy, and resected while the traction was done. In case of SMTs near EGJ, tumor traction using thread and identification of the EGJ was mandatory to make secure resection for prevention of further stenosis.

approach. In cases of small, endophytic, posterior wall intraluminal lesions were explored through anterior gastrotomy, and resected while the traction was done. In case of SMTs near EGJ, tumor traction using thread and identification of the EGJ was mandatory to make secure resection for prevention of further stenosis. RESULTS Clinicopathologic characteristics There were 55 males and 70 females with a mean age of 57.9 ± 12.7 years (range, 19-83 years). The mean tumor size was 2.8 ± 1.7 cm (range, 0.4-8.5 cm). Histopathologic results revealed 70 GISTs, 18 leiomyomas, 15 ectopic pancreases, 11 schwannomas, 10 carcinoids and 1 glomus tumor. Among all cases, 115 wedge resections (92%), 9 Billroth-II distal gastrectomies (7.2%), and one total gastrectomy were performed via laparoscopic approach. There was no resection margin positive case and the majority of cases (95 cases) had resected margin within 10 mm. In addition, there was no tumor recurrence at the resection margin during the median 13 months (range, 1-100 months) of follow-up. Seven patients underwent concurrent operations (Table 1), such as cholecystectomy for gall bladder stones, herniorrhaphy for inguinal hernia, right hemicolectomy for right colon cancer, Nissen fundoplication for gastroesophageal reflux disease, and total thyroidectomy for thyroid cancer. Mean operation time for all cases and wedge resection cases were 106.8 ± 73.9 minutes (range, 27-375 minutes) and 95.8 ± 46.3 minutes (range, 27-270 minutes), respectively. The mean postoperative hospital stay was 5.4 ± 3.8 days (range, 2-23 days). The average number of linear staples used during laparoscopic wedge resection was 2.1 ± 1.9 (range, 0-5) (Table 1). There were 2 postoperative complications out of 125 patients (1.6%) which were gastric outlet obstruction and leakage of staple line in wedge resection cases which are located at antrum lesser curvature side. Those complications were treated with reoperative laparoscopic gastrojejunostomy and primary closure, respectively. There was no perioperative mortality.

ut of 125 patients (1.6%) which were gastric outlet obstruction and leakage of staple line in wedge resection cases which are located at antrum lesser curvature side. Those complications were treated with reoperative laparoscopic gastrojejunostomy and primary closure, respectively. There was no perioperative mortality. Characteristics of tumors (location, growth pattern, and size) The pattern of tumor location according to pathologic diagnosis was significantly different (Table 2). The body was the most frequent site of gastric SMTs. GIST was most frequently distributed except cardia. All the fundic lesions were GISTs. Leiomyoma was predominantly located at the cardia; 58.8% of cardiac lesions were leiomyoma. Ectopic pancreas and schwannomas were usually located at distal part of the stomach. Four out of 23 antral SMTs located near pyloric ring. One of them involved the pyloric ring. Regarding the growth pattern and size, GIST and neurogenic tumor tended to grow exophytically, while more portions of leiomyoma, carcinoid and ectopic pancreas grow with endophytic feature (Table 3). GIST was the largest (3.1 ± 1.9 cm) among all gastroduodenal SMTs and schwannoma was the next (2.3 ± 1.3 cm). Almost all tumors larger than 5 cm were GISTs except one schwannoma. GIST comprised 20 cases (44.4%) among the SMTs less than 2 cm (Fig. 1).

arcinoid and ectopic pancreas grow with endophytic feature (Table 3). GIST was the largest (3.1 ± 1.9 cm) among all gastroduodenal SMTs and schwannoma was the next (2.3 ± 1.3 cm). Almost all tumors larger than 5 cm were GISTs except one schwannoma. GIST comprised 20 cases (44.4%) among the SMTs less than 2 cm (Fig. 1). Comparison of clinicopathologic and surgical outcomes according to the tumor location The comparison of clinicopathologic features and surgical outcomes between three locations are described at Table 4. Among all gastroduodenal SMTs, there were 17 cardiac lesions (area I), 11 peripyloric lesions including 7 duodenal SMTs and 4 prepyloric SMTs (area II) and 97 SMTs located except area I and area II (area III). Mean age of area I group was significantly younger than the others. Regarding disease entity, leiomyoma was the dominant in area I and GIST was dominant at area II and area III. Endophytic lesions were more common in area I and area II rather than area III. There was no significant difference in distribution of tumor size between three groups. In addition, no difference was found in operation time, length of hospital stay and complication. However, less laparoscopic staplers were used for area II SMTs during wedge resection. In area I group, except one patient with huge shwannoma, all patients underwent laparoscopic wedge resection, and there was no stricture or reflux postoperatively. Among area II cases, 1 carcinoid at duodenal bulb and two GISTs involving pyloric ring underwent laparoscopic assisted distal gastrectomy and the others underwent laparoscopic wedge resection including 1 hybrid resection with intraoperative gastrofiberscope in small size duodenal carcinoid. Following wedge resection, concurrent gastrojejunostomy was mandatory in 2 patients resulting structural deformity after wedge resection.

assisted distal gastrectomy and the others underwent laparoscopic wedge resection including 1 hybrid resection with intraoperative gastrofiberscope in small size duodenal carcinoid. Following wedge resection, concurrent gastrojejunostomy was mandatory in 2 patients resulting structural deformity after wedge resection. Characteristics of 70 GISTs and their oncologic outcomes Among 70 GISTs there were 8 patients in high, 17 in intermediate, 32 in low, and 13 in the very low risk group, according to NIH GIST risk classification [5]. There was no statistical correlation between risk grade and tumor location or morphologic feature. The mean tumor size was 2.7 ± 1.6 cm (range, 0.4-8.5 cm). Linear regression analysis shows the close correlation between mitotic figure and tumor size. (Mitotic figure = 0.564 + 1.432 × tumor size, P = 0.002, R = 0.144) (Fig. 2). All patients underwent R0 curative resection except 1 patient with peritoneal sarcomatosis involved in high risk group. The patient who received palliative resection was diagnosed with gastric SMT 2 years prior to surgery, which increased in size from 1.7 to 8.5 cm. On diagnostic laparoscopy, carcinomotosis nodules were already scattered in the peritoneal cavity and omentum. There was 1 recurrence out of 69 GIST patients who underwent curative surgery (median, 15 months; range, 1-64 months). In addition, survival analysis between high risk group and other groups differed significantly in 3-year disease free survival (Fig. 3) (high risk group vs. intermediate and low risk group: 85.7% vs. 100%, P = 0.028).

rrence out of 69 GIST patients who underwent curative surgery (median, 15 months; range, 1-64 months). In addition, survival analysis between high risk group and other groups differed significantly in 3-year disease free survival (Fig. 3) (high risk group vs. intermediate and low risk group: 85.7% vs. 100%, P = 0.028). DISCUSSION Since Fowler and White [6] performed first laparoscopic wedge resection for gastric SMT, laparoscopic surgery for gastric SMT has rapidly increased with the pace of diagnosis. The major concern during operation for gastroduodenal SMTs is GIST. Because treatment strategy for GIST was not involving lymph node dissection, local resection with grossly negative margin and avoidance of tumor rupture are the recommended treatment option [7]. With satisfaction of those conditions, any type of laparoscopic approach can be justified for the gastric GIST and other SMTs without limitations, theoretically. However there are always some limitations regarding with the tumor size or difficult locations.

nce of tumor rupture are the recommended treatment option [7]. With satisfaction of those conditions, any type of laparoscopic approach can be justified for the gastric GIST and other SMTs without limitations, theoretically. However there are always some limitations regarding with the tumor size or difficult locations. The SMTs larger than 2 cm are usually recommended for surgical resection [2]. However when the tumor size is less than 2 cm, making a decision for operation is less certain. If SMT is not a GIST or another malignant condition, surgical resection is not mandatory, because most non-GIST SMTs such as leiomyoma, ectopic pancreas or schwannoma are benign condition. In our series, there were 20 GISTs (44.4%) among all STMs less than 2 cm in size, and there was one malignant carcinoid tumor with size less than 2 cm. Especially, the size of the palliative resection case was less than 2 cm when diagnosed 2 year before surgery. For these reasons, it is hard to say that observation is the choice for the gastric SMTs less than 2 cm. Surgical resection is required when the morphologic feature or biopsy is suspicious for GIST or others with malignant potentials.

he palliative resection case was less than 2 cm when diagnosed 2 year before surgery. For these reasons, it is hard to say that observation is the choice for the gastric SMTs less than 2 cm. Surgical resection is required when the morphologic feature or biopsy is suspicious for GIST or others with malignant potentials. Regarding the correlation of diagnosis and tumor location, there were some reports showing similar results with our study [8]. According to our data, there are some patterns of tumor location. (1) All the SMTs in fundus are GIST. (2) Leiomyoma is the most frequent tumor among cardiac lesions. (3) Ectopic pancreas and schwannoma are mostly located at the distal part of the stomach. Considering these patterns, we can recommend surgical resection for the SMTs in fundus, even the size is small. For other sites, preoperative endoscopic incisional biopsy or endoscopic ultrasound (EUS)-guided fine needle biopsy can be helpful in making a preoperative diagnosis and avoiding unnecessary surgery, especially in cardia.

hese patterns, we can recommend surgical resection for the SMTs in fundus, even the size is small. For other sites, preoperative endoscopic incisional biopsy or endoscopic ultrasound (EUS)-guided fine needle biopsy can be helpful in making a preoperative diagnosis and avoiding unnecessary surgery, especially in cardia. Laparoscopic surgical resection cannot be easily applied to tumors located near the EGJ and pylorus, because of high risk of deformity or leakage [9,10]. Lee et al. [8] showed the size of SMTs in cardia is smaller than that of body and fundus. Furthermore endophytic SMTs were significantly more common at cardia. In our study there was no difference in size between cardia and noncardia group, but more endophytic lesions occurred in the cardia. Additionally, younger patients had more cardia tumors. Regarding with area II SMTs, it includes 7 in duodenal bulb and 4 in prepyloric antrum including 2 at pylorus. There was no complication in area I and area II such as reflux or outlet obstruction. However, in two cases of duodenal bulb, we performed preventive laparoscopic gastrojejunostomy due to structural deformity following wedge resection. Actually, a case included in area III showed gastric outlet obstruction. In this case, the lesion was located at antrum, lesser curvature side. Maybe, longitudinal stapling made structural deformity and gastric outlet obstruction. For this reason, thorough consideration for the direction of stapling is needed when exogastric resection for the SMTs located antrum, lesser curvature near pylorus.

this case, the lesion was located at antrum, lesser curvature side. Maybe, longitudinal stapling made structural deformity and gastric outlet obstruction. For this reason, thorough consideration for the direction of stapling is needed when exogastric resection for the SMTs located antrum, lesser curvature near pylorus. Regarding surgical procedures, small, endophytic features and posterior wall location might suggest a need for gastrotomy and transgastric resection. In our group, more transgastric resections were required in cardia group not only for visualization of endophytic morphology and posterior wall mass, but also for visualization of EGJ during resection not to make injury. In our experience, when we perform transgastric resection for endophytic SMTs, traction of the mass was done by suturing the mass before clamping the laparoscopic stapler, so it seems that resection was done with partial thickness of the gastric wall. This technique can minimize the extent of resection and make secure resection away from the injury of EGJ.

nsgastric resection for endophytic SMTs, traction of the mass was done by suturing the mass before clamping the laparoscopic stapler, so it seems that resection was done with partial thickness of the gastric wall. This technique can minimize the extent of resection and make secure resection away from the injury of EGJ. In our series, 70 cases of GIST including 8 high risk patients underwent curative laparoscopic resection except 1 peritoneal sarcomatosis case. Among curative resection cases, one female patient who underwent laparoscopic resection for an 8.5 cm GIST (7 mitosis/50 high-power field) developed recurrence. The CT scan performed 6 months postoperatively revealed recurrence at the small bowel mesentery and trocar site. Imatinib was started at the dose of 400 mg per day and the masses regressed after medication for 1 year. She stopped medication for 8 months because of anorexia and general weakness. The trocar site tumor returned, and Imatinib was restarted. Now the patient is in the complete resolution state, and medication is maintained. There are some reports showing oncologic outcomes regarding recurrence following laparoscopic resection for gastric GIST [4,11,12]. However, the sample size is small and there were only small numbers of high risk patients in laparoscopic resection group. Otani et al. [2] reported 3 recurrences among 9 high risk GIST patients and 96.1% of 5-year disease free survival rate. Although our data showed similar rate of recurrence in high risk patients compared with other reports with open surgery, considering the number of recurred cases, larger size (>5 m) high risk GIST should be reconsidered when performing laparoscopic resection.

IST patients and 96.1% of 5-year disease free survival rate. Although our data showed similar rate of recurrence in high risk patients compared with other reports with open surgery, considering the number of recurred cases, larger size (>5 m) high risk GIST should be reconsidered when performing laparoscopic resection. Other gastric SMTs such as leiomyoma, ectopic pancreas and schwannomas are benign slow growing neoplasms with excellent prognosis after surgical resection. They are usually asymptomatic but may become clinically evident when complicated by pathologic changes such as inflammation, bleeding, obstruction, and malignant transformation. They may occur everywhere in the stomach. In our series, gastric cardia was the most common site for leiomyoma with endophytic nature. Ectopic pancreas and schwannomas were mostly located at the distal part of the stomach, with endophytic growth for ectopic pancreas and exphophytic growth pattern for schwannoma. All these tumors were below 5 cm in size except one 5.5-cm-sized schwannoma located at body anterior wall.

n with standard oral diets in patients undergoing major surgical procedures. Control patients received a standard oral diet and were compared to patients receiving 10 days of nasogastric enteral nutrition. Major complications were reduced from 30% in the control group to 10% in the enteral nutrient group in this study. A recent meta-analysis of 107 studies reported that preoperative smoking was found to be associated with an increased risk of the following postoperative complications: general morbidity, wound complications, general infections, pulmonary complications, neurological complications, and admission to the intensive care unit [14]. Another meta-analysis of 140 studies investigated preoperative smoking and postoperative wound healing complications and found a higher risk of wound healing complications among smokers than among nonsmokers and smoking cessation intervention reduced surgical site infections (OR, 0.43; 95% confidence interval [CI], 0.21-0.85) [15]. In the present study, we confirmed that smoking was a high risk factor for ileus, wound infection, intra-abdominal abscess, pneumonia and anastomotic leakage.

leiomyoma with endophytic nature. Ectopic pancreas and schwannomas were mostly located at the distal part of the stomach, with endophytic growth for ectopic pancreas and exphophytic growth pattern for schwannoma. All these tumors were below 5 cm in size except one 5.5-cm-sized schwannoma located at body anterior wall. There are some limitations to our study. First, this is retrospective and noncomparative study. Since August 2004, we performed gastric SMTs mostly with laparoscopic approach except for very large or complicated cases. For this reason, we had very little data of open resection for gastric SMTs during the contemporary period. Second, we analyzed the diagnosis of SMTs according to only gross features. If we had data of predictive diagnosis according to CT or EUS findings, there may be more valuable results regarding estimation of diagnosis preoperatively. In conclusion, laparoscopic resection was suitable and safe for relatively small to medium sized gastroduodenal SMTs including GISTs even in the cardia or peripylorus including duodenal first portion. In cardiac lesions, laparoscopic wedge resection is safely adopted. However, stricture should be considered for peripyloric SMTs. No potential conflict of interest relevant to this article was reported. Fig. 1 Distribution of gastroduodenal submucosal tumors according to diagnosis and size. GIST, gastrointestinal stromal tumor. Fig. 2 Linear regression model shows close correlation of tumor size and mitotic figures in gastrointestinal stromal tumor.

In conclusion, laparoscopic resection was suitable and safe for relatively small to medium sized gastroduodenal SMTs including GISTs even in the cardia or peripylorus including duodenal first portion. In cardiac lesions, laparoscopic wedge resection is safely adopted. However, stricture should be considered for peripyloric SMTs. No potential conflict of interest relevant to this article was reported. Fig. 1 Distribution of gastroduodenal submucosal tumors according to diagnosis and size. GIST, gastrointestinal stromal tumor. Fig. 2 Linear regression model shows close correlation of tumor size and mitotic figures in gastrointestinal stromal tumor. Fig. 3 Disease free survival between high risk versus low and intermediate risk groups of gastrointestinal stromal tumor patients underwent curative resection. Table 1 Clinicopathologic and surgical outcomes of 125 gastroduodenal submucosal tumors underwent laparoscopic resection Values are presented as mean ± standard deviation (range) or number (%). GIST, gastrointestinal stromal tumor; LADG, laparoscopy assisted-distal gastrectomy; LATG, laparoscopy assisted total gastrectomy; RHC, right hemicolectomy. a)Pyloric stricture (1) and leakage (1) in gastric submucosal tumor. Table 2 Prevalence of gastroduodenal submucosal tumors by tumor location Values are presented as number (%). GIST, gastrointestinal stromal tumor. Table 3 Growth pattern and size of gastric submucosal tumors by diagnosis Values are presented as number (%) or mean ± standard deviation. GIST, gastrointestinal stromal tumor

a)Pyloric stricture (1) and leakage (1) in gastric submucosal tumor. Table 2 Prevalence of gastroduodenal submucosal tumors by tumor location Values are presented as number (%). GIST, gastrointestinal stromal tumor. Table 3 Growth pattern and size of gastric submucosal tumors by diagnosis Values are presented as number (%) or mean ± standard deviation. GIST, gastrointestinal stromal tumor Table 4 Comparison of clinicopathologic and surgical results according to the tumor location Values are presented as number (%) or mean ± standard deviation. GIST, gastrointestinal stromal tumor; LADG, laparoscopy assisted-distal gastrectomy; LATG, laparoscopy assisted total gastrectomy.

INTRODUCTION The stress of surgery can increase the rate of perioperative morbidity and mortality [1]. Especially, the rate of postoperative complication is higher in gastrointestinal surgery, which results in increased hospital stay and cost [2]. The reported prevalence of malnutrition in gastrointestinal surgery patients ranges from 30% to 50% [3]. Malnutrition has been consistently associated with poor clinical outcomes, for example; impaired wound healing, higher infection rates and mortality as well as longer hospital stay, leading to increased overall costs [4,5]. Perioperative nutritional support in malnourished patients decreases postoperative complications such as wound infections and sepsis [4,6]. Therefore, nutritional risk screening (NRS) may be helpful to decrease the rate of postoperative complications. Routine screening of patients to identify risk of malnutrition has been recommended by many national, international, and specialist organizations [7]. NRS 2002 was introduced at the European Society for Clinical Nutrition and Metabolism (ESPEN) in 2002 [8]. This method is a reliable, easily applied and reproducible tool for identifying patients at nutritional risk in hospital. Its predictive value was documented by a retrospective analysis of 128 randomized controlled trials of nutritional support [9]. The aims of the present study were to evaluate the prevalence of malnutrition, by means of screening tool, NRS 2002, and to analyze the role of malnutrition in predicting postoperative complications in patients undergoing surgery for colorectal cancer.

NRS 2002 was introduced at the European Society for Clinical Nutrition and Metabolism (ESPEN) in 2002 [8]. This method is a reliable, easily applied and reproducible tool for identifying patients at nutritional risk in hospital. Its predictive value was documented by a retrospective analysis of 128 randomized controlled trials of nutritional support [9]. The aims of the present study were to evaluate the prevalence of malnutrition, by means of screening tool, NRS 2002, and to analyze the role of malnutrition in predicting postoperative complications in patients undergoing surgery for colorectal cancer. METHODS All patients diagnosed with colorectal cancer and scheduled for elective surgery in a single center between February 2010 and July 2011 were enrolled this study. During this period, a total of 545 patients went into hospital for surgery. We interviewed all patients at admission. Three hundred fifty-two patients who precisely answered their weight status and amount of oral intake status were enrolled in this study. There were no restrictions with regard to tumor stage or comorbidity. Data of patient characteristics, operative findings, pathologic reports, and postoperative outcome records were collected retrospectively. In addition, preoperative weight loss and amount of oral intake during 3 months before admission, nutritional risk as determined by the NRS 2002 at hospital admission, and patient social history: smoking status (active smoker) and alcohol consumption (intake over 70 g/day) were recorded. We defined a group of weight loss as decreased more than 5% in 3 months. A group of decrease of food oral intake was defined as decreased more than 25% in 3 months. Body height and weight were measured on the day of admission, and body mass index (BMI) was calculated. Serum albumin level was determined on the day of admission to hospital. Postoperative complications during hospital stay includes anastomotic leakage, intra-abdominal bleeding, ileus (more than two weeks), wound infection, intra-abdominal abscess, pneumonia, chylous leakage and so on.

y mass index (BMI) was calculated. Serum albumin level was determined on the day of admission to hospital. Postoperative complications during hospital stay includes anastomotic leakage, intra-abdominal bleeding, ileus (more than two weeks), wound infection, intra-abdominal abscess, pneumonia, chylous leakage and so on. Nutritional risk screening 2002 The NRS 2002 is used to predict outcome based on risk parameters identified in the nutritional assessment [8]. Nutritional risk is evaluated by two components: impaired nutritional status and severity of disease. The NRS 2002 is based on four variables-weight loss, BMI, general condition and amount of food intake in the preceding week-in addition to the patient's age and the severity of the underlying disease. The total score, calculated from the impaired nutritional status section (score, 0-3), the score for severity of disease (indicator of stress metabolism and increased nutritional requirements; score 0-3) and age adjustment (score + 1 for age over 70 years), ranges from 0 to 7. Patients are classified as being at nutritional risk (score 3 or more) or not (score less than 3) according to the total score obtained.

re for severity of disease (indicator of stress metabolism and increased nutritional requirements; score 0-3) and age adjustment (score + 1 for age over 70 years), ranges from 0 to 7. Patients are classified as being at nutritional risk (score 3 or more) or not (score less than 3) according to the total score obtained. Statistical analysis Statistical analyses were performed using PASW version 18.0 (SPSS Inc., Chicago, IL, USA). Continuous variables (age, BMI, and operative time) were dichotomized, using the mean value of each variable. Chi-square or Fisher exact test for categorical variables was used for statistical comparisons of clinical parameters, operative time, operative methods, preoperative nutritional status and NRS 2002. Multivariate analysis to detect risk factors for postoperative complications was conducted with a logistic regression model. Chi-square tests were also used to analyze morbidity variables associated with weight loss. A value of P < 0.05 was deemed statistically significant. RESULTS Ninety-five of 352 patients (27.0%) had complications; deaths were excluded from this analysis. There was one death in hospital (mortality rate 0.3%). The cause of death was acute myocardial infarction. Major postoperative complications are shown in Table 1.

Statistical analysis Statistical analyses were performed using PASW version 18.0 (SPSS Inc., Chicago, IL, USA). Continuous variables (age, BMI, and operative time) were dichotomized, using the mean value of each variable. Chi-square or Fisher exact test for categorical variables was used for statistical comparisons of clinical parameters, operative time, operative methods, preoperative nutritional status and NRS 2002. Multivariate analysis to detect risk factors for postoperative complications was conducted with a logistic regression model. Chi-square tests were also used to analyze morbidity variables associated with weight loss. A value of P < 0.05 was deemed statistically significant. RESULTS Ninety-five of 352 patients (27.0%) had complications; deaths were excluded from this analysis. There was one death in hospital (mortality rate 0.3%). The cause of death was acute myocardial infarction. Major postoperative complications are shown in Table 1. There were 202 men and 150 female with a median age of 62.9 years (range, 20-92 years). The median BMI was 24.2 kg/m2 (range, 16-33 kg/m2). One hundred fifty-four patients (43.8%) had comorbidity. The most common comorbidities were hypertension (138 patients, 39.2%), diabetes (18 patients, 5.1%), heart problem (7), pulmonary (6), liver cirrhosis (5) and others. Mean length of hospital stay was 8.2 days (range, 3-22 days).

s 24.2 kg/m2 (range, 16-33 kg/m2). One hundred fifty-four patients (43.8%) had comorbidity. The most common comorbidities were hypertension (138 patients, 39.2%), diabetes (18 patients, 5.1%), heart problem (7), pulmonary (6), liver cirrhosis (5) and others. Mean length of hospital stay was 8.2 days (range, 3-22 days). Table 2 shows the results of the univariate and multivariate analyses for factors potentially contributing to postoperative complications. Age, sex, underlying disease and American Statistical Association (ASA) class were not risk factors for complication. Smoking was a significant risk factor of morbidity (18.4% vs. 44.1%, P = 0.001). Tumor location and stage were not risk factors for postoperative complication. The mean operative time was 283 ± 95 minutes. Operative time and laparoscopic procedure were not independent factors for postoperative complication.

mplication. Smoking was a significant risk factor of morbidity (18.4% vs. 44.1%, P = 0.001). Tumor location and stage were not risk factors for postoperative complication. The mean operative time was 283 ± 95 minutes. Operative time and laparoscopic procedure were not independent factors for postoperative complication. The prevalence of patients at nutritional risk in this surgical population was 99 (28.1%) with NRS 2002. NRS 2002 was used to classify nutritional risk, the complication rate was higher for patients at risk and those not at risk (37.4% [37 of 99] vs. 22.9% [58 of 253], P = 0.006). BMI and serum albumin were not risk factors of postoperative complication. Weight loss and decrease of food oral intake were risk factors of postoperative complication (20.6% vs. 34.8%, P = 0.003 and 23.6% vs. 40.3%, P = 0.004). Multivariate analysis indicated that malnutrition (odds ration [OR], 3.05; P = 0.045), heavy smoking (OR, 3.32; P = 0.001) and weight loss (OR, 2.31; P = 0.002) were independent risk factors influencing postoperative complications. The postoperative hospital stays were longer in the nutritional risk group (8.9 ± 4.2 days) than in the no risk group (7.8 ± 3.5 days) (P = 0.019). Results of analysis of the relationship between risk factors for postoperative complication and duration of hospital stays are detailed in Table 3. The relationship between malnutrition and each complication are shown in Table 4. Malnutrition was an independent risk factor for anastomotic leakage (P = 0.027) and wound infection (P = 0.01).

among smokers than among nonsmokers and smoking cessation intervention reduced surgical site infections (OR, 0.43; 95% confidence interval [CI], 0.21-0.85) [15]. In the present study, we confirmed that smoking was a high risk factor for ileus, wound infection, intra-abdominal abscess, pneumonia and anastomotic leakage. Malnutrition was found to be associated with a significant risk of anastomotic leakage and wound infection. Zhu et al. [16] reported that preoperative malnutrition increased the rate of anastomotic leakage in which 132 patients underwent low anterior resection. In the series by Zhu et al. [16], anastomotic leakage increased hospital length and cost. Kang et al. [17] further supported this finding that malnutrition (OR, 2.81; 95% CI, 2.32-3.40), on multivariate analysis, was an independent risk factor for anastomotic leakage after anterior resection for rectal cancer in 72,055 patients. Putwatana et al. [18] reported that malnutrition is an important risk factor for postoperative infectious and wound complications in patients undergoing major surgery.

2-3.40), on multivariate analysis, was an independent risk factor for anastomotic leakage after anterior resection for rectal cancer in 72,055 patients. Putwatana et al. [18] reported that malnutrition is an important risk factor for postoperative infectious and wound complications in patients undergoing major surgery. In conclusion, the present study has demonstrated that patients at nutritional risk have higher complication rates after surgery for colorectal cancer. Especially, malnutrition increases the rate of anastomotic leakage and wound infection. Malnutrition was also a significant risk factor for the length of hospital stay. A large scaled prospective study of whether supplementing nutritional deficits reduces postoperative complication rates is required. It is expected that NRS 2002 would be helpful in screening malnutrition. No potential conflict of interest relevant to this article was reported. Table 1 Major postoperative complications (n = 352) Table 2 Univariate and multivariate analyses for factors potentially contributing to postoperative complication Values are presented as number (%). OR, odds ratio; CI, confidence interval; Preop, preoperative; NRS, nutritional risk screening. Table 3 The length of hospital stays and risk factors for postoperative complication Values are presented as mean ± standard deviation. NRS, nutritional risk screening. Table 4 Postoperative complications by malnutrition Values are presented as number (%). OR, odds ratio; CI, confidence interval.

INTRODUCTION Colorectal cancer (CRC) is the second leading cause of cancer related death in Western countries and the third most common cancer in Korea [1,2]. Approximately one-fourth of CRC patients have metastasis on diagnosis. Liver is the most common site of metastasis and lung is the second most common site in CRC [3,4]. Autopsy data showed that 15% of patients with CRC have pulmonary metastasis, and that 9.4% of all pulmonary metastases at autopsy are from CRC [5].

2]. Approximately one-fourth of CRC patients have metastasis on diagnosis. Liver is the most common site of metastasis and lung is the second most common site in CRC [3,4]. Autopsy data showed that 15% of patients with CRC have pulmonary metastasis, and that 9.4% of all pulmonary metastases at autopsy are from CRC [5]. For the assessment of the chest in the initial staging of patients with CRC, chest x-ray (CXR), abdominal CT (with pulmonary hilar extension), chest CT, PET (positron emission tomography) or combined PET/CT modalities have all been described [6]. Traditionally, pulmonary staging for CRC has been carried out by means of CXR. Chest CT is not performed routinely if a patient does not show abnormality on CXR [3]. Nowadays, chest CT is performed more frequently due to its high sensitivities of 51%-73% and specificities of up to 74%, regardless of the result of CXR [7,8,9]. And, the advancement of CT technology detects not only more numerous nodules but also smaller ones [10,11]. However, this modality has the potential to detect more indeterminate lung lesions (20%-30%) that may require further investigations, referrals and follow-up. Actually, these lesions are usually difficult to determine and seldom malignant. (10%-20%) [3,12,13] And, additional assessments, such as repeat CT, PET and percutaneous or open biopsy can increase not only patients' burden but also patients' worry of the exposure to radiation during CT scan.

, referrals and follow-up. Actually, these lesions are usually difficult to determine and seldom malignant. (10%-20%) [3,12,13] And, additional assessments, such as repeat CT, PET and percutaneous or open biopsy can increase not only patients' burden but also patients' worry of the exposure to radiation during CT scan. The aim of this study was to suggest a guideline for performing chest CT for preoperative pulmonary staging in the patients who have no abnormal finding on CXR, which could prevent performing chest CT indiscriminately and reduce patients' burden. METHODS One hundred twenty patients who had been undergone colorectal surgery at Ewha Womans University Mokdong Hospital due to CRC without any pulmonary nodule on CXR were included in this study. They were all diagnosed with CRC pathologically and received CXR and chest CT for preoperative pulmonary staging. Patients who had exhibited metastatic lesion on CXR regardless of the result of chest CT were excluded. Patients' medical records were reviewed and analyzed retrospectively. On chest CT, pulmonary nodules that had been confirmed as metastasis by radiologists were referred to as 'metastatic nodule' and nodules that had been suspected as benign nodule where the possibility of metastasis had not been excluded by radiologists were referred to as 'indeterminate nodule'. Radiologists determined the 'metastatic nodule' with the characteristics of smooth margin, monogonal shape and diffuse scattered distribution.

odule' and nodules that had been suspected as benign nodule where the possibility of metastasis had not been excluded by radiologists were referred to as 'indeterminate nodule'. Radiologists determined the 'metastatic nodule' with the characteristics of smooth margin, monogonal shape and diffuse scattered distribution. Patients were divided into two groups by the presence of 'metastatic nodule' or 'indeterminate nodule' and analyzed in the six contents. The contents are in intervals from the time of surgery to the appearance of extrapulmonary metastasis, the positivity of pulmonary metastasis on PET, the presence of preoperative extrapulmonary metastasis, serum level of CEA, the presence of metastatic lymph node (LN) on abdominal CT, and the location of primary tumor. The interval from the time of surgery to the appearance of extrapulmonary metastasis was used for the assessment of the clinical value of the positivity of chest CT and five other contents were analyzed for the evaluation of the relationship with pulmonary metastasis. The interval from the time of surgery to the appearance of extrapulmonary metastasis was estimated by the Kaplan-Meier method and differences between the groups in the other four contents were analyzed with chi-square test. A level of P < 0.05 was regarded as statistically significant.

Patients were divided into two groups by the presence of 'metastatic nodule' or 'indeterminate nodule' and analyzed in the six contents. The contents are in intervals from the time of surgery to the appearance of extrapulmonary metastasis, the positivity of pulmonary metastasis on PET, the presence of preoperative extrapulmonary metastasis, serum level of CEA, the presence of metastatic lymph node (LN) on abdominal CT, and the location of primary tumor. The interval from the time of surgery to the appearance of extrapulmonary metastasis was used for the assessment of the clinical value of the positivity of chest CT and five other contents were analyzed for the evaluation of the relationship with pulmonary metastasis. The interval from the time of surgery to the appearance of extrapulmonary metastasis was estimated by the Kaplan-Meier method and differences between the groups in the other four contents were analyzed with chi-square test. A level of P < 0.05 was regarded as statistically significant. RESULTS Of 120 patients enrolled in this study, 69 patients were male and 51 patients were female. Their age distribution and mean age were from 37 to 85 and 64.2 years old, respectively. The tumors originated from the colon in 74 patients (61.7%) and rectum in 46 patients (38.3%). According to the TNM classification proposed by the American Joint Committee on Cancer cancer staging manual, 7th edition [14], 2 CRCs (1.7%) were stage 0, 19 CRCs (15.8%) were stage I, 38 CRCs (31.7%) were stage II, 31 CRCs (25.8%) were stage III, and 30 CRCs (25.0%) were stage IV (Table 1).

um in 46 patients (38.3%). According to the TNM classification proposed by the American Joint Committee on Cancer cancer staging manual, 7th edition [14], 2 CRCs (1.7%) were stage 0, 19 CRCs (15.8%) were stage I, 38 CRCs (31.7%) were stage II, 31 CRCs (25.8%) were stage III, and 30 CRCs (25.0%) were stage IV (Table 1). For the assessment of clinical value of positivity on chest CT, we divided patients by the presence of metastatic nodules or indeterminate nodule on preoperative chest CT and compared the mean interval from the time of surgery to the appearance of extrapulmonary metastasis. In the patients with metastatic nodules, the mean interval was 83.7 weeks and it was 150.7 weeks in the patients without metastatic nodules (P < 0.001). After adjusting for pathologic stage, it showed significant value (P = 0.048). When indeterminate nodules were present, the mean interval was 150.9 weeks and it was 146.6 weeks when indeterminate nodules were not present (P = 0.185). Adjusting for pathologic stage, it did not show significant value (P = 0.812).

0.001). After adjusting for pathologic stage, it showed significant value (P = 0.048). When indeterminate nodules were present, the mean interval was 150.9 weeks and it was 146.6 weeks when indeterminate nodules were not present (P = 0.185). Adjusting for pathologic stage, it did not show significant value (P = 0.812). To find the factors associated with metastatic pulmonary nodules on preoperative evaluation, we divided patients into two groups by the presence of metastatic nodules and compared them in five contents of the positivity of pulmonary metastasis on PET, the presence of preoperative extrapulmonary metastasis, serum level of CEA, the presence of metastatic LNs on abdominal CT, and the location of primary tumor (Table 2). Of 21 patients with metastatic nodules on chest CT, 5 patients (23.8%) showed pulmonary metastasis on PET, but patients without metastatic nodules did not show any pulmonary metastasis on PET (P < 0.001).

s, serum level of CEA, the presence of metastatic LNs on abdominal CT, and the location of primary tumor (Table 2). Of 21 patients with metastatic nodules on chest CT, 5 patients (23.8%) showed pulmonary metastasis on PET, but patients without metastatic nodules did not show any pulmonary metastasis on PET (P < 0.001). Among the 21 patients with metastatic pulmonary nodules, 47.6% showed extrapulmonary metastasis on preoperative evaluation but, only 10.1% of 99 patients without metastatic pulmonary nodules, had extrapulmonary metastatic lesion (P < 0.001). In the patients with metastatic nodules on chest CT, 13 patients (61.9%) showed elevated serum CEA level above 10 ng/mL (normal range, 0-5 ng/mL). Meanwhile, there were 20 patients (21.1%) among those without metastatic nodules on chest CT, which showed significant difference (P < 0.001). Considering the presence of metastatic LN on abdominal CT, pulmonary metastatic nodule on chest CT did not show significant relationship with the presence of metastatic LN on abdomen CT (P = 0.223). Also, rectal cancer did not show significant association with metastatic nodules on chest CT (P = 0.639).

ce (P < 0.001). Considering the presence of metastatic LN on abdominal CT, pulmonary metastatic nodule on chest CT did not show significant relationship with the presence of metastatic LN on abdomen CT (P = 0.223). Also, rectal cancer did not show significant association with metastatic nodules on chest CT (P = 0.639). To reveal the association of indeterminate pulmonary nodules with the factors analyzed to find the relationship with metastatic pulmonary nodules, we divided patients by the presence of indeterminate pulmonary nodules on chest CT and compared them in the same manner as metastatic pulmonary nodules (Table 3). In the patients with or without indeterminate nodule, there was no patient showing pulmonary metastasis on PET. Of 20 patients with indeterminate nodule on chest CT, no patient had extrapulmonary metastasis, and 10 patients among 79 patients without indeterminate nodule (12.7%) showed extrapulmonary metastasis. This result had no statistical significance (P = 0.206). In the patients with indeterminate nodule on chest CT, 3 patients (15.8%) exhibited elevation of serum CEA level above 10 ng/mL, but compared with the patients without indeterminate nodule, there was no significant value (P = 0.529). Considering metastatic LN on abdominal CT, 14 patients (70.0%) and 55 patients (69.6%) showed the existence and absence of indeterminate nodule on chest CT, respectively, and there was no significant relationship between them (P = 0.974). Patients with rectal cancer presented indeterminate nodule in only 4 patients (20.0%) and 33 patients (41.8%) did not exhibit indeterminate nodule. This result was not significant statistically, either (P = 0.072).

ate nodule on chest CT, respectively, and there was no significant relationship between them (P = 0.974). Patients with rectal cancer presented indeterminate nodule in only 4 patients (20.0%) and 33 patients (41.8%) did not exhibit indeterminate nodule. This result was not significant statistically, either (P = 0.072). Of 21 patients with metastatic pulmonary nodule, 16 patients showed aggravated metastatic lesion on follow-up chest CT after CRC surgery and 5 patients did not show any interval change of pulmonary nodule. Among the 5 patients without interval change of pulmonary nodule, two patients had surgical resection of metastatic pulmonary lesion performed, which had been proved as metastatic colon cancer, pathologically. In the patients with indeterminate pulmonary nodule, only one patient showed aggravation of metastatic lesion on follow-up study (Fig. 1).

interval change of pulmonary nodule, two patients had surgical resection of metastatic pulmonary lesion performed, which had been proved as metastatic colon cancer, pathologically. In the patients with indeterminate pulmonary nodule, only one patient showed aggravation of metastatic lesion on follow-up study (Fig. 1). DISCUSSION Most guidelines concerning the staging of CRC agree that the chest should be imaged preoperatively, but there is disagreement regarding the exact type of imaging modality [6]. The 2005 Australian Government National Health and Medical Research Council Clinical Prevention, Early Detection and Management of Colorectal Cancer, the 2007 guidelines of the management of CRC issued by the Association of Coloproctology of Great Britain and Ireland, and the 2010 National Comprehensive Cancer Network Guidelines of colon and rectal cancer recommend CT scan as a routine preoperative staging modality instead of CXR [5,6,7,8,9,10,11,12,13,14,15,16,17]. While, the Scottish Guidelines Network and the American Society of Colon and Rectal Surgeons do not specify which form of imaging is most appropriate [18,19]. Regardless of this disagreement, with high sensitivities and specificities, the use of chest CT as a routine preoperative pulmonary staging is increasing [7,8,9]. But, recently, some reports suggest the disadvantage of routine preoperative pulmonary staging with CT, such as costs, radiation exposure, prolonged uncertainty because of the frequent finding of indeterminate lesions and increased patients' anxiety [6,20]. In a study by Povoski et al. [21], the authors reported a positive yield for malignancy of only 4% on CT and a positive predictive value for CT of 36% for detection of malignant lesions of the lung. In another study by Grossmann et al. [20], a prospective study of 200 patients with CRC, detected indeterminate pulmonary nodule in 50 patients. Out of 50 patients, 48 additional investigations were required. But, malignant pulmonary changes were detected only in 10 of the patients and no patient the operative plan changed or received neoadjuvant treatment. The authors concluded that routine chest CT staging should not be advocated. In our study, there were 21 patients with metastatic nodule and 20 patients with indeterminate nodule among 120 patients with CRC. To assess the clinical value of metastatic and indeterminate nodule, we analyzed the interval from the time of surgery to the appearance of extrapulmonary metastasis.

ould not be advocated. In our study, there were 21 patients with metastatic nodule and 20 patients with indeterminate nodule among 120 patients with CRC. To assess the clinical value of metastatic and indeterminate nodule, we analyzed the interval from the time of surgery to the appearance of extrapulmonary metastasis. Patients with metastatic nodule showed significant shorter interval than the patients without metastatic nodule. But, comparing with the patients without indeterminate nodule, patients with indeterminate nodule did not show significant results. This suggests that the indeterminate nodule can mimic pulmonary staging but does not have significant effect on the patients' clinical course.

than the patients without metastatic nodule. But, comparing with the patients without indeterminate nodule, patients with indeterminate nodule did not show significant results. This suggests that the indeterminate nodule can mimic pulmonary staging but does not have significant effect on the patients' clinical course. With limited clinical value of indeterminate pulmonary nodules and increasing detection of them by the advancement of CT technology, some reports advocated that chest CT should not be performed as a routine preoperative pulmonary staging and defining high-risk patient groups and predictive factors for pulmonary metastasis is required to prevent indiscriminate chest CT and reduce patients' burden [6,20]. Traditionally, chest CTs have been performed when abnormality on CXR is present. And, several authors suggesting high-risk groups of developing pulmonary metastasis have included patients with rectal cancer and those with liver metastasis [20,22]. The perceived higher risk of developing pulmonary metastasis from patients with rectal cancer has been attributed to the direct spread into the systemic circulation via the inferior and middle rectal veins. Meanwhile, the patients with colon cancer without liver metastasis are felt to be at low risk of developing pulmonary metastasis. The venous drainage of the colon is via the portal system and the first site of spread has always been regarded as the liver. Tan et al. [23] demonstrated patients with rectal cancer were strongly associated with the presence of isolated pulmonary metastasis compared to colon cancer patients (odds ratio, 2.11; 95% confidence interval, 1.21-3.70). And, when liver metastasis is present, the subsequent spread can then occur to the lungs via systemic circulation. In our study, rectal cancer was not associated with metastatic pulmonary nodule on chest CT but the presence of extrapulmonary metastasis, such as liver, was associated with pulmonary metastasis. Additionally, the positivity of pulmonary metastasis on PET and elevated serum level of CEA above 10 ng/mL were also associated with pulmonary metastatic nodule. With these results, we can determine the high-risk group of pulmonary metastasis in patients with CRC as positivity of PET, extrapulmonary metastasis, and elevated serum CEA level above 10 ng/mL.

nary metastasis on PET and elevated serum level of CEA above 10 ng/mL were also associated with pulmonary metastatic nodule. With these results, we can determine the high-risk group of pulmonary metastasis in patients with CRC as positivity of PET, extrapulmonary metastasis, and elevated serum CEA level above 10 ng/mL. To conclude, in our opinion, when there is no evidence of pulmonary metastasis on CXR, it would be better to perform chest CT only in the high-risk groups determined as positivity of PET, extrapulmonary metastasis, and elevated serum CEA level above 10 ng/mL, not as routine imaging. And, it can be helpful to reduce patients' burden such as costs, radiation exposure, and prolonged uncertainty. No potential conflict of interest relevant to this article was reported. Fig. 1 Results of follow-up study for pulmonary nodules after surgery. a)Two patients with metastatic nodule on chest CT were performed surgical resection of metastatic pulmonary lesion; Lesions were proved as metastatic colon cancer, pathologically. CRC, colorectal cancer; CXR, chest x-ray. Table 1 Patient characteristics (n = 120) Values are presented as number (%). Table 2 Factors associated with metastatic pulmonary nodules on chest CT Values are presented as number (%). LN, lymph node. Table 3 Factors associated with indeterminate pulmonary nodules on chest CT Values are presented as number (%). LN, lymph node.

INTRODUCTION Although paraduodenal hernia is a rare congenital malformation caused by abnormal retroperitoneal fixation of the intestinal mesentery, it represents the most common type of congenital internal hernia [1,2]. These hernias result from small bowel loops herniating through the paraduodenal fossae and should always be considered when a patient with no previous surgical history presents with an intestinal obstruction [3]. We present a case of a patient who was diagnosed with concomitant acute cholecystitis and left paraduodenal hernia based on computed tomography and underwent laparoscopic reduction of a herniated bowel and closure of the hernial orifice.

ent with no previous surgical history presents with an intestinal obstruction [3]. We present a case of a patient who was diagnosed with concomitant acute cholecystitis and left paraduodenal hernia based on computed tomography and underwent laparoscopic reduction of a herniated bowel and closure of the hernial orifice. CASE REPORT A 74-year-old woman presented to the Emergency Department with persistant right upper quadrant pain that began 3 hours prior to presentation. She had an unremarkable medical history, but asymptomatic gallstones were detected during routine check-up. More specifically, she had no history of abdominal surgery or abdominal pain prior to this visit. Physical examination revealed a thin woman (height, 156 cm; weight, 49 kg) with a blood pressure of 110/70 mmHg, a pulse of 64 beats/min, and a body temperature of 36.6℃. The abdomen was tender in the right upper quadrant. No guarding and rebound tenderness were noted. The laboratory data showed neutrophilia (white blood cells, 9,710 / mm3 with 81.4% segmented neutrophils). Other blood chemistry parameters including liver function test were unremarkable. CT revealed multiple gallstones with gallbladder wall thickening, marked dilatation of stomach and duodenum and a sac-like mass of small bowel loops to the left of the ligament of Treitz (Fig. 1) suggesting acute cholecystitis and left paraduodenal hernia. After performing CT, the patient developed bilous vomiting without left abdominal pain. We proceeded to perform laparoscopic exploration of the abdomen with cholecystectomy. The defect was located at the Treitz ligament where proximal jejunal loops were noted to be herniating through the defect (Fig. 2). About 50 cm of jejunal loops were easily reduced and the bowel appeared viable. The 3-cm defect was closed using 3-0 Vicryl intracorporeal interrupted sutures. Laparoscopic cholecystectomy was then performed. The total operation time was 105 minutes. The postoperative course was uneventful and the patient was discharged on postoperative day 4. During the 6 months follow-up period, the patient remained completely free of symptoms.

3-0 Vicryl intracorporeal interrupted sutures. Laparoscopic cholecystectomy was then performed. The total operation time was 105 minutes. The postoperative course was uneventful and the patient was discharged on postoperative day 4. During the 6 months follow-up period, the patient remained completely free of symptoms. DISCUSSION Paraduodenal hernia is the most common form of internal hernias, accounting for more than 50% of all reported cases [1]. Paraduodenal hernias result from abnormal rotation of the midgut during embryonic development and can be divided into two subtypes, left and right paraduodenal hernias. Left paraduodenal hernia (hernia of Lanzert) is about three times more common than its right counterpart (Walayer's hernia) [4]. Left paraduodenal hernias arise from the fossa of Lanzert, a congenital defect that is presents in approximately 2% of the population and located at the inferior mesenteric vein and left branches of the middle colic artery [1,5]. Although paraduodenal hernias are congenital, most patients present between the 4th and 6th decades of life (median age, 47 years) with a male to female ratio of 3:1 [6]. The most common presentation is acute small bowel obstruction in the setting of recurrent vague abdominal pain [2,6]. Approximately 50% of patients with paraduodenal hernias have episodes of intestinal obstruction at certain periods in their lives [2,6]. The symptoms observed in these cases range from temporary colicky abdominal pain to signs of intestinal obstruction. Our patient was unusual in that she presented at an advanced age of 74, without prior history of abdominal pain or other gastrointestinal symptoms. The diagnosis of paraduodenal hernia formation is often difficult to make due to its ambiguous presentation. Therefore, CT scanning is a valuable initial tool for investigation. The most common radiologic signs of left paraduodenal hernia formation include clustering of small bowel loops, a sac-like mass with encapsulation at or above the ligament of Treitz, duodeno-jejunal junction depression, mass effect on the posterior stomach wall, engorgement and crowding of the mesentery vessels with frequent right displacement of the main mesenteric trunk, and depression of the transverse colon.

all bowel loops, a sac-like mass with encapsulation at or above the ligament of Treitz, duodeno-jejunal junction depression, mass effect on the posterior stomach wall, engorgement and crowding of the mesentery vessels with frequent right displacement of the main mesenteric trunk, and depression of the transverse colon. Once diagnosed, left paraduodenal hernias should be surgically treated because they carry a risk of incarceration, with the potential for bowel obstruction and strangulation. Surgical management essentially consists of reduction of the herniated small bowel loops and closure of the hernia orifice. Care must be taken not to damage the left colic artery or inferior mesenteric vessels, which are often found anterior to the hernia opening. Laparoscopy is indicated when there are no signs of bowel necrosis or dilatation of the incarcerated bowel loops [7]. A recent small case series comparing laparoscopy to open repair of paraduodenal hernias showed that the laparoscopic approach resulted in shorter hospital stay, earlier intake of a soft diet and lower rate of postoperative ileus [8].

here are no signs of bowel necrosis or dilatation of the incarcerated bowel loops [7]. A recent small case series comparing laparoscopy to open repair of paraduodenal hernias showed that the laparoscopic approach resulted in shorter hospital stay, earlier intake of a soft diet and lower rate of postoperative ileus [8]. In conclusion, left paraduodenal hernias are rare cause of intestinal obstruction; however, in the setting of recurrent small bowel obstruction and no previous surgical history, it is crucial to consider internal hernias in the differential diagnosis. Furthermore, timely surgical intervention should be performed to minimize the morbidity and mortality associated with this condition. When there is no evidence of bowel necrosis, laparoscopic surgery may be the surgical method of choice because of its minimal invasiveness and aesthetic advantage. ACKNOWLEDGEMENTS This research was supported by the Chung-Ang University Research Grants in 2010. No potential conflict of interest relevant to this article was reported. Fig. 1 Computed tomography showed a sac-like mass of jejunal loops (arrows) in the left upper quadrant. Fig. 2 Intraoperative view demonstrating a loop of small bowel prolapsing (arrow) through Landzert's fossa (arrowheads).

INTRODUCTION Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract. Most of these tumors (60%-70%) present in the stomach. The treatment of choice is surgical excision of the tumor and resection of infiltrated tissue. Prior to the year 2000, there was no known effective therapy for unresectable or metastatic GIST, because these tumors are extremely resistant to conventional cytotoxic chemotherapy and radiotherapy [1]. The discovery that these tumors express the CD117 antigen has led to substantial advances in the understanding of their biology. We know that GISTs usually have activating mutations in either KIT (75%-80%) or the platelet-derived growth factor receptor-α gene (PDGFRA) (5%-10%), which encode 2 closely related receptor tyrosine kinases; therefore, these mutations provide a rationale for the use of targeted therapies [2,3,4]. Because imatinib mesylate (Gleevec, Novartis Pharma, Basel, Switzerland), an inhibitor of KIT and PDGFRA tyrosine kinases, is now available for the treatment of metastatic and unresectable GISTs, it is important to understand the natural history of these tumors [1,2]. Although imatinib has greatly improved the survival of patients with advanced GIST, primary refractoriness or secondary resistance to imatinib therapy occurs in the majority of patients [1,2].

or the treatment of metastatic and unresectable GISTs, it is important to understand the natural history of these tumors [1,2]. Although imatinib has greatly improved the survival of patients with advanced GIST, primary refractoriness or secondary resistance to imatinib therapy occurs in the majority of patients [1,2]. Currently, the only approved second-line drug is sunitinib malate, which was approved in 2006 by the U.S. Food and Drug Administration for the treatment of GIST patients following progression or resistance to imatinib [4]. Sunitinib malate (Sutent, Pfizer, New York, NY, USA) is an oral multitargeted tyrosine kinase inhibitor of KIT, platelet-derived growth factor recepter (PDGFR), all 3 isoforms of vascular endothelial growth factor receptor (VEGFR-1, VEGFR-2, VEGFR-3), Fms-like tyrosine kinase-3 receptor, and the receptor encoded by the ret protooncogene (RET). The mechanism of sunitinib activity against GIST is similar to imatinib [3,4]. Moreover, sunitinib exerts an additional antiangiogenic activity because it inhibits the activation of VEGFR. Because of this activity, sunitinib has been thought to be beneficial for patients with imatinib-resistant GIST [3,5].

ogene (RET). The mechanism of sunitinib activity against GIST is similar to imatinib [3,4]. Moreover, sunitinib exerts an additional antiangiogenic activity because it inhibits the activation of VEGFR. Because of this activity, sunitinib has been thought to be beneficial for patients with imatinib-resistant GIST [3,5]. The most common treatment-related adverse events of sunitinib have been reported to be fatigue, diarrhea, skin discoloration, nausea, mucositis, arterial hypertension, hand-and-foot syndrome, decreased left ventricular ejection fraction, and hypothyroidism. However, sunitinib is generally well tolerated and has an acceptable toxicity profile [3,4]. The overall rate of gastrointestinal perforation associated with sunitinib is unknown, since only a few cases have been reported from trials and case reports, and the mechanism of bowel perforation from sunitinib is unknown [5,6]. Here, we present an extremely rare case of bowel perforation associated with sunitinib therapy for GIST.

The most common treatment-related adverse events of sunitinib have been reported to be fatigue, diarrhea, skin discoloration, nausea, mucositis, arterial hypertension, hand-and-foot syndrome, decreased left ventricular ejection fraction, and hypothyroidism. However, sunitinib is generally well tolerated and has an acceptable toxicity profile [3,4]. The overall rate of gastrointestinal perforation associated with sunitinib is unknown, since only a few cases have been reported from trials and case reports, and the mechanism of bowel perforation from sunitinib is unknown [5,6]. Here, we present an extremely rare case of bowel perforation associated with sunitinib therapy for GIST. CASE REPORT A 78-year-old woman with an abdominal mass for more than 1 month was admitted to Chosun University Hospital. Physical examination revealed a large mass in the periumbilical area. Abdominal computed tomography revealed an 18 cm abdominal mass with extensive central necrosis. She underwent complete resection of the mass, with total gastrectomy, distal pancreatectomy, splenectomy, and transverse colectomy (Fig. 1). Postoperative histopathologic examination showed a gastric GIST with negative resection margins and no metastatic lymph nodes. The mass was a 15 cm × 9 cm gastric GIST with 14 mitoses/50 high-power fields, and was categorized as a high-risk tumor. Immunostaining showed that the tumor was positive for C-KIT and CD34, and negative for S100 expression (Fig. 2). Adjuvant chemotherapy using oral imatinib mesilate was recommended to the patient. However, she declined treatment because it was too expensive.

0 high-power fields, and was categorized as a high-risk tumor. Immunostaining showed that the tumor was positive for C-KIT and CD34, and negative for S100 expression (Fig. 2). Adjuvant chemotherapy using oral imatinib mesilate was recommended to the patient. However, she declined treatment because it was too expensive. Eight months after the operation, the patient was found to have recurrent GIST involving the hilum and subcapsular region of the right lobe of the liver and peritoneal nodules. Imatinib (400 mg/day) was started as palliative treatment (Fig. 3A, B). At a 3-month follow-up, the liver masses had decreased and imatinib was found to be well tolerated by the patient, who continued on the same dose of iminitib (Fig. 3C, D). Follow-up imaging 6 months later showed peritoneal seeding in the region of the distal pancreas and a small amount of left pleural effusion and ascites (Fig. 3E, F). The patient refused second-line treatment, and imatinib therapy was continued despite the progression. Two months later, she was admitted because of severe dyspnea due to a large amount of pleural effusion and ascites (Fig. 4A). She requested second-line palliative oral medication without undergoing additional diagnostic evaluation.

fused second-line treatment, and imatinib therapy was continued despite the progression. Two months later, she was admitted because of severe dyspnea due to a large amount of pleural effusion and ascites (Fig. 4A). She requested second-line palliative oral medication without undergoing additional diagnostic evaluation. Before she received sunitinib, a complete blood count (CBC) showed the following: white blood cell (WBC) count, 2,990 × 103/µL; neutrophils, 65% (1,943 × 103/µL); hemoglobin, 9.1 g/dL; and platelets, 222 × 103/µL. Partial thromboplastin time (PTT) and activated partial thromboplastin time (aPTT) were in the normal range. The patient's grade I anemia and neutropenia were due to imatinib toxicity. Examination of the pleural effusion revealed the following: WBC, 1,296/m3 (polymorphonuclear cells, 60%); pH, 7.20; lactate dehydrogenase (LDH), 1,266 U/L; and atypical cells. Cultures of the pleural effusate were negative. The results of these laboratory tests suggested malignant pleural effusion. The patient's therapy was changed to oral sunitinib administered at 50 mg/day in cycles consisting of 4 weeks of sunitinib followed by 2 weeks of rest. On day 7 of the first cycle of sunitinib therapy, the volume of the patient's pleural effusion was unchanged, but her dyspnea had improved, and she requested discharge from the hospital. On day 21, sunitinib was found to be well tolerated except for grade I neutropenia (WBC, 2,390 × 103/µL; neutrophils, 1,769 × 103/µL) with markedly decreased pleural effusion and ascites (Fig. 4B). Oral sunitinib was continued at 50 mg/day.

d, but her dyspnea had improved, and she requested discharge from the hospital. On day 21, sunitinib was found to be well tolerated except for grade I neutropenia (WBC, 2,390 × 103/µL; neutrophils, 1,769 × 103/µL) with markedly decreased pleural effusion and ascites (Fig. 4B). Oral sunitinib was continued at 50 mg/day. On day 26 of the first cycle of sunitinib therapy, the patient had a sudden onset of sharp, generalized abdominal pain. An imaging study revealed intraperitoneal free gas with many bubbles near the distal pancreatic region, suggesting small bowel perforation (Fig. 5), and the patient was hospitalized. The admission CBC showed the following: WBC, 1.19 × 103/µL; neutrophils, 63%; hemoglobin, 10.6 g/dL; and platelet count, 89 × 103/µL. The PT and aPTT were 10.9 and 25.6 seconds, respectively. She was diagnosed with generalized peritonitis due to bowel perforation and grade III neutropenia (750 × 103/µL) due to sunitinib toxicity. We recommended emergency surgery; however, the patient's guardian refused consent. The patient expired the next day.

3/µL. The PT and aPTT were 10.9 and 25.6 seconds, respectively. She was diagnosed with generalized peritonitis due to bowel perforation and grade III neutropenia (750 × 103/µL) due to sunitinib toxicity. We recommended emergency surgery; however, the patient's guardian refused consent. The patient expired the next day. DISCUSSION Bowel perforation due to the toxicity of chemotherapeutic agents is a serious adverse event, and perforation is known to occur in patients with a chemosensitive malignancy such as gastrointestinal lymphoma [7]. Knowledge of the numerous intracellular signaling pathways involved in tumorigenesis enabled the identification of several potential molecular targets for the therapy of solid tumors. However, adverse events of new targeted therapies, such as bowel perforation and tumor rupture, are new challenges for the surgical oncologist [5]. The overall rate of gastrointestinal perforation associated with sunitinib is unknown [5,6]. One study found that emergency surgery for hemorrhage, tumor perforation, or abscess was needed in 3%-9% of patients receiving second-line therapy with sunitinib [5]. However, gastrointestinal (GI) perforation has been reported in <1% of patients taking sunitinib, and there was an extremely rare case of bowel perforation during sunitinib treatment for GIST [4,8].

morrhage, tumor perforation, or abscess was needed in 3%-9% of patients receiving second-line therapy with sunitinib [5]. However, gastrointestinal (GI) perforation has been reported in <1% of patients taking sunitinib, and there was an extremely rare case of bowel perforation during sunitinib treatment for GIST [4,8]. The mechanism of bowel perforation associated with sunitinib toxicity is also unknown. Sunitinib has an additional antiangiogenic activity because it inhibits the activation of VEGFR such as bevacizumab. Bevacizumab, the first angiogenesis inhibitor approved for use in the United States, is a humanized anti-VEGF monoclonal antibody well known to be associated with the adverse event of GI perforation. The mechanism causing bowel perforation has also not been established; however, several mechanisms of action have been postulated [9].

he first angiogenesis inhibitor approved for use in the United States, is a humanized anti-VEGF monoclonal antibody well known to be associated with the adverse event of GI perforation. The mechanism causing bowel perforation has also not been established; however, several mechanisms of action have been postulated [9]. Hypothetical mechanisms for GI perforation in patients treated with chemotherapy (including new targeted therapies) include the following: First, these drugs, such as bevacizumab, sunitinib, and sorafenib, block the VEGF receptors on endothelial cells and have a significant impact on the capillary beds of small intestinal villi. Such inhibition was found to significantly reduce the capillary density within these intestinal villi. Hence, antiangiogenic drugs may contribute to the development of microperforations within the intestinal wall secondary to the reduced regenerative capacity of the intestinal mucosa because of decreased blood vessel density. Second, in a variety of localized pathologic conditions, such as tumor-associated peptic ulcer disease, diverticulitis, or colitis, the intraluminal pressure is increased by tumor obstruction. These proposed risk factors may predispose bowel perforation in patients treated with chemotherapy (especially, antiangiogenic therapy). Third, bowel ischemia may be due to various thromboembolic events after antiangiogenic therapy. And last, rapid tumor necrosis as a result of chemotherapy or new targeted therapies may lead to bowel perforation in patients with bowel metastasis or invasion [5,6,7,8,9,10].

motherapy (especially, antiangiogenic therapy). Third, bowel ischemia may be due to various thromboembolic events after antiangiogenic therapy. And last, rapid tumor necrosis as a result of chemotherapy or new targeted therapies may lead to bowel perforation in patients with bowel metastasis or invasion [5,6,7,8,9,10]. A mechanism for the perforation occurring in our patient during administration of sunitinib as a second-line therapy might have been the rapid death of tumor invading the GI mucosa. The cytotoxic and antiangiogenic activity of sunitinib may have resulted in a dramatic tumor response [3,4,6,8,10]. In conclusion, we presented an extremely rare case of bowel perforation associated with sunitinib therapy for imatinib-refractory GIST. Although we could not obtain pathologic confirmation through emergency surgery, we postulate that the dramatic reduction during sunitinib treatment for disseminated peritoneal metastases and bowel invasion in our patient with recurrent GIST of gastric origin, led to bowel perforation. No potential conflict of interest relevant to this article was reported. Fig. 1 (A, B) Abdominal computer tomography revealed an 18-cm size huge mass with extensive central necrosis in the abdomen. (C, D) Resected specimens showed large gastrointestinal stromal tumor mass with adhesion of stomach, small bowel, transverse colon, distal pancreas and spleen.

No potential conflict of interest relevant to this article was reported. Fig. 1 (A, B) Abdominal computer tomography revealed an 18-cm size huge mass with extensive central necrosis in the abdomen. (C, D) Resected specimens showed large gastrointestinal stromal tumor mass with adhesion of stomach, small bowel, transverse colon, distal pancreas and spleen. Fig. 2 The pathologic finding. (A) Spindle-shaped (arrow) tumor cells are composing bundles or fascicles (H&E, ×200). (B) Multiple mitosis (arrows) are also noted (H&E, ×400). (C) Immunohistochemically, the tumor was positive for CD34 (×100). (D) C-kit (×100). Fig. 3 (A, B) The gastrointestinal stromal tumor relapsed on the liver hilum and subcapsular area of the right lobe of the liver with peritoneal nodules. (C, D) Three months later of imatinib treatment, the mass of the liver hilum and liver capsule was decreased. (E, F) Follow-up image showed the recurrence of a peritoneal seeding mass in distal pancreatic area and a small amount of left pleural effusion and ascites. Fig. 4 (A) A large amount of pleural effusion showed in left pleural space. (B) On 21 days of sunitinib, chest x-ray revealed markedly decreased pleural effusion. Fig. 5 (A-D) On 26 days of the first cycle of sunitinib therapy, abdomen computed tomography showed an intraperitoneal free gas and many bubbles near the distal pancreatic area, potentially due to a small bowel.

INTRODUCTION Bezoar stones are concrete masses of indigestible material. The phytobezoar is a common type of bezoar. It is composed of indigestible vegetable-like material. The incidence has been reported as 0.4% in the general population [1]. Phytobezoars are commonly reported in patients who have had previous gastric surgery [2,3]. Most commonly, bezoars produce mechanical obstructive symptoms but when they cause gastrointestinal bleeding or perforation, bezoars are associated with high mortality [4]. Therefore, it is very important to remove a bezoar to prevent mortality and morbidity. The treatment of bezoar is endoscopy or surgery. We recently experienced a 79-year-old woman diagnosed with extrahepatic duct phytobezoar. Although biliary phytobezoar is extremely rare, a few cases of extrahepatic duct phytobezoar have been reported previously [5,6]. We successfully treated this case with intraoperative transenteral endoscopic removal. This report concerns an extremely rare case of extrahepatic duct phytobezoar and intraoperative transenteral endoscopic treatment including imaging and review of the literature. CASE REPORT A 79-year-old woman came to the Emergency Department due to severe cramping abdominal pain and vomit for 2 days. She had a 40-year history of repeated hepatobiliary operation because of cholecystitis and postoperative complication. But, she and her family could not recall the precise operation name, type and its postoperative complication. She had a history of intestinal obstruction 6 months prior and was treated conservatively.

She had a 40-year history of repeated hepatobiliary operation because of cholecystitis and postoperative complication. But, she and her family could not recall the precise operation name, type and its postoperative complication. She had a history of intestinal obstruction 6 months prior and was treated conservatively. All vital signs, including body temperature, pulse, and blood pressure, were within normal limits. Laboratory findings in Emergency Department were unremarkable. Chest and abdomen radiographs were also unremarkable. The patient underwent and abdomino-pelvic CT scan to evaluate the cause of abdominal pain. The CT scan revealed dilatation and a large stone of the extrahepatic duct with air-biliary gram, parenchymal atrophy of the left hepatic lobe and no remarkable findings in the right hepatic lobe (Fig. 1). An endoscopic retrograde cholagio-pancreatography (ERCP) was then performed to evaluate the biliary tract. There was nothing found in the common bile duct on ERCP (Fig. 2).

xtrahepatic duct with air-biliary gram, parenchymal atrophy of the left hepatic lobe and no remarkable findings in the right hepatic lobe (Fig. 1). An endoscopic retrograde cholagio-pancreatography (ERCP) was then performed to evaluate the biliary tract. There was nothing found in the common bile duct on ERCP (Fig. 2). Our results lead us to consider extrahepatic duct stone with obstruction and change of biliary drainage system due to the previous hepatobiliary operation. Surgical procedure was indicated and exploration was performed thereafter. There was severe fibrous adhesion between diaphragm, liver, stomach, small bowel, transverse colon and peritoneum, especially in the right upper quadrant area. There was jejuno-jejunostomy between the jejunal limb from the duodenum and jejunal limb from hepatico-jejunostomy 15 cm distally from the Treitz ligament (Fig. 3). There was a hepatico-jejunostomy site in the porta hepatis area. Small enterotomy was performed below the jejuno-jejunostomy site (Fig. 3). Intraoperative endoscopy was performed by transenterotomy using a 15-mm Xcel trocar (Ethicon Inc., Somerville, NJ, USA) (Fig. 4). There were hepatico-jejunostomy sites and concrete materials in the extrahepatic duct just above the stoma (Fig. 5). Endoscopic fragmentation, removal and saline irrigation were performed successfully. The removed mass-like material was not stone but phytobezoar composed of indigestible vegetable and food-like materials (Fig. 6). The patient's postoperative course was uneventful and she is doing well following surgery.

toma (Fig. 5). Endoscopic fragmentation, removal and saline irrigation were performed successfully. The removed mass-like material was not stone but phytobezoar composed of indigestible vegetable and food-like materials (Fig. 6). The patient's postoperative course was uneventful and she is doing well following surgery. DISCUSSION Phytobezoar is a common type of bezoar. It composed of indigestible vegetable-like material. The incidence has been reported as 0.4% in the general population [1]. Common site of phytobezoar are the stomach and small bowel. Phytobezoars are commonly reported in patients who have had previous gastric surgery [2,3]. However, our patient had not had gastric surgery but cholecystectomy and hepatico-jejunostomy due to postcholecystectomy complication. Phytobezoar in the biliary tract is very rare and few cases of extrahepatic duct phytobezoar are reported in the literature [5,6]. That seems to be related to increased intestinal luminal pressure which allows reflux of indigestible vegetable and diverse food materials from the distal small bowel when especially, intestinal obstruction is developed [5]. Therefore, there is the possibility of formation of phytobezoar in the intra- or extrahepatic biliary tract in cases of new entry formation from the hollow viscus to the biliary tract such as choledoco-jejunostomy, choledoco-duodenostomy, hepatico-jejunostomy, cholecysto-duodenostomy, sphincteroplasty, etc.

Phytobezoar in the biliary tract is very rare and few cases of extrahepatic duct phytobezoar are reported in the literature [5,6]. That seems to be related to increased intestinal luminal pressure which allows reflux of indigestible vegetable and diverse food materials from the distal small bowel when especially, intestinal obstruction is developed [5]. Therefore, there is the possibility of formation of phytobezoar in the intra- or extrahepatic biliary tract in cases of new entry formation from the hollow viscus to the biliary tract such as choledoco-jejunostomy, choledoco-duodenostomy, hepatico-jejunostomy, cholecysto-duodenostomy, sphincteroplasty, etc. Most commonly, the phytobezoar is a rare cause of gastrointestinal tract obstruction. Maybe, the cause of pain was intrahepatic duct obstruction in our patient. In other clinical manifestations, when they cause gastrointestinal bleeding or perforation, bezoars are associated with a high mortality [4]. Therefore, it is very important to remove a bezoar to prevent mortality and morbidity.

act obstruction. Maybe, the cause of pain was intrahepatic duct obstruction in our patient. In other clinical manifestations, when they cause gastrointestinal bleeding or perforation, bezoars are associated with a high mortality [4]. Therefore, it is very important to remove a bezoar to prevent mortality and morbidity. Gastroscopy is a useful diagnostic tool of gastric phytobezoars and CT scan is the most useful diagnostic method of small bowel phytobezoar [7]. Differentiated diagnosis between stone and phytobezoar in the biliary tract is difficult because stones and concrete phytobezoars are radiolucent with similar shapes and the biliary tract is a very unusual site of phytobezoar. Naturally, extrahepatic duct phytobezoar is near impossible due to the anatomical structure and location such as the ampulla of vater, common bile duct and bifurcation of common hepatic duct. So, extrahepatic duct phytobezoar is difficult to diagnose preoperatively.

biliary tract is a very unusual site of phytobezoar. Naturally, extrahepatic duct phytobezoar is near impossible due to the anatomical structure and location such as the ampulla of vater, common bile duct and bifurcation of common hepatic duct. So, extrahepatic duct phytobezoar is difficult to diagnose preoperatively. Surgical or endoscopic removal are treatments of choice for phytobezoars. Especially, surgical removal is the treatment of choice for phytobezoars that endoscopy cannot approach or fail. We successfully treated a case of extrahepatic duct phytobezoar with intraoperative transenteral endoscopic removal. Intraoperative transenteral endoscopy is an alternative treatment or diagnostic modality that can evaluate unknown small bowel bleeding or unknown small bowel intraluminal lesion during operation [8]. The benefit of using trocar during intraoperative endoscopy is its easy approach in the small bowel, aseptic from endoscopic equipment, and anchoring effect like the human mouth and neck [8].

gnostic modality that can evaluate unknown small bowel bleeding or unknown small bowel intraluminal lesion during operation [8]. The benefit of using trocar during intraoperative endoscopy is its easy approach in the small bowel, aseptic from endoscopic equipment, and anchoring effect like the human mouth and neck [8]. In this patient, the gastroscopy and ERCP could not approach and evaluate the hepatico-jejunostomy site preoperatively because of Roux-en Y anastomosis between the jejunal limb from duodenum and the jejunal limb from hepatico-jejunostomy (Fig. 3). On surgical exploration, the entire gastrointestinal tract must be explored to exclude other bezoar and prevent recurrent bowel obstruction caused by residual bezoar [9]. Other nonsurgical treatment options include sodium bicarbonate powder, a liquid diet, enzymatic digestion with various agents, endoscopic fragmentation and oral intake (or endoscopic injection ) of 'Coca-Cola' [10]. In conclusion, we have presented a case of extrahepatic duct phytobezoar successfully treated with intraoperative transenteral endoscopic removal. Although it is considered extremely rare, it can be one of the possible causes of extrahepatic duct obstruction. For its great rarity and particular treatment approach, we report this case with review of the literature. No potential conflict of interest relevant to this article was reported.

In conclusion, we have presented a case of extrahepatic duct phytobezoar successfully treated with intraoperative transenteral endoscopic removal. Although it is considered extremely rare, it can be one of the possible causes of extrahepatic duct obstruction. For its great rarity and particular treatment approach, we report this case with review of the literature. No potential conflict of interest relevant to this article was reported. Fig. 1 The CT scan revealed dilatation and large stone of intrahepatic duct with air-biliary gram, parenchymal atrophy of left hepatic lobe and unremarkable right hepatic lobe. (A) Transverse section view. (B) Coronal section view. Fig. 2 Endoscopic retrograde cholangiopancreatography. There was not founded common bile duct. Fig. 3 Schematic outline of operation field appearance. Fig. 4 Intraoperative transenteral endoscopy. (A) 15-mm Xcel trocar (Ethicon Inc., Somerville, NJ, USA). (B) Transenteral endoscopy using Trocar. (C) Inner appearance of transenteral endoscopy. Fig. 5 Endoscopic procedure appearance. (A) There is a phytobezoar in hepatico-jejunostomy stoma. (B) Hepatico-jejunostomy stoma appearance after endoscopic removal of phytobezoar. Fig. 6 The removed phytobezoar.

INTRODUCTION Clonorchis sinensis causes an important foodborne parasitic infection that predominantly occurs as a hepatobiliary disease caused by the ingestion of a raw fish contaminated with infective cysts [1]. On the ingestion of raw fish, encysted parasites are released owing to the action of gastric juice and digestion of the cyst wall by trypsin in the duodenum, and the parasites develop into mature worms. The adult flukes are predominantly present in the intrahepatic bile ducts, but occasionally they may be present in the pancreatic duct and extrahepatic bile ducts. Hepatobiliary complications of C. sinensis infection include cholelithiasis, pyogenic cholangitis, biliary obstruction, and cholangiocarcinoma secondary to mechanical injury to the biliary epithelium by the suckers of the worm and prolonged inflammation [2,3,4]. However, primary acute cholecystitis associated with C. sinensis infection is extremely rare [5]. Herein, we report on a case of primary acute cholecystitis associated with C. sinensis infection. CASE REPORT A 68-year-old man was admitted to the Emergency Department with a 2-day history of right upper quadrant pain and fever. This patient was resident in a town located near a river and reported a history of occasional ingestion of raw fish. His past medical history indicated that the patient had undergone radical subtotal gastrectomy and Billroth-II anastomosis because of gastric cancer 10 years ago and inguinal herniorrhaphy two years ago.

CASE REPORT A 68-year-old man was admitted to the Emergency Department with a 2-day history of right upper quadrant pain and fever. This patient was resident in a town located near a river and reported a history of occasional ingestion of raw fish. His past medical history indicated that the patient had undergone radical subtotal gastrectomy and Billroth-II anastomosis because of gastric cancer 10 years ago and inguinal herniorrhaphy two years ago. The patient exhibited a blood pressure of 140/80 mmHg, a pulse rate of 84 beats/min, a respiratory rate of 20 breaths/min, and a body temperature of 37.8℃. Physical examination indicated that he was acutely ill appearance without icteric sclera; we also noted tenderness in the right upper abdominal quadrant. Routine hematological and biochemical investigations revealed leukocytosis and abnormal liver function test results: White blood cell, 12,400/mm3 (89% neutrophils); AST, 64 U/L; ALT, 94 U/L; total bilirubin, 2.8 U/L; and direct bilirubin, 1.4 U/L. Abdominal CT showed a distended gallbladder, wall thickening, and pericholecystic fluid collection with mild dilatation of the extrahepatic bile duct (Fig. 1). MR cholangiography showed a distended gallbladder, pericholecystic fluid collection, and mild extrahepatic bile duct dilation without obstructive lesion (Fig. 2).

Abdominal CT showed a distended gallbladder, wall thickening, and pericholecystic fluid collection with mild dilatation of the extrahepatic bile duct (Fig. 1). MR cholangiography showed a distended gallbladder, pericholecystic fluid collection, and mild extrahepatic bile duct dilation without obstructive lesion (Fig. 2). This patient had undergone laparotomy for possible peritonitis and a previous gastrectomy. During surgery, we observed not only turbid bile and necrotized gallbladder without gallstones, but also several flukes in the gall bladder and cystic duct (Fig. 3). On operative cholangiography to investigate the common bile duct (CBD), we did not observe bile duct dilatation or obstructive lesions (Fig. 4). Pathologic examination of the gallbladder showed severe inflammatory mucosal changes and parasite ova, which was confirmed by the presence of C. sinensis (Fig. 5). The postoperative course was uneventful, and the patient was discharged following the administration of praziquantel. DISCUSSION A recent survey revealed that clonorchiasis, a disease caused by infection with the trematode C. sinensis, remains highly prevalent, particularly in the riverside areas of Korea [6].

Pathologic examination of the gallbladder showed severe inflammatory mucosal changes and parasite ova, which was confirmed by the presence of C. sinensis (Fig. 5). The postoperative course was uneventful, and the patient was discharged following the administration of praziquantel. DISCUSSION A recent survey revealed that clonorchiasis, a disease caused by infection with the trematode C. sinensis, remains highly prevalent, particularly in the riverside areas of Korea [6]. Hepatobiliary complications of C. sinensis infection include cholelithiasis, pyogenic cholangitis, biliary obstruction, and cholangiocarcinoma, secondary to mechanical injury to the biliary epithelium by the suckers of the worm and prolonged inflammation. Most patients with complications resulting from C. sinensis infection present with cholangitis due to biliary obstruction by the adult worms or stones [2,3,4]. Although primary acute cholecystitis associated with C. sinensis infection is extremely rare, the frequent ingestion of raw fish over a long period of time in endemic areas may lead to the requirement that C. sinensis related acute cholecystitis be included in the differential diagnosis of suspected cases of clonorchiasis.

ough primary acute cholecystitis associated with C. sinensis infection is extremely rare, the frequent ingestion of raw fish over a long period of time in endemic areas may lead to the requirement that C. sinensis related acute cholecystitis be included in the differential diagnosis of suspected cases of clonorchiasis. In this case study, MR cholangiography revealed mild extrahepatic bile duct dilation, which suggests a history of radical subtotal gastrectomy rather than C. sinensis infection. Furthermore, we observed many flukes in the gallbladder and cystic duct during the surgery, which were not identified by MR cholangiography most likely owing to the flat morphology of the organism and due to its scattered distribution. Radiological examinations are essential in the diagnosis of biliary tree diseases such as clonorchiasis. Clonorchiasis is primarily detected by screening sonography of the liver according to its pathognomonic findings of diffuse dilatation of the intrahepatic bile ducts, periductal echogenicity, and floating materials in the gallbladder. Periductal enhancement on dynamic contrast-enhanced CT or MR imaging may be a specific finding of active clonorchiasis [7,8].

creening sonography of the liver according to its pathognomonic findings of diffuse dilatation of the intrahepatic bile ducts, periductal echogenicity, and floating materials in the gallbladder. Periductal enhancement on dynamic contrast-enhanced CT or MR imaging may be a specific finding of active clonorchiasis [7,8]. Diffuse dilatation of the intrahepatic bile ducts up to the peripheral margin of the liver is observed, but larger intrahepatic and extrahepatic bile ducts are usually not dilated or minimally dilated. These findings reflect the pathophysiology of bile ducts in C. sinensis. Adult C. sinensis worms usually reside in the medium-sized or small intrahepatic bile ducts. They are rarely found in the extrahepatic bile ducts except in cases of heavy infection. The histopathological changes to the bile ducts due to C. sinensis infection present as mucosal hyperplasia and periductal fibrosis with persistent ductal dilation [7]. We think that the possible pathogenesis of cholecystitis associated with C. sinensis infection might be an allergic reaction to the metabolites released from the adult worm in the CBD and gallbladder.

ue to C. sinensis infection present as mucosal hyperplasia and periductal fibrosis with persistent ductal dilation [7]. We think that the possible pathogenesis of cholecystitis associated with C. sinensis infection might be an allergic reaction to the metabolites released from the adult worm in the CBD and gallbladder. The relationship between cholelithiasis and C. sinensis infection is controversial. Qiao et al. [2] reported that C. sinensis eggs were detected in gallbladder stones, which suggests an association between C. sinensis infection and gallbladder stone formation, especially pigmented stones. Howerver, Choi et al. [9] reported that any evidence regarding C. sinensis was not related to an increased risk of either gallbladder or extrahepatic stones, but that it is significantly associated with the formation of intrahepatic stones. In this case, we did not detect any gallstones, and whether C. sinensis infection is the etiological factor for cholecystolithiasis remains unclear. We report on a rare case of primary acute cholecystitis associated with C. sinensis infection. This finding may provide incentive to initiate further studies of the pathogenesis of clonorchiasis-associated cholecystitis in prevalent areas. ACKNOWLEDGEMENTS This paper was supported by Wonkwang University 2012. No potential conflict of interest relevant to this article was reported.

We report on a rare case of primary acute cholecystitis associated with C. sinensis infection. This finding may provide incentive to initiate further studies of the pathogenesis of clonorchiasis-associated cholecystitis in prevalent areas. ACKNOWLEDGEMENTS This paper was supported by Wonkwang University 2012. No potential conflict of interest relevant to this article was reported. Fig. 1 Axial unenhanced (A) and contrast-enhanced abdominal computed tomography images (B) show a distended gallbladder with wall thickening and pericholecystic fluid collection. It also shows minimal dilatation of the peripheral intrahepatic bile ducts. Fig. 2 MR cholangiography shows a distended gallbladder, pericholecystic fluid collection, and mild extrahepatic bile duct dilation without obstructive lesions. Fig. 3 Operative finding shows several flukes removed from the cystic duct and gallbladder. Fig. 4 Operative cholangiography shows neither bile duct dilatation nor obstructive lesions. Fig. 5 Histopathological examinations show a severe inflammatory mucosal change of the gallbladder (A: H&E, ×40) and ovum (B: H&E, ×200), which is confirmed by the presence of Clonorchis sinensis.

INTRODUCTION Salvage liver transplantation (LT) has been proposed for patients who undergo primary liver resection for hepatocellular carcinoma (HCC), due to recurrence of HCC, or deterioration in liver function [1,2]. However, the technical feasibility of salvage LT must be considered in patients who have undergone prior liver resection. In particular, prior major hepatectomy such as right hepatectomy makes subsequent recipient hepatectomy and vascular graft reconstruction technically difficult [1,3]. As a result, a few salvage LTs after major hepatectomy have been reported and furthermore, few reports are available on salvage living donor liver transplantation (LDLT) after major hepatectomy due to obvious technical difficulties [1,3]. Herein, we describe a successful case of salvage dual graft LDLT after major hepatectomy. SURGICAL TECHNIQUE A 48-year old man was transferred to Daegu Catholic University Medical Center because of hematemesis. He underwent right hepatectomy due to HCC 4 years ago. Gastroduodenoscopy and CT showed variceal bleeding at the third portion of the duodenum and newly developed HCC at segment IV. Thus, we performed a transjugular intrahepatic portosystemic shunt and coil embolization for identified bleeding duodenal varices fed from the superior pancreaticoduodenal vein. After his condition recovered, we planned LDLT as treatment for intrahepatic recurrence and poor liver function.

developed HCC at segment IV. Thus, we performed a transjugular intrahepatic portosystemic shunt and coil embolization for identified bleeding duodenal varices fed from the superior pancreaticoduodenal vein. After his condition recovered, we planned LDLT as treatment for intrahepatic recurrence and poor liver function. The patient's height was 172 cm and body weight was 65 kg. His 41-year-old wife initially volunteered to be a living donor. But, preoperative 3-dimensional CT estimated right and left lobe volume to be 630 and 200 mL (76% and 24% volume ratio), respectively, which did not meet our criteria for right lobe donation (remnant liver volume > 30% of the entire liver). Therefore, the other donor candidate, his 44-year-old younger sister, was evaluated. CT-volumetric analysis showed that the right and left lobe volumes were 470 and 240 mL, respectively (66% and 34% volume ratio), which was safe by our criteria. However, this donor's right lobe had insufficient safe volume for the recipient: graft-to-recipient weight ratio (GRWR), 0.72%. Thus, neither of the two available donors was suitable and the decision was made to perform LDLT using dual grafts. We planned to harvest the right lobe of second donor and the left lobe of first donor to ensure donor safety and adequate total graft volume.

the recipient: graft-to-recipient weight ratio (GRWR), 0.72%. Thus, neither of the two available donors was suitable and the decision was made to perform LDLT using dual grafts. We planned to harvest the right lobe of second donor and the left lobe of first donor to ensure donor safety and adequate total graft volume. Heavy adhesions were encountered between the cut surface and the omentum and intestine due to prior liver resection during the recipient's operation (Fig. 1A). Thus, sharp dissection and meticulous bleeding control were required to avoid massive bleeding. Mobilizing the remaining liver was the same as that for primary LDLT after fully dissecting the surface adhesions. The hepatic hilum had severe adhesions and fibrotic changes due to hilar dissection during the prior right hepatectomy. After the hilar dissection, we isolated the only remnant left hepatic artery, which was a very short stump of the right portal vein (PV), and the bile duct (Fig. 1B).

dissecting the surface adhesions. The hepatic hilum had severe adhesions and fibrotic changes due to hilar dissection during the prior right hepatectomy. After the hilar dissection, we isolated the only remnant left hepatic artery, which was a very short stump of the right portal vein (PV), and the bile duct (Fig. 1B). The first liver graft during the donor operations (right lobe: actual graft weight, 460 g; GRWR, 0.71%) was harvested from the younger sister, and the second liver graft (left lobe: actual graft weight, 211 g; GRWR, 0.32%) was harvested from his wife. The total graft weight was 617 g, and GRWR was 0.95%. A cryopreserved iliac vein graft was prepared to produce a portal venous conduit for PV reconstruction to the right lobe graft, because there was insufficient right PV to secure a classic anastomosis. This venous conduit was interposed to the PV orifice of the right graft to substitute for the recipient's right PV on the back table. The reconstruction procedures for dual LDLT with right and left lobes have been described in various reports in detail, including hepatic vein reconstruction for dual grafts [4]. The interposition vein of the right graft PV was anastomosed to the recipient's right portal stump without kinking (Fig. 2), followed by an end-to-end anastomosis of the left graft PV. The only remnant left hepatic artery was used for hepatic artery reconstruction of the right graft. However, additional inflow was needed for the other graft, so the right gastroepiploic artery (RGEA) was used as arterial inflow for the left graft (Fig. 2). The bile duct of the right graft was reconstructed with duct-to-duct anastomosis, and the bile duct of the left graft was reconstructed with hepaticojejunostomy. Intraoperative and postoperative Doppler ultrasound studies and three-dimensional CT revealed good hepatic artery, PV, and hepatic vein flow to both grafts (Fig. 3). The patient has recovered well with normal graft function and has been doing well for 31 months after LDLT.

ft was reconstructed with hepaticojejunostomy. Intraoperative and postoperative Doppler ultrasound studies and three-dimensional CT revealed good hepatic artery, PV, and hepatic vein flow to both grafts (Fig. 3). The patient has recovered well with normal graft function and has been doing well for 31 months after LDLT. DISCUSSION Salvage LT has been performed as a life-saving treatment for patients with intrahepatic recurrence of HCC or liver function deterioration after primary liver resection [1,5]. However, the technical difficulty during salvage LT and the risk for postoperative complications make most surgeons hesitate to perform LT. Initial clinical studies reported that salvage LT after liver resection is associated with higher operative mortality, increased risk of recurrence, and poorer outcome than those of primary LT [6]. However, recent clinical studies have indicated that salvage LT is a technically feasible procedure [1,3]. Belghiti et al. [7] reported that liver resection prior to LT does not significantly increase the technical difficulty or impair survival after LT. Hwang et al. [1] also concluded that combinations of recipients with a prior hepatectomy and living donor liver grafts for salvage LT are feasible, suggesting that salvage procedures should be extended to LDLT. Although the most recent studies have shown that salvage does not increase the difficulty of surgery, the salvage LT group had a longer operative time, more intraoperative bleeding, and increased transfusion volume, particularly in cases of a prior major hepatectomy [5,8].

salvage procedures should be extended to LDLT. Although the most recent studies have shown that salvage does not increase the difficulty of surgery, the salvage LT group had a longer operative time, more intraoperative bleeding, and increased transfusion volume, particularly in cases of a prior major hepatectomy [5,8]. Moreover, several technical aspects should be considered when performing a recipient hepatectomy, particularly in cases involving a prior major hepatectomy. The first is in regard to heavy adhesions. Some recipients may have vigorous portal collaterals, which lead to massive intraoperative bleeding and unstable condition [1,3,5]. The second technical concern is for hilar dissection, particularly when hilar dissection has been conducted extensively during major hepatectomy [5]. The third is securing vascular reconstruction for graft inflow and outflow. A remnant right hepatic artery and PV are usually short or do not exist in cases of prior right hepatectomy [1.3]. Thus, only prior minor hepatectomy has been acceptable for salvage LDLT in many centers, and few reports have described salvage LDLT after major hepatectomy [1,3]. Furthermore, transplant surgeons might be confronted with more serious technical obstacles during salvage LDLT with dual grafts in patients who had undergone prior major hepatectomy and so there have been only a few reports of dual graft LDLT with prior minor liver resection [1]. Several serious difficulties were encountered in the present case to secure PV and hepatic artery reconstruction because only the left hepatic artery was available, as the native recipient's hepatic arteries and the very short right PV stump remained after a prior right hepatectomy. We utilized a cryopreserved cadaveric iliac vein graft as a substitute for the lost right PV to secure PV reconstruction to the right graft. When the native hepatic artery is unavailable, various arterial sources such as the RGEA, the splenic artery, the left gastric artery, the gastroduodenal artery, and other interposition graft has been introduced as good alternative inflow to the graft during LDLT [9,10]. In this case, we performed hepatic artery reconstruction with the RGEA because it provided sufficient length to reconstruct the left graft arterial stumps during transplantation.

ery, the gastroduodenal artery, and other interposition graft has been introduced as good alternative inflow to the graft during LDLT [9,10]. In this case, we performed hepatic artery reconstruction with the RGEA because it provided sufficient length to reconstruct the left graft arterial stumps during transplantation. CONCLUSION Salvage dual graft LDLT can be a feasible option for a patient with prior major hepatectomy in a situation with inadequate graft size for sufficient graft volume. However, accurate preoperative planning and experienced surgical techniques lead to a successful operation. In addition, further accumulation of cases is warranted to evaluate the efficacy of complicated procedures like this case. No potential conflict of interest relevant to this article was reported. Fig. 1 Intraoperative photographs showing salvage living donor liver transplantation with dual graft. (A) Severe perihepatic adhesion was exposed after complete mobilization of remnant liver. (B) We isolated the only remnant left hepatic artery (arrow) and short stump of right portal vein above bifurcation (arrowhead) after hilar dissection. Fig. 2 Intraoperative photograph (A) and illustration (B) of vascular and biliary reconstruction of salvage dual graft living donor liver transplantation. Cryopreserved iliac vein conduit was interposed from portal vein of right-sided graft to right portal vein stump of recipient (arrow) and recipient's right gastroepiploic artery (arrowhead) was anastomosed to left hepatic artery of left-sided graft.

construction of salvage dual graft living donor liver transplantation. Cryopreserved iliac vein conduit was interposed from portal vein of right-sided graft to right portal vein stump of recipient (arrow) and recipient's right gastroepiploic artery (arrowhead) was anastomosed to left hepatic artery of left-sided graft. Fig. 3 Postoperative Doppler ultrasonography and CT scan. (A) Doppler ultrasonography showed good hepatic artery flow to left-sided graft using right gastroepiploic artery. (B) Dynamic CT scan on postoperative day 14 demonstrated good portal flow to both grafts. (C) The CT scan on 2 years after transplantation also showed good patency of interposed vein graft (arrowhead) used for portal vein reconstruction.

http://dx.doi.org/10.4174/astr.2014.87.1.9 Ann Surg Treat Res 2014;87(1):9-13 The affiliation of the 8th author-corresponding author, Moo Jun Baek-was misprinted. The affiliation should be corrected as follows: Corrected affiliation of 8th author 5Department of Surgery, Soonchunhyang University College of Medicine, Cheonan, Korea Corrected affiliation in corresponding author section Department of Surgery, Soonchunhyang University College of Medicine, 31 Suncheonhyang 6-gil, Dongnam-gu, Cheonan 330-930, Korea

INTRODUCTION Acute liver failure is a life-threatening disease, and is encountered commonly in clinical practice [1]. Although various treatment methods have been developed, the results were disappointing and liver transplantation remains the only definitive treatment [2,3]. However, not all patients with acute liver failure are able to receive liver transplantation in time because of the lack of donor organs. The problems of liver transplantation include high mortality and morbidity rates related to the surgery as well as the requirement for long-term immunosuppressant use. Upon recovering from acute liver failure, patients generally do not suffer any sequelae [4]. Therefore, alternative treatments that can provide at least temporary liver support are necessary until spontaneous recovery or a suitable donor liver becomes available. Hepatocyte transplantation has been investigated as an alternative treatment for acute liver failure patients. Hepatocyte transplantation has several advantages over whole-liver transplantation [5]. A single donor could potentially provide hepatocytes for several patients, and hepatocyte transplantation does not interfere with subsequent liver transplantation. While intact livers can only be transplanted within short time after procurement, hepatocyte may be cryopreserved or cultured for immediate availability in emergencies. Hepatocyte transplantation is a less-invasive treatment than whole-liver transplantation. This minimally invasive treatment can be performed with low morbidity and mortality, a short period of hospitalization, and at low cost.

ement, hepatocyte may be cryopreserved or cultured for immediate availability in emergencies. Hepatocyte transplantation is a less-invasive treatment than whole-liver transplantation. This minimally invasive treatment can be performed with low morbidity and mortality, a short period of hospitalization, and at low cost. However, for the clinical application of hepatocyte transplantation, some problems remain to be resolved, such as enabling long-term survival of isolated hepatocytes and preservation without decreasing hepatocyte function [6]. This study was performed to establish the fundamental basis of hepatocyte transplantation for the purpose of clinical application. We examined the ideal culture conditions by investigating isolated rat hepatocytes cultured in media containing different glucose concentrations. METHODS Experimental animals Male Sprague-Dawley rats weighing 200-250 g were used. A 1-week period was allowed prior to the experiment for acclimatization to the laboratory environment. The animal facility had a 12-hour light/dark cycle, ambient temperature of 25℃, and humidity of 40%. All experiments were performed after obtaining approval from the Ethics Committee for animal experiments and in accordance with the animal experimentation guidelines.

t for acclimatization to the laboratory environment. The animal facility had a 12-hour light/dark cycle, ambient temperature of 25℃, and humidity of 40%. All experiments were performed after obtaining approval from the Ethics Committee for animal experiments and in accordance with the animal experimentation guidelines. Rat operations Experimental rats were anesthetized by intraperitoneal injection of zolazepam (Zoletil, Virbac, Carros Cedex, France) and xylazine (Rompum, Bayer, Toronto, ON, Canada). The liver was exposed by U-shaped incision, and 1 mL of freshly prepared heparin solution (0.1 mL of heparin [5,000 IU/mL] + 2.4 mL of physiological saline) was injected into the infrarenal inferior vena cava (IVC); the final heparin concentration was 200 IU/mL. The portal vein was catheterized with a 22-gauge intravenous needle 5 mm inferior to the liver, which was immobilized, and used for application of the perfusion solution. In addition, the infrahepatic and suprahepatic IVC were cut. The two-step perfusion method described by Seglen [7] was employed. First, Ca2+-free medium (Gibco 17701, Life Technologies, Grand Island, NY, USA) was perfused through the portal vein at a rate of 25 mL/min for 10 minutes. Second, Ca2+ and collagenase medium (Gibco 17703, Life Technologies) was perfused through the same route at the same rate. The perfused rat liver was disconnected from the perfusion apparatus and resected (Fig. 1).

ogies, Grand Island, NY, USA) was perfused through the portal vein at a rate of 25 mL/min for 10 minutes. Second, Ca2+ and collagenase medium (Gibco 17703, Life Technologies) was perfused through the same route at the same rate. The perfused rat liver was disconnected from the perfusion apparatus and resected (Fig. 1). Isolation and culture of rat hepatocytes The resected liver was transferred to a plastic petri dish containing Hank's Balanced Salt Solution (HBSS; Gibco 14175-095, Life Technologies). The Glisson's capsule of the resected liver was opened. While the liver was being held in the portal region with forceps and gently shaken, the cells were liberated from the connective-vascular tissue. The resulting cell suspension was filtered through a sterile Perlon filter (100 µm) and allowed to sediment for 15 minutes. The supernatant was removed, and the remaining cell suspension was washed with 40 mL of HBSS and dispensed into sterile centrifuge tubes. Other cells, connective tissue, and contaminants were removed by centrifugation at 500 rpm for 5 minutes three times. A trypan blue exclusion test was performed to calculate the number of viable hepatocytes and the liver cells were prepared for primary culture (Fig. 2).

HBSS and dispensed into sterile centrifuge tubes. Other cells, connective tissue, and contaminants were removed by centrifugation at 500 rpm for 5 minutes three times. A trypan blue exclusion test was performed to calculate the number of viable hepatocytes and the liver cells were prepared for primary culture (Fig. 2). Aliquots of 1.0 × 106 viable cells were seeded in 100 × 15-mm petri dishes (Nunclon 150350, Sigma-Aldrich Co., St. Louis, MO, USA) containing culture medium according to the experimental group. The cells were cultures in Dulbecco's modified Eagle's Medium (DMEM) supplemented with 10% fetal bovine serum, penicillin, and streptomycin at 37℃ in a 5% CO2 incubator. DMEM contains 1,606 mg/L of amino acids, 31.6 mg/L of vitamins, 200 mg/L of calcium chloride, and 3,700 mg/L of sodium bicarbonate. The culture medium was changed on days 3, 7, 10, and 14. Experimental groups Experiments groups were classified according to the glucose concentration in the medium. (1) Low-glucose group (n = 6): 1-g/L D-Glucose DMEM (Gibco 11885-084, Life Technologies) (2) High-glucose group (n = 6): 4.5-g/L D-Glucose DMEM (Gibco 11965-092, Life Technologies) Evaluation of cultured rat hepatocytes The cultured rat hepatocytes were evaluated by morphological and functional methods at 3, 7, 10, and 14 days. Total cell count and viability Total cell count and viability of cultured rat hepatocytes were measured using the trypan blue exclusion test and a hemocytometer on days 3, 7, 10, and 14.

Evaluation of cultured rat hepatocytes The cultured rat hepatocytes were evaluated by morphological and functional methods at 3, 7, 10, and 14 days. Total cell count and viability Total cell count and viability of cultured rat hepatocytes were measured using the trypan blue exclusion test and a hemocytometer on days 3, 7, 10, and 14. Total cell count = volume of cells (mL) × 2 (dilution factor) × mean number of cells (stained cells + unstained cells) × 104 Viability (%) = viable cell count (unstained cell count)/total cell count (stained cell count + unstained cell count) × 100. Cultured hepatocyte function The concentrations of albumin, ammonia, and urea were measured in culture medium after 3, 7, 10, and 14 days in culture. The albumin concentration was measured by enzyme-linked immunosorbent assay using affinity-purified anti-rat albumin antibody (A110-134A, Bethyl, Montgomery, TX, USA), rat reference serum (RS10-100, Bethyl), and horseradish peroxidase-conjugated antirat albumin detection antibody (A110-134P, Bethyl). The ammonia and urea concentrations were measured 3 days after the addition of 1-mM NH4Cl when replacing the culture medium. Ammonia concentration was measured using an Ammonia Assay Kit (AA0100, Sigma-Aldrich Co.). Urea concentration was determined by coupled enzyme reaction, which yields a colorimetric (570 nm) product proportional to the amount of urea present, using a Sigma Urea Assay Kit (MAK006, Sigma-Aldrich).

cing the culture medium. Ammonia concentration was measured using an Ammonia Assay Kit (AA0100, Sigma-Aldrich Co.). Urea concentration was determined by coupled enzyme reaction, which yields a colorimetric (570 nm) product proportional to the amount of urea present, using a Sigma Urea Assay Kit (MAK006, Sigma-Aldrich). Histological assessment The morphology of cultured rat hepatocytes was examined by hematoxylin and eosin staining. The albumin receptor was confirmed by immunofluorescence analysis. The cultured cell suspension was fixed with 10% formalin for 15 minutes at room temperature and incubated for 10 minutes in phosphate-buffered saline containing 0.25% Triton X-100 (PBST) for permeabilization. The cells were incubated with 1% bovine serum albumin in PBST for 30 minutes to block nonspecific antibody binding. Finally, the cells were incubated sequentially with antialbumin antibody (ab106582, Abcam, Cambridge, UK) and rabbit antichicken IgY H&L secondary antibody (ab6749, Abcam). Statistical analysis All data are expressed as means ± standard deviation. Experimental results were tested by one-way analysis of variance with repeated measures and Bonferroni post hoc test. Comparisons between two groups were performed using the Mann-Whitney U test. Statistical analysis was performed using PASW Statistics ver. 18.0 (SPSS Inc., Chicago, IL, USA). In all analyses, P < 0.05 was taken to indicate statistical significance.

alysis of variance with repeated measures and Bonferroni post hoc test. Comparisons between two groups were performed using the Mann-Whitney U test. Statistical analysis was performed using PASW Statistics ver. 18.0 (SPSS Inc., Chicago, IL, USA). In all analyses, P < 0.05 was taken to indicate statistical significance. RESULTS Total cell count and viability Total cell count showed smaller increases in the low-glucose group than the high-glucose group, although the difference was not statistically significant (F(1,10) = 3.045, P = 0.112), and total cell count in the low-glucose group differed significantly between time points (F(3,15) = 14.552, P < 0.001). Total cell count in the low glucose group on day 7 was significantly different from those on days 10 (P = 0.024) and 14 (P = 0.040). There were no significant differences between the two groups at each time point (Fig. 3A). The viability of cultured rat hepatocytes was greater in the low-glucose group than the high-glucose group, but the difference was not statistically significant (F(1,10) = 2.477, P = 0.147). The viability in the low-glucose group differed significantly between time points (F(3,15) = 6.606, P = 0.005). The viability in the low-glucose group on day 3 was significantly different from that on day 14 (P = 0.025). There were no significant differences between the two groups at any time point (Fig. 3B).

= 0.147). The viability in the low-glucose group differed significantly between time points (F(3,15) = 6.606, P = 0.005). The viability in the low-glucose group on day 3 was significantly different from that on day 14 (P = 0.025). There were no significant differences between the two groups at any time point (Fig. 3B). Cultured hepatocyte function test The concentrations of albumin, ammonia, and urea were measured in culture medium as a means of determining hepatocyte function. The albumin level was not significantly different between the two groups (F(1, 10) = 0.005, P = 0.943), but differed significantly between time points in both the low-glucose group (F(1.339, 6.693) = 24.753, P = 0.001) and the high-glucose group (F(1.822, 9.111) = 14.583, P = 0.002). The albumin level in the low-glucose group on day 3 was significantly different from those on day 7 (P = 0.034), 10 (P = 0.017), and 14 (P = 0.018), and that in the high-glucose group on day 7 was significantly different from those on days 10 (P = 0.033) and 14 (P = 0.030) (Fig. 4A).

1.822, 9.111) = 14.583, P = 0.002). The albumin level in the low-glucose group on day 3 was significantly different from those on day 7 (P = 0.034), 10 (P = 0.017), and 14 (P = 0.018), and that in the high-glucose group on day 7 was significantly different from those on days 10 (P = 0.033) and 14 (P = 0.030) (Fig. 4A). The ammonia level was not significantly different between the two groups (F(1, 10) = 0.113, P = 0.744), but differed significantly between time points in both the low-glucose group (F(3, 15) = 20.758, P < 0.001) and the high-glucose group (F(3, 15) = 19.309, P < 0.001). The ammonia level in the low-glucose group on day 3 was significantly different from those on days 7 (P = 0.030), 10 (P = 0.005), and 14 (P = 0.012), and that in the high-glucose group on day 3 was significantly different from those on days 7 (P = 0.040), 10 (P = 0.034), and 14 (P = 0.014) (Fig. 4B). The urea level was not significantly different between the two groups (F(1, 10) = 0.012, P = 0.709), and did not differ significantly between time points in either the low-glucose group (F(1.506, 7.529) = 3.698, P = 0.084) or the high-glucose group (F(1.591, 7.957) = 4.400, P = 0.058) (Fig. 4C).

The ammonia level was not significantly different between the two groups (F(1, 10) = 0.113, P = 0.744), but differed significantly between time points in both the low-glucose group (F(3, 15) = 20.758, P < 0.001) and the high-glucose group (F(3, 15) = 19.309, P < 0.001). The ammonia level in the low-glucose group on day 3 was significantly different from those on days 7 (P = 0.030), 10 (P = 0.005), and 14 (P = 0.012), and that in the high-glucose group on day 3 was significantly different from those on days 7 (P = 0.040), 10 (P = 0.034), and 14 (P = 0.014) (Fig. 4B). The urea level was not significantly different between the two groups (F(1, 10) = 0.012, P = 0.709), and did not differ significantly between time points in either the low-glucose group (F(1.506, 7.529) = 3.698, P = 0.084) or the high-glucose group (F(1.591, 7.957) = 4.400, P = 0.058) (Fig. 4C). Histological assessment The results of histological examination indicated that the typical shape of hepatocytes; i.e., as round nucleus, prominent nucleoli, and polygonal cytoplasm, was well maintained in both groups after 3 days in culture. On day 7, the shape of the nucleus was maintained, but the cytoplasm was transformed into a spindle shape. These changes were exaggerated on day 10, and were more prominent in the high glucose group. Although there were no significant morphological differences between the two groups, in the low-glucose group, the cellularity was more abundant and cytoplasm transformed more slowly compared to the high-glucose group (Fig. 5).

These changes were exaggerated on day 10, and were more prominent in the high glucose group. Although there were no significant morphological differences between the two groups, in the low-glucose group, the cellularity was more abundant and cytoplasm transformed more slowly compared to the high-glucose group (Fig. 5). Immunofluorescence staining for albumin indicated that there were no significant morphological differences between the two groups. On day 3, strong staining was detected in the cytoplasm in both groups. However, only weak staining was detected on day 7 and there was no staining on day 10 in both groups (Fig. 6). DISCUSSION In 1976, Matas et al. [8] reported that hepatocyte transplantation capable of continuous enzyme production could be an effective treatment for homozygous recessive Gunn rats lacking the enzyme uridine diphosphate glucuronyl transferase. The first hepatocyte transplantation in human subjects was attempted by Mito et al. [9] in 1992. Patients with chronic liver disease received infusion of autologous hepatocytes into the spleen. They confirmed the stability of hepatocyte transplantation. Subsequently, there have been many experimental studies of hepatocyte transplantation, and this procedure has been applied clinically in patients with acute liver failure, liver cirrhosis, enzymatic deficiency, and metabolic disease. Hepatocyte transplantation has been performed mainly in patients with enzymatic deficiency and metabolic disease because good results are expected in such cases, even when accounting for only <5% of the total hepatocyte mass [10].

s with acute liver failure, liver cirrhosis, enzymatic deficiency, and metabolic disease. Hepatocyte transplantation has been performed mainly in patients with enzymatic deficiency and metabolic disease because good results are expected in such cases, even when accounting for only <5% of the total hepatocyte mass [10]. Hepatocyte transplantation is under investigation as a possible therapeutic alternative for acute liver failure patients, but many problems remain to be resolved before clinical use [6]. The issues currently under investigation include isolation of hepatocytes, long-term survival of the hepatocytes, the conditions necessary to maintain hepatocyte metabolism, the quantity problem, storage, and the route of administration. This study was performed to determine the optimum conditions for isolation and culture of hepatocytes, and the ideal conditions for their long-term survival.

long-term survival of the hepatocytes, the conditions necessary to maintain hepatocyte metabolism, the quantity problem, storage, and the route of administration. This study was performed to determine the optimum conditions for isolation and culture of hepatocytes, and the ideal conditions for their long-term survival. Methods of hepatocyte isolation can be divided into mechanical methods and those that use enzymes. Earlier methods were mostly mechanical, and cell suspension of liver tissue enabled hepatocyte isolation, but most cells were damaged and the survival rate was low. Howard et al. [11] reported the effects of incubation with collagenase, which breaks down liver tissue. Berry and Friend [12] developed the collagenase perfusion method, which enables a uniform distribution in vivo. This method allowed the isolation and culture of hepatocytes with a high survival rate. Seglen [7] studied the ideal conditions and the optimal enzyme concentration for the collagenase perfusion method, and developed the two-step collagenase-perfusion technique. This technique has been adopted widely and was used in the present study. For the clinical application of hepatocyte transplantation, hepatocytes should have viability >60% with an absence of microbial contamination [13]. The greatest obstacle to the clinical application of hepatocyte transplantation is currently the lack of good quality human hepatocytes. The viability of isolated hepatocytes in this study was >80%.

on of hepatocyte transplantation, hepatocytes should have viability >60% with an absence of microbial contamination [13]. The greatest obstacle to the clinical application of hepatocyte transplantation is currently the lack of good quality human hepatocytes. The viability of isolated hepatocytes in this study was >80%. When hepatocytes are cultured in standard cell culture medium in a container with a plastic surface, the cells lose their gap junctions within 12-24 hours and adopt a flattened shape. The unique functions of the tissue are lost in 3-5 days, and the cells die within 1-2 weeks [14]. To improve this short-term survival and instability of function, conditions such as growth factors, nutrients, extracellular matrix, and cell-cell interaction are important. Methods to facilitate these conditions have been developed, such as adding growth factors or hormones to the culture medium [15], culturing cells with matrix-adhesion factors, coating the container surface with collagen, polystyrene, or laminin to act as an extracellular matrix [16], and inducing cell-cell interaction by culturing along with other cell types, such as endothelial cells [17].

g growth factors or hormones to the culture medium [15], culturing cells with matrix-adhesion factors, coating the container surface with collagen, polystyrene, or laminin to act as an extracellular matrix [16], and inducing cell-cell interaction by culturing along with other cell types, such as endothelial cells [17]. The present study was performed to determine the optimal conditions for culturing hepatocytes while maintaining their function and enabling long-term survival. Here, the importance of the glucose concentration in the culture medium was investigated. Culture media are commercially available with a high or low glucose concentration (4.5-g/L and 1.0-g/L glucose, respectively). In the present study, the low-glucose group showed better cell proliferation than the high-glucose group in terms of morphological assessment, although the difference was not statistically significant in terms of functional assessment. The two groups did not differ significantly with respect to hepatocyte function. In both groups, the function of cultured hepatocytes decreased significantly over time. In addition, cell morphology and function were maintained for up to 3 days in culture. After 7 days, both groups show deterioration of cell morphology and reduced cell function. These changes were more prominent in the high glucose group.

h groups, the function of cultured hepatocytes decreased significantly over time. In addition, cell morphology and function were maintained for up to 3 days in culture. After 7 days, both groups show deterioration of cell morphology and reduced cell function. These changes were more prominent in the high glucose group. Current clinical research uses a method involving isolation of hepatocytes from surgical liver biopsies of patients with benign liver disease or liver cancer, and using these hepatocytes fresh or after cryopreservation when necessary. Therefore, it is important to establish the optimal conditions for isolation and culturing of hepatocytes without adversely affecting their function. This study was limited in that the number of samples was small, and that a methodologically basic method was used. The parameters for investigation the function of cultured hepatocytes were also simple. However, further studies based on these findings may facilitate determination of the optimal conditions for hepatocyte culture. This study was considered to be an important first step in the clinical application of hepatocyte transplantation, although too basic.

on the function of cultured hepatocytes were also simple. However, further studies based on these findings may facilitate determination of the optimal conditions for hepatocyte culture. This study was considered to be an important first step in the clinical application of hepatocyte transplantation, although too basic. In conclusion, the morphological assessment indicated that low-glucose culture medium is better than high-glucose culture medium for culturing of hepatocytes, although there was not significantly different in functional assessment. The cultured hepatocytes with low-glucose culture medium could be maintained for 7 days. Further studies of culture media supplemented with growth factors and hormones are necessary to determine the optimal culture conditions. No potential conflict of interest relevant to this article was reported. Fig. 1 Operative view of cannulation in the portal vein (A) and infusion of collagenase solution with whitish discoloration of the liver (B). Fig. 2 Evaluation of cell viability by trypan blue exclusion test (×200). Viable cells with an intact plasma membrane exclude dyes, such as trypan blue, whereas damaged cells (arrows) become stained, with particularly strong staining in the nucleus. The viability of isolated hepatocytes in this photograph was about 85%. Fig. 3 The changes in total cell count (A) and viability (B) according to glucose concentration in the culture medium. Data are means ± standard error of the mean. Asterisks indicate significant differences between time points (*P < 0.05).

Fig. 2 Evaluation of cell viability by trypan blue exclusion test (×200). Viable cells with an intact plasma membrane exclude dyes, such as trypan blue, whereas damaged cells (arrows) become stained, with particularly strong staining in the nucleus. The viability of isolated hepatocytes in this photograph was about 85%. Fig. 3 The changes in total cell count (A) and viability (B) according to glucose concentration in the culture medium. Data are means ± standard error of the mean. Asterisks indicate significant differences between time points (*P < 0.05). Fig. 4 Changes in liver function, including albumin (A), ammonia (B), and urea (C) levels, according to the glucose concentration in the culture medium. Data are means ± standard error of the mean. Asterisks indicate significant differences between time points (*P < 0.05). Fig. 5 Histological features of cultured rat hepatocytes (H&E, ×400). (A) Low-glucose group. (B) High-glucose group. Fig. 6 Histological features of cultured rat hepatocytes (immunofluorescence staining, ×200). (A) Low-glucose group. (B) High-glucose group.

INTRODUCTION Laparoscopic left lateral sectionectomy (LLLS) has been accepted with respect to its usefulness and benefits related to minimally invasive surgery [1,2,3]. After a consensus meeting held in 2008 (Louisiville statement), LLLS was introduced as a standard procedure for patients suitable for minimally invasive surgery [4]. Subsequently, Nguyen and Geller [5] also reported that LLLS is becoming a standard procedure and accounted for 20% of 3,000 laparoscopic liver resections performed until 2008. However, the technique required for this procedure continues to evolve and best practice has not been established. Some surgeon prefer to use the Cavitron Ultrasonic Surgical Aspirator (CUSA, Salleylab, CO, USA) to isolate glissonian pedicles to segments II and III and control individual pedicles with surgical clips [6,7,8]. On the other hand, others prefer to control glissonian pedicles to segments II and III simultaneously using endoscopic stapling devices without isolating pedicles [9,10,11,12]. The aims of this study are to present our surgical outcomes for LLLS by surgical technique, that is, whether glissonian pedicles were isolated and controlled individually or whether endoscopic staples were used to control glissonian pedicles to segments II and III, and to provide a rationale for LLLS using endoscopic staples from the perspective of liver anatomy.

gical outcomes for LLLS by surgical technique, that is, whether glissonian pedicles were isolated and controlled individually or whether endoscopic staples were used to control glissonian pedicles to segments II and III, and to provide a rationale for LLLS using endoscopic staples from the perspective of liver anatomy. METHODS We retrospectively analyzed and compared clinical outcomes (operation times, drainage length, transfusion requirements, hospital stay, complication rate) in 35 patients that underwent LLLS between April 2004 and February 2012. Patients were dichotomized by surgical technique into an individual group (n = 21; glissonian pedicles isolated and controlled individually) or a batch (n = 14; glissonian pedicles simultaneously controlled using endoscopic staples). We included patients with a malignant tumor, intrahepatic lithiasis, and benign tumor within American Society of Anesthesiologists Classification 1, 2, but excluded those with portal vein (PV) thrombus, or an intrahepatic duct stone at the left main bile duct. All 35 patients were of Child-Pugh class A. There was no significant difference between the individual and the batch group (Table 1). Operation time, drainage length, hospital stay, transfusion during perioperative period, and postoperative complication were analyzed.

intrahepatic duct stone at the left main bile duct. All 35 patients were of Child-Pugh class A. There was no significant difference between the individual and the batch group (Table 1). Operation time, drainage length, hospital stay, transfusion during perioperative period, and postoperative complication were analyzed. Surgical technique The procedures are both conducted with the patient supine in the reverse Trendelenburg position. LLLS is performed by two surgeons (operator, assistant) and one scopist. The operator stands to the right of the patient with the assistant and the scopist on the patient's left. Four ports are placed as shown in Fig. 1. Carbon dioxide pneumoperitoneum is maintained at 12 mmHg to minimize the risk of gas embolism. We use a 90' flexible scope and a 12-mm trochar is inserted in the supraumbilical area. An additional 12-mm trochar is inserted at around the intersection of the right subcostal and midclavicular lines and 5-mm trochar is inserted at around the intersection of the right subcostal and midaxillary lines. The assistant inserts the 5-mm trochar in the left subcostal area. The Pringle maneuver is not used during transaction of liver parenchyme. Intraoperative ultrasonography is performed to exclude any other lesion, to define tumor size, and to position and remark the resection anatomy. The falciform ligament and triangular ligament are divided with a Harmonic scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) up to the level of the inferior vena cava (IVC) and the left hepatic vein (LHV) through the right port. The left round ligament is divided up to the Arantius duct to free the left lateral segment and to allow easy stapling of the LHV. A Harmonic scalpel is used to dissect the anterosuperior portion of liver to reach umbilical plate (Fig. 2). After reaching the glissonian pedicle of left lobe (Fig. 3), glissonian pedicles to segments II and III are controlled using either of two methods.

the left lateral segment and to allow easy stapling of the LHV. A Harmonic scalpel is used to dissect the anterosuperior portion of liver to reach umbilical plate (Fig. 2). After reaching the glissonian pedicle of left lobe (Fig. 3), glissonian pedicles to segments II and III are controlled using either of two methods. In the individual group, glissonian pedicles were separately dissected and controlled and the LHV was controlled with Hemolock or metallic clips instead of the Endo-GIA. In the batch group, glissonian pedicles and surrounding liver tissue were controlled using an Endo-GIA (Ethicon Endo-Surgery Inc.) with a 60-mm white cartridge to the left side of the glissonian sheath (Fig. 4). In case of incomplete control of glissonian pedicles, we could perform the additional individual method or control with LHV simultaneously using endoscopic staples. Remnant liver parenchyme was dissected with a Harmonic scapel, and then the LHV, within liver parenchyme, was divided using the Endo-GIA using a 60-mm white cartridge (Fig. 5). Finally, in both group, specimen extraction was conduction using a protective bag through a supraumbilical port site subsequently extended by a midline incision. After careful hemostasis, an Argon beam was applied to the transection surface and fibrin glue was applied to staple lines. Prophylactic abdominal drains were placed in the transection surface (Fig. 6).

was conduction using a protective bag through a supraumbilical port site subsequently extended by a midline incision. After careful hemostasis, an Argon beam was applied to the transection surface and fibrin glue was applied to staple lines. Prophylactic abdominal drains were placed in the transection surface (Fig. 6). Statistical analysis Statistical analysis was conducted using IBM SPSS Statistics ver. 19.0 (IBM Co., Armonk, NY, USA). Comparisons between nonparametric variables were analyzed using the Mann-Whitney U test and comparisons between categorical variables using the chi-square test. P-values of <0.05 were considered statistically significant. RESULTS Between April 2004 and February 2012, 35 patients (20 males, 15 females) underwent LLLS. Patient characteristics are summarized in Table 2. In 21 patients, LLLS was performed for a malignant tumor, diagnoses were hepatocellular carcinoma (n = 10), metastasis from colorectal cancer (n = 8), cholangiocarcinoma (n = 1; diagnosed postopreatvely), biliary cystadenocarcinoma (n = 1), and combined hepatocellular carcinoma and cholangiocellular carcinoma (n = 1). In the other 14 patients, LLLS was performed for a benign lesion, diagnoses were intrahepatic lithiasis (n = 7), hemangioma (n = 3), a huge cyst (n = 3) and a pseudotumor (n = 1).

iagnosed postopreatvely), biliary cystadenocarcinoma (n = 1), and combined hepatocellular carcinoma and cholangiocellular carcinoma (n = 1). In the other 14 patients, LLLS was performed for a benign lesion, diagnoses were intrahepatic lithiasis (n = 7), hemangioma (n = 3), a huge cyst (n = 3) and a pseudotumor (n = 1). The surgical results are summarized in Table 3 and Fig. 7. The Individual method was conducted in 21 patients and the batch method was conducted in 14. Mean operation time was 265.3 ± 21.3 minutes (mean ± standard deviation) and 170.0 ± 22.9 minutes in the individual and the batch group and mean operation time was significantly shorter in the batch group (P = 0.007). Mean drainage length was 4.8 ± 1.6 and 2.6 ± 1.5 days in the individual and the batch group. There was significantly shorter in batch group, also (P = 0.006). Mean postoperative hospital stay was 10.7 ± 1.1 and 9.4 ± 0.8 days in the individual and the batch group. There was not significant differences between the individual and the batch group (P = 0.460). No transfusion was required in the batch group, but 4 of 21 patients in the individual group needed a blood transfusion during surgery. Postoperative laboratory findings between the individual and the batch group were not statistically significant. One open conversion due to tumor rupture occured in the individual group. Three cases of postoperative atelectasis were encountered in the individual group but only one in the batch group. We did not experience gas embolism, bile leakage, postoperative bleeding, bile duct injury, or vascular injury in either group. There was no postoperative death (defined as death during first 90 postoperative days). The average number of the Endo-GIA we used in the batch group was 2.92 ± 0.14.

y one in the batch group. We did not experience gas embolism, bile leakage, postoperative bleeding, bile duct injury, or vascular injury in either group. There was no postoperative death (defined as death during first 90 postoperative days). The average number of the Endo-GIA we used in the batch group was 2.92 ± 0.14. In terms of medical cost, the batch group tends to be more expensive compared to the individual group [9]. However, since medical insurance system in South Korea reduces the burden of medical cost in patients, we believe the medical cost needs not to be considered otherwise at least in our country. DISCUSSION Since the first report of LLLS in 1996 [13], LLLS has become a popular treatment option, and many authors have reported on its feasibility and safety [1,2,3,9,11,12]. Currently, LLLS is accepted as a standard anatomic liver resection technique for any lesions located in segments II and III [2,10]. LLLS is a suitable procedure for training of laparoscopic hepatectomy, because it contains various procedures such as liver mobilization, liver parenchyme transection, and control of glissonian pedicles and vessels. We used the individual method to gain surgical experience in the early period, and later, that we randomly divided patients by surgical techniques (the individual group and the batch group) depending on surgeon's preference during the surgery. For this reason, the individual group is larger than the batch group, and patients in the upcoming future will be treated, preferably, with batch method.

, and later, that we randomly divided patients by surgical techniques (the individual group and the batch group) depending on surgeon's preference during the surgery. For this reason, the individual group is larger than the batch group, and patients in the upcoming future will be treated, preferably, with batch method. Using the endoscopic stapling device to control all glissonian pedicles simultaneously, we could fasten the operation, but we had been worry about bile leakage, bleeding, or injury of glissonian pedicles to segment IV. Although the small number of cases treated (n = 14) preclude conclusions, we did not encounter any significant morbidity, such as, bleeding, bile leakage, or injury of glissonian pedicles to segment IV. Accordingly before concluding that LLLS using stapling devices is a straightforward, reproducible technique, we reviewed the published literatures to provide a rationale for our technique from an anatomic perspective.

ignificant morbidity, such as, bleeding, bile leakage, or injury of glissonian pedicles to segment IV. Accordingly before concluding that LLLS using stapling devices is a straightforward, reproducible technique, we reviewed the published literatures to provide a rationale for our technique from an anatomic perspective. Cho et al. [14,15] introduced three types of left biliary and portal systems and reported that regardless of type, segment IV ducts joined medially to the umbilical portion. Gumbs et al. [3] and Linden et al. [11] also supported our rationale for endoscopic stapling technique. During LLLS, the surgical resection margin is located at the left side of the umbilical portion, injury of segment IV duct is not an issue. Furthermore, variations of the PV are less than that those of bile duct, and the branch of the left PV to segment IV originates at the right side of the umbilical portion, and thus, injury of the PV is also unlikely. The arterial anatomy presented several variants that required modification of the dissection. In patients with a normal anatomy, there is a single branch to segment IV. In patients with a left hepatic artery originating from the left gastric artery, the artery to segment IV can always be preserved, and such patients, the arterial branch to segment IV originates at the right side of the umbilical portion, and thus, there is no need to consider injury of the arterial branch to segment IV [16]. Although it has a little risk, the stapler technique can result in injury of the arterial branch to segment IV, and result in atropy of segment IV. However, it does not cause any significant morbidity [17].

f the umbilical portion, and thus, there is no need to consider injury of the arterial branch to segment IV [16]. Although it has a little risk, the stapler technique can result in injury of the arterial branch to segment IV, and result in atropy of segment IV. However, it does not cause any significant morbidity [17]. In this study, we report that portal pedicles, the LHV can be dissected using endoscopic staplers without bleeding or bile leakage. The LHV is the most critical structure and failure to secure it can lead to massive bleeding and gas embolism. However, dissection of the left round ligament and triangular ligament up to the level of the Arantius duct and the IVC enables staples to be easily placed through the LHV and ensure security. Furthermore, laparoscopic ultrasound examination, allow more accurate evaluation of the LHV and increases procedural safety. For the entire batch group, we used Endo-GIA with a 60-mm white cartridge. There were no significant postoperative complications, including bile leakage or bleeding etc. A white cartridge has a 2.5-mm open staple height and a 1.0-mm closed staple height. We think that in patients with thicker pedicle, blue or gold cartridge can be used to prevent bile leakage due to duct disruption or delayed opening, but we are worry about bleeding from main pedicle.

ding bile leakage or bleeding etc. A white cartridge has a 2.5-mm open staple height and a 1.0-mm closed staple height. We think that in patients with thicker pedicle, blue or gold cartridge can be used to prevent bile leakage due to duct disruption or delayed opening, but we are worry about bleeding from main pedicle. Left PV thrombosis can be happened after the staple procedure in LLLS, especially, when the staple is very close to umbilical portion or injury the right side of pedicles. The distance from umbilical portion has not been measured in our study, just we did were that (1) tried to start liver parenchymal dissection a little bit left side of falciform ligament and (2) tried to apply staple a little bit left side of umbilical portion, not to involve the middle portion. Anyway at this moment, it is difficult to define what distance from umbilical portion is acceptable to prevent PV thrombosis and further research should be conducted in the upcoming future. Recently we changed our surgical treatment strategy for intrahepatic stone. For the patients with stricture at the main junction of segments II or III glissonian pedicle, we tried laparoscopic left hemihepatectomy of liver because of hidden malignancy. In this study, 3 cases of intrahepatic stone were enrolled in the batch group. Fortunately our cases did not have any serious complication. But we are ought to remember risk of hidden malignancy, left hemihepatectomy rather than LLLS can be performed in patients with intrahepatic stone depending on the surgeon's experience and decision.

ases of intrahepatic stone were enrolled in the batch group. Fortunately our cases did not have any serious complication. But we are ought to remember risk of hidden malignancy, left hemihepatectomy rather than LLLS can be performed in patients with intrahepatic stone depending on the surgeon's experience and decision. In patients with chronic hepatitis or cirrhosis, individual method often causes excessive blood loss and ascites accumulation because of pre-existing coagulopathy and aggravation of portal hypertension [18]. Mean operation time and mean drainage length in the batch group were significantly shorter than in the individual group (170.0 ± 22.9 and 265.3 ± 21.3 minutes, P = 0.007; 2.6 ± 1.5 and 4.8 ± 1.6 days, P = 0.006). Mean hospital stay was similar in the batch and the individual group (9.4 ± 0.8 and 10.7 ± 1.1 days, P = 0.460). Mean hospital stay was somewhat long, which we attribute to regional circumstances and customs. No significant intergroup difference was found for transfusion or postoperative laboratory finding and complications. We did not encounter conversion cases (batch to individual or individual to batch technique). Even though our cases were not large enough to conclude, depending on our experience, LLLS with batch method was done without conversion or interruption. These can lead to gain confidence with our surgical technique.

ications. We did not encounter conversion cases (batch to individual or individual to batch technique). Even though our cases were not large enough to conclude, depending on our experience, LLLS with batch method was done without conversion or interruption. These can lead to gain confidence with our surgical technique. LLLS can be regarded as anatomic resection of liver, we believe that it's surgical result for malignant tumor is at least compatible to open surgery [19]. But our cases were not enough and we did not analyze the surgical results of open left lateral sectionectomy of liver during the same study period. Because most of cases at that period were done with laparoscopic technique. Furthermore, main focus of this study is surgical technique for LLLS. In conclusion, our experience indicates that LLLS using endoscopic staples can be performed without extensive vascular isolation, and with acceptable low morbidity. Furthermore, this technique was found to be easier and safer technique and to have better outcomes without morbidity or mortality. In our opinion, LLLS using endoscopic staples should be considered a standard procedure for LLLS. No potential conflict of interest relevant to this article was reported. Fig. 1 The four ports used for laparoscopic left lateral sectionectomy. Fig. 2 Dissection of liver parenchyme using a Harmonic scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA). Starting just left of the falciform ligament. Fig. 3 Exposure of glissonian pedicles after liver parenchymal dissection.

No potential conflict of interest relevant to this article was reported. Fig. 1 The four ports used for laparoscopic left lateral sectionectomy. Fig. 2 Dissection of liver parenchyme using a Harmonic scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA). Starting just left of the falciform ligament. Fig. 3 Exposure of glissonian pedicles after liver parenchymal dissection. Fig. 4 (A) Transection of glissonian pedicles to segments II and III using an Endo-GIA (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) and a 60-mm white cartridge. (B) Transection of glissonian pedicles to segments II and III using an Endo-GIA and a 60-mm white cartridge. Arrows: staple lines after using an Endo-GIA. Fig. 5 Transection of the left hepatic vein using an Endo-GIA (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) and a 60-mm white cartridge. Fig. 6 Postoperative finding of laparoscopic left lateral sectionectomy using an Endo-GIA (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) and a 60-mm white cartridge. Arrow: The staple line is always located at the lowermost portion of transected liver parenchyma. Fig. 7 Postoperative laboratory finding in the individual group and batch group. There was no significant difference between the individual and the batch group (A, P = 0.584; B, P = 0.617; C, P = 0.107). POD, postoperative day. Table 1 Preoperative demographics betweem the individual group and the batch group Values are presented as mean ± standard deviation or number. Table 2 Patients and tumor characteristics SD, standard deviation; HCC, hepatocellular carcinoma; CCC, cholangiocellular carcinoma.

Fig. 7 Postoperative laboratory finding in the individual group and batch group. There was no significant difference between the individual and the batch group (A, P = 0.584; B, P = 0.617; C, P = 0.107). POD, postoperative day. Table 1 Preoperative demographics betweem the individual group and the batch group Values are presented as mean ± standard deviation or number. Table 2 Patients and tumor characteristics SD, standard deviation; HCC, hepatocellular carcinoma; CCC, cholangiocellular carcinoma. Table 3 Surgical results the individual method vs. the batch method Values are presented as mean ± standard deviation or number.

INTRODUCTION It has been reported that liver cancer is the fifth most common malignant tumor worldwide and the fourth most common malignant cancer nationwide [1], and according to domestic statistics of South Korea, five-year survival rates from hepatocellular carcinoma (HCC) was 15.3% [2], a relatively low survival rate compared to its high incidence. Liver cirrhosis is the factor with the most decisive influence on the incidence of HCC, and about 90% of patients with HCC have chronic infections of hepatitis B or C virus, known as the basal diseases of cirrhosis [3]. Hepatectomy, radiofrequency thermal ablation (RFA), transcatheter arterial chemoembolization, and liver transplantation were conducted for the treatment of HCC, and hepatic function reserve is an important consideration in selecting treatment methods for HCC. Of the current treatment methods of HCC, hepatectomy has been known as a radical treatment method [4,5,6]. RFA had been introduced as an alternative therapy for hepatectomy, but recently, it has also been used as the primary treatment method of small HCC according to the status of patients. Liver transplantation (LT) has been recognized as ideal therapy of primary HCC, because it can treat basal cirrhosis as well as HCC [7]. But hepatic resection (HR) revealed similar survival and recurrence to LT in the setting of well compensated cirrhosis and early HCC [8]. Also, thanks to a shortage of donors, high medical expenses, and restriction of criteria, LT is not generally undergone as the primary therapy of HCC.

l cirrhosis as well as HCC [7]. But hepatic resection (HR) revealed similar survival and recurrence to LT in the setting of well compensated cirrhosis and early HCC [8]. Also, thanks to a shortage of donors, high medical expenses, and restriction of criteria, LT is not generally undergone as the primary therapy of HCC. In cases where the possibility of postoperative complication caused by hepatic failure induced from cirrhosis is high, where HR is impossible due to the development of intrahepatic multiple mass at the time of diagnosis of HCC, and where the cancer mass is located in an area where surgical approach or resection is impossible, an operation cannot be performed [9], and just 9%-27% of HCC patients can receive hepatectomy [10,11,12,13,14]. Thus, several nonsurgical therapies including transcatheter arterial chemoembolization, percutaneous ethanol injection and RFA have been used as an alternative to surgery. Of these therapies, percutaneous ethanol injection and RFA were regarded as optimal treatment modalities for small HCC [15]. Furthermore, RFA has been reported to achieve the optimal efficacy of treatment for small HCC [14,16,17]. Since its first introduction in 1996, RFA has been used mainly as an alternative therapy for the treatment of HCC and recently, it considered as first-line treatment of small HCC even when eligible for HR. According to recent studies, the pre-eminence of HR over RFA for small HCCs was suspected in that HR failed to demonstrate superiority in terms of overall survival (OS) and disease-free survival (DFS), also higher occurrence of major complications after surgery were reported [18,19]. However, as rising early detection of small HCC due to generalization of ultrasound screening for patients at risk of HCC and the preference for noninvasive therapy have been rising, RFA has widely been performed as first-line treatment modality of small HCC.

of major complications after surgery were reported [18,19]. However, as rising early detection of small HCC due to generalization of ultrasound screening for patients at risk of HCC and the preference for noninvasive therapy have been rising, RFA has widely been performed as first-line treatment modality of small HCC. Therefore, this study examined the efficacies of HR and RFA for small HCC, conducted at a single hospital, for the same period through the comparison of complications, recurrences, OS rate, and DFS rate. In addition, it also investigated the factors affecting the prognosis of HCC. METHODS Patients Patients who were diagnosed with HCC and underwent HR or RFA as their first treatment modalities at Chonnam National University Hospital from Jan. 1, 2005 to Dec. 31, 2009 were included in this study. Since the patients who were subject to the RFA were limited to the relatively small size of HCC, only the cases applicable to RFA were sampled from cases that underwent HR for the comparison of two the treatment methods. Namely, patients with three or fewer nodules 3 cm or less in diameter or a single nodule of 5 cm or less were selected. Patients who underwent HR and RFA simultaneously were excluded because the influence of the treatment methods on recurrences and period of survival could not be distinguished. Retrospective study was conducted on the basis of the medical records of 129 consecutive patients who underwent HR and 57 who underwent RFA for the treatment of HCC.

t HR and RFA simultaneously were excluded because the influence of the treatment methods on recurrences and period of survival could not be distinguished. Retrospective study was conducted on the basis of the medical records of 129 consecutive patients who underwent HR and 57 who underwent RFA for the treatment of HCC. Written informed consent was obtained from all the patients before HR and RFA. This study was approved by the Institutional Review Board of the ethical committee of Chonnam National University Hospital and also granted waiver for individual patient consent in the view point of being evaluated retrospectively (2012-173). The diagnosis of HCC HCC was diagnosed using liver biopsy, imaging study, and serum α-FP. All 129 patients of HR group confirmed HCC histopathologically after HR and 5 cases (8.7%) of RFA group were diagnosed through ultrasound-guided fine needle aspiration cytology before procedure. Of the diagnoses in the RFA group through noninvasive approaches [20], (1) 4 cases (7.0%) were equivalent to α-FP of the patients with risk factors including cirrhosis, chronic hepatitis B, and chronic hepatitis C showed an increase of 200 ng/dL or more with typical HCC findings of early arterial enhancement and early wash-out at portal-delayed phase in dynamic CT or dynamic MRI, (2) 42 cases (73.9%) reported α-FP of 200 ng/dL or less but typical HCC findings both in dynamic CT and dynamic MRI, and (3) 11 cases (19.3%) indicated typical findings of HCC in dynamic CT or dynamic MRI of 2 cm or more in size with cirrhosis.

nt and early wash-out at portal-delayed phase in dynamic CT or dynamic MRI, (2) 42 cases (73.9%) reported α-FP of 200 ng/dL or less but typical HCC findings both in dynamic CT and dynamic MRI, and (3) 11 cases (19.3%) indicated typical findings of HCC in dynamic CT or dynamic MRI of 2 cm or more in size with cirrhosis. Clinical characteristics Baseline evaluation included gender, age, presence or absence of cirrhosis, HBsAg, anti-HCV, albumin, AST, ALT, α-FP, total bilirubin, PT, platelet count, indocyanine green retention rate at 15 minutes (ICG R-15), Child-Pugh class, presence or absence of portal hypertension, size and number of HCC, length of hospital stay, complications, and aspects of recurrence of all patients. Diagnosis of cirrhosis in HR group was based on final histopathologic report. But determination of cirrhosis in RFA group was done by integrating radiologic findings suggestive of cirrhosis such as diffuse liver nodularity, change of echotexture, atrophy or hypertrophy of parenchyma and signs of portal hypertension. Of patients diagnosed with cirrhosis, portal hypertension was diagnosed when (1) gastric or esophageal varix was found by gastroduodenoscopy or conspicuous findings in abdominal imaging study or (2) a conspicuous splenomegaly was observed by abdominal imaging study with decreased the platelet count below 100,000/mm3 [21].

patients diagnosed with cirrhosis, portal hypertension was diagnosed when (1) gastric or esophageal varix was found by gastroduodenoscopy or conspicuous findings in abdominal imaging study or (2) a conspicuous splenomegaly was observed by abdominal imaging study with decreased the platelet count below 100,000/mm3 [21]. In order to apply the same criteria to both groups, the size of the HCC was measured with the maximum diameter of mass from the abdominal CT conducted before treatment procedure. Complications were confined to cases of surgical complication grade II or more, which require medication, surgical and radiologic intervention [22]. Recurrence Local recurrence was defined as the cases in which recurrence was found around resection margin in HR group and recurrence was found at the periphery of the ablated zone in subsequent CT scans after complete ablation was confirmed in RFA group. Intrahepatic distant recurrence was defined as the cases in which recurrence was observed at a region not adjacent to the primary lesion within same segment or in different segments. Survival The concluding time of OS was based on the date of death in cases of death and on the date of the most recent follow-up visit in cases of survival. The concluding time of DFS was based on the date of the confirmation of the recurrence by imaging test in cases of recurrence and on the date of the last imaging test in cases of nonrecurrence. OS and DFS were computed monthly with the period from the date of surgical operation or RFA to the concluding date of OS and DFS, respectively.

me of DFS was based on the date of the confirmation of the recurrence by imaging test in cases of recurrence and on the date of the last imaging test in cases of nonrecurrence. OS and DFS were computed monthly with the period from the date of surgical operation or RFA to the concluding date of OS and DFS, respectively. Methods of hepatectomy Of the patients who were diagnosed with clinical HCC and eligible to undergo HR considering the location and the distribution of tumor, the patients who were not limited in hepatic reserve to undergo HR at the preoperative test were selected for HR. The range of hepatectomy was determined by considering ICG R-15 results and position of tumor, and anatomical resection was performed if possible. Forty-four of 129 patients (34.1%) underwent wedge resection, 29 (22.5%) segmentectomy, 33 (25.6%) bisegmentectomy, and 23 (17.8%) major HR. Eight of 129 patients (6.2%) underwent laparoscopic hepatectomy, and 121 (93.8%) were treated with open hepatectomy. All patients were finally diagnosed with HCC by histopathological study. Three patients showed no findings of residual tumor infiltration at the resection margin grossly, but microscopic finding revealed the margin positive at the resection margin.

scopic hepatectomy, and 121 (93.8%) were treated with open hepatectomy. All patients were finally diagnosed with HCC by histopathological study. Three patients showed no findings of residual tumor infiltration at the resection margin grossly, but microscopic finding revealed the margin positive at the resection margin. Methods of RFA Patients with the deterioration of liver function over Child-Pugh class B, patients belonging to high-risk groups of HR due to poor general conditions and patients expressing their wishes to reject the surgical operation in spite of recommended hepatectomy were selected as the subjects of the study. Fifty of 59 patients (84.7%) who underwent RFA were treated with percutaneous approach, and 9 patients (15.3%) were treated with RFA after laparotomy under general anesthesia, which included 8 patients who gave up hepatectomy after diagnostic laparotomy and converted to RFA and 1 patient treated with RFA after laparotomy for the surgical operation of choledocholithiasis. Every procedure of RFA was performed by interventional radiologist regardless of place - whether operation room or ultrasonography suite. RFA instruments were used as: CC-I (Radionics, Burlington, MA, USA) with clustered cooled-tip needle (17 gauge, electrode length of 2-3 cm). For percutaneous intervention, 2 mL of Fentanyl (Fentanyl, Hana Pharmacy, Seoul, Korea) was administered for sedation and local anesthesia from skin to hepatic capsule was conducted along to expected electrode insertion route with 2% Lidocane HCl (Lidocaine, Gwangmyeong Pharmacy, Seoul, Korea) and radiofrequency electrode was inserted into the center of targeting HCC under real time ultrasound guidance. RFA was performed with consecutive activation mode and a 17-G dual clustered cooled-tip electrode was introduced to index tumor. RF current was conducted through from generator with settings to deliver maximal power in the automatic impedance control mode. RFA was applied for 8-12 minutes continuously. End point of RFA was determined mainly according to ultrasound imaging of fully covered of index tumor by hyperechoic ablated zone. Tumors larger than a diameter of 3.5 cm required multiple overlapping ablations [23]. There was no premature stop of procedure caused by pain discomfort. To prevent hemorrhage and seeding along the track, the electrode was drawn back with thermocoagulation of inserted track.

of index tumor by hyperechoic ablated zone. Tumors larger than a diameter of 3.5 cm required multiple overlapping ablations [23]. There was no premature stop of procedure caused by pain discomfort. To prevent hemorrhage and seeding along the track, the electrode was drawn back with thermocoagulation of inserted track. Dynamic CT was conducted on the day after intervention, and when low attenuation shown in the images of arterial and portal phases contained enough to cover the index HCC and there was no contrast enhancement near the region of thermal therapy, patient discharge was planned without additional sessions of RFA. But if tumoral enhancement was detected, additional sessions were performed for residual tumor. One of 57 patients (1.7%) showed incomplete necrosis, and one week later, RFA was performed again to achieve complete necrosis. The completeness of RFA was confirmed with dynamic CT performed 1 month after procedure. Follow-up After treatments HR and RFA, dynamic CT, serum α-FP and liver function test were regularly conducted every 2-6 months after discharge from hospital, and cases of suspected recurrence were confirmed by dynamic MRI. In case of recurrence, rehepatectomy, transcatheter arterial chemoembolization, or RFA was performed selectively.

reatments HR and RFA, dynamic CT, serum α-FP and liver function test were regularly conducted every 2-6 months after discharge from hospital, and cases of suspected recurrence were confirmed by dynamic MRI. In case of recurrence, rehepatectomy, transcatheter arterial chemoembolization, or RFA was performed selectively. Statistical analysis Comparison of nominal variables was conducted with the chi-square test and the analysis of continuous variables used the independent t-test. The analysis of the survival employedthe Kaplan-Meier method and the significance of differences between groups was compared with the log-rank test. The Cox regression model was used for the univariate and the multivariate analysis of the factors affecting the prognosis of HCC. Multivariate analysis was conducted with all factors of P < 0.100 in the univariate. All statistical analyses were performed with the statistical program SPSS ver. 17.0 (SPSS Inc., Chicago, IL, USA) and P < 0.05 was considered as a statistically significant value.

analysis of the factors affecting the prognosis of HCC. Multivariate analysis was conducted with all factors of P < 0.100 in the univariate. All statistical analyses were performed with the statistical program SPSS ver. 17.0 (SPSS Inc., Chicago, IL, USA) and P < 0.05 was considered as a statistically significant value. RESULTS Patients' characteristics (Table 1) The male to female ratio of total HCC cases was 6.4:1, with there being more male patients than female patients (P < 0.001), and there was no difference in the sex ratio between the two groups (P = 0.254). Cirrhosis was found in 96 patients of the HR group (74.4%) and 48 of the RFA group (84.2%). In the etiology of liver cirrhosis, hepatitis B infection was the most common infection in both groups at 69.8% and 52.1%, respectively, and there was no significant difference in the percentages of hepatitis B infection (P = 0.104). In Child-Pugh class, which can estimate the progress of cirrhosis, the entire HR group was diagnosed as class A, but 43 of the RFA group (89.6%) was diagnosed as class A and 5 (10.4%) as class B, and it was found that cirrhosis had progressed further in the RFA group (P = 0.002). The mean diameters of the HCC were 3.0 ± 1.0 cm and 2.3 ± 1.0 cm in the HR group and the RFA group, respectively, and the tumors of the RFA group were smaller than those of the HR group (P < 0.001). There was no difference in the serum α-FP distributions in the two groups after dividing them into over and below serum α-FP 20 ng/mL (P = 0.617) and total bilirubin was higher in the RFA group at 1.1±0.6 g/dL than in the HR group at 0.9 ± 0.4 g/dL (P = 0.004). There were more patients who had portal hypertension in the RFA group (P < 0.001). The mean follow-ups between the two groups were 28.2 and 28.3 months for the HR group and the RFA group, respectively, and there was no difference between the two groups (P = 0.964). The mean lengths of hospital-stay were 14.5 days in the HR group and 6.0 days in the RFA group, demonstrating longer stay in the HR group (P < 0.001).

ow-ups between the two groups were 28.2 and 28.3 months for the HR group and the RFA group, respectively, and there was no difference between the two groups (P = 0.964). The mean lengths of hospital-stay were 14.5 days in the HR group and 6.0 days in the RFA group, demonstrating longer stay in the HR group (P < 0.001). Complications The percentages of incidence of complications was 17.8% in the HR group and 10.5% in the RFA group, higher in the HR group, but there was no statistical difference (P = 0.206) (Table 2). Three patients (2.3%) died of hepatic failure and ensuing disseminated intravascular coagulation after surgical operation (1 right hepatectomy case, 1 segmentectomy case, and 1 wedge resection case). Recurrence (Table 3) Fifty-nine of 129 patients (45.8%) treated with HR reported recurrence, and remote recurrence was the most frequent type of recurrence at 11 cases (39.5%). Thiry-six of 57 patients (63.1%) treated with RFA reported recurrence and showed higher recurrence rates than the HR group (P = 0.038). Local recurrence was found in 17 patients of the RFA group (29.8%) and 2 patients of the HR group (1.6%), significantly higher in the RFA group (P < 0.001). Of the local recurrence in RFA group, 10 of 17 recurrence cases (58.8%) reported recurrence within 1 year and 7 (41.2%) within 2 years, and 2 local recurrence cases of the HR group were within 1 year.

ents of the RFA group (29.8%) and 2 patients of the HR group (1.6%), significantly higher in the RFA group (P < 0.001). Of the local recurrence in RFA group, 10 of 17 recurrence cases (58.8%) reported recurrence within 1 year and 7 (41.2%) within 2 years, and 2 local recurrence cases of the HR group were within 1 year. OS rates and DFS rates (Table 4) The 1-, 3- and 5-year OS rates in the HR group were 91.3%, 78.8%, and 64.9%, compared to 94.6%, 74.4%, and 74.4% in the RFA group, and the mean OS was 50.7 ± 2.1 and 53.2 ± 3.0 months, respectively, with no difference in the OS between the two groups (P = 0.725) (Fig. 1A). The 1- and 3-year DFS rates in the HR group were 70.0% and 53.0%, compared to 65.2% and 24.7% in the RFA group, respectively. The DFS rates of HR group was significantly higher than RFA group in this study (P = 0.015) (Fig. 1B). Additionally, DFS was estimated in dividing subgroups such as HCC of 3 or less centimeters (Fig. 2A) and ranging from 3 to 5 centimeters (Fig. 2B). Mean DFS was 38.5 ± 3.4 months for HR group of 3 or less centimeters of HCC and 22.0 ± 2.6 for the RFA group, with significantly longer DFS in the HR group (P = 0.003). DFS in the subgroup ranging from 3 to 5 centimeters showed higher tendency in the HR group over RFA group, but could not reach a significant difference (P = 0.099). OS in the subgroups below and over 3 cm of HCC showed no difference between the two groups (P = 0.838 and P = 0.682, respectively).

e HR group (P = 0.003). DFS in the subgroup ranging from 3 to 5 centimeters showed higher tendency in the HR group over RFA group, but could not reach a significant difference (P = 0.099). OS in the subgroups below and over 3 cm of HCC showed no difference between the two groups (P = 0.838 and P = 0.682, respectively). Prognostic factors of HCC Factors affecting the OS were analyzed based on the entire 186 subjected patients (Table 5). Univariate analysis reported that recurrence (P = 0.021), total bilirubin (P = 0.013), and portal hypertension (P < 0.001) were analyzed as significant prognostic factors, but multivariate analysis showed that recurrence (P = 0.036) and portal hypertension (P = 0.036) were independent prognostic factors affecting the OS. As a result of univariate analysis of the factors affecting DFS, treatment methods (P = 0.009), number of tumor (P = 0.006), total bilirubin (P = 0.046), portal hypertension (P < 0.001), and α-FP (P < 0.001) were analyzed as the significant prognostic factors, but multivariate analysis reported that portal hypertension (P = 0.048) and α-FP (P = 0.008) were the significant independent prognostic factors of DFS (Table 6).

of tumor (P = 0.006), total bilirubin (P = 0.046), portal hypertension (P < 0.001), and α-FP (P < 0.001) were analyzed as the significant prognostic factors, but multivariate analysis reported that portal hypertension (P = 0.048) and α-FP (P = 0.008) were the significant independent prognostic factors of DFS (Table 6). DISCUSSION Staging of tumors in most solid cancers is deeply related to prognosis, but the prognosis of HCC is closely related to basal liver state [24,25], as well as HCC stage. In addition, a variety of complementary treatment modalities to HR have been used due to limitations in treatment methods depending on the existence of basal liver diseases including cirrhosis. RFA has been widely known as the most effective therapy for small HCC among current nonsurgical, locoregional treatment methods [14,15,16,17], and in particular, it has been reported that its therapeutic achievement for HCC of 2 or less centimeters in the size of tumor was similar to that of surgical HR [19]. But there are only a few studies that compared treatment effects between HR and RFA and, in particular, only one randomized controlled study was reported. Chen et al. [26] conducted a randomized controlled study with 180 patients diagnosed with HCC with a single nodule of 5 or less centimeters and reported that the treatment efficacies of RFA and HR for 4-year survival was similar in the two groups at 68% and 64%, respectively. But Ueno et al. [27] questioned the objectivity of the study by Chen et al. [26] in that its follow-up period was relatively short at 2 years and that the 4-year survival from RFA and HR was 70% or less.

ign or borderline malignant pancreatic tumors [1,5,7,8]. However, these reports included case reports and small series. Therefore, the purpose of this study was to present the surgical experience in our institution and to analyze the postoperative outcome of LE for benign or borderline malignant tumors of the pancreas. In particular, there is very limited information on the outcomes of LE compared with laparoscopic distal pancreatectomy (LDP). Therefore, we investigated clinical outcomes to evaluate the safety and efficacy of LE compared with LDP in benign or borderline malignant tumors of the pancreas. METHODS After Soonchunhyang University Bucheon Hospital Institutional Review Board's approval, from May 2005 to December 2011, 11 consecutive patients who underwent LE for benign or borderline malignant tumors of the pancreas were recruited into the current study. We retrospectively analyzed the medical rescords and this study conformed to the ethical guidelines of the Declaration of Helsinki.

e treatment efficacies of RFA and HR for 4-year survival was similar in the two groups at 68% and 64%, respectively. But Ueno et al. [27] questioned the objectivity of the study by Chen et al. [26] in that its follow-up period was relatively short at 2 years and that the 4-year survival from RFA and HR was 70% or less. Our study demonstrated that HR for HCC of 5 or less centimeters showed no significant increase OS compared to RFA, but an extension of DFS was expected (P = 0.015). We should estimate the reason of this discordance between OS and DFS that death from HCC was influenced not only by treatment modality or recurrence of malignancy itself but also by another factor represented as cirrhosis [28]. RFA has some advantages compared to HR such as being less invasive, having a relatively rapid recovery period, and short hospital stay. But it also has shortcomings such as more frequent local recurrence after treatment than HR [29]. This study confirmed three cases of mortality due to postoperative complications of hepatectomy although there was no statistical significance. Furthermore, HR group indicated higher incidences of complications compared to RFA. In addition, HR has weaknesses such as a longer hospital stay and a longer recovery period after operation.

irmed three cases of mortality due to postoperative complications of hepatectomy although there was no statistical significance. Furthermore, HR group indicated higher incidences of complications compared to RFA. In addition, HR has weaknesses such as a longer hospital stay and a longer recovery period after operation. The local recurrence rate of RFA group in this study was higher at 29.8% than HR group at 1.6% (P < 0.001). Mulier et al. [29] argued that the diameter of HCC was the greatest influential factor on local recurrence, and while HCC of 3 or less centimeters in the diameter showed a local recurrence rate of 3.6% in the first year after RFA, while HCC of 3-5 cm showed 21.7%. Ng et al. [30] suggested in their analysis of correlation between recurrence type and survival that cases of local recurrence indicated lower OS than that of no recurrence but that it showed higher OS than cases of remote recurrence or metastasis. However, this study showed no difference in the OS between the local recurrence group and the intrahepatic distant recurrent or remote metastasis group (P = 0.892).

al that cases of local recurrence indicated lower OS than that of no recurrence but that it showed higher OS than cases of remote recurrence or metastasis. However, this study showed no difference in the OS between the local recurrence group and the intrahepatic distant recurrent or remote metastasis group (P = 0.892). Ueno et al. [27] conducted a study with patients who met the Milan criteria to compare an RFA group that was divided into a percutaneous treatment group and a surgical approach group with an HR group and found that the surgically approached RFA group showed much higher DFS (P = 0.001) and OS (P = 0.010) than the percutaneously approached group. There was no statistical significance in comparison to the HR group, but the surgically approached RFA group indicated a higher OS. Our study conducted RFA with nine patients through surgical approaches, but since the sample size was small, statistical analysis was not conducted. As a result of analyzing the factors affecting OS, recurrence and portal hypertension were confirmed as independent risk factors (Table 5), and portal hypertension and serum α-FP were independent risk factors related to DFS (Table 6). It suggests that the prognosis of HCC is involved with the conservation of liver function as well as the radical treatment itself.

g OS, recurrence and portal hypertension were confirmed as independent risk factors (Table 5), and portal hypertension and serum α-FP were independent risk factors related to DFS (Table 6). It suggests that the prognosis of HCC is involved with the conservation of liver function as well as the radical treatment itself. However, portal hypertension and α-FP, which were analyzed as independent prognostic factors affecting DFS in this study, were unfavorably distributed in the RFA group than in the HR group as shown in the Table 1 (P < 0.001 and P = 0.617, respectively). Accordingly, patients with α-FP of 20 ng/mL or less and no portal hypertension were reselected for subgroup analysis, and consequently, the authors could not find any statistical difference in DFS between HR and RFA subgroup (P = 0.228) (Fig. 3). Yet, this study has several limitations; First, this study was performed retrospectively and under a nonrandomized design. Second, treatment groups were not well matched in terms of well admitted prognostic factors of HCC such as α-FP level, Child-pugh class, bilirubin level and size of HCC, being biased unfavorably for RFA group with exception of size of tumor. Third, diagnosis of HCC and cirrhosis of patients in RFA group were not based on histopahologic evidence but on radiologic and clinical findings.

itted prognostic factors of HCC such as α-FP level, Child-pugh class, bilirubin level and size of HCC, being biased unfavorably for RFA group with exception of size of tumor. Third, diagnosis of HCC and cirrhosis of patients in RFA group were not based on histopahologic evidence but on radiologic and clinical findings. In conclusion, when hepatectomy was conducted to treat small HCC, a more significant extension of DFS could be expected than RFA. Thus, HCC with three or fewer nodules 3 cm or less in diameter or a single nodule of 5 cm or less should be performed hepatectomy as the primary treatment if the patient's liver function and general conditions are good enough to undergo surgical operation. Despite a higher recurrence rate, RFA was revealed to have similar OS as HR for the treatment of HCC within the Milan criteria. And in terms of less invasiveness, RFA has advantages over HR. So, RFA can be an alternative therapy for patients who are eligible for surgical resection. No potential conflict of interest relevant to this article was reported. Fig. 1 Overall (A) and disease-free survival (B) of all patients in the two treatment groups. (A) The overall survival were not significantly different (P = 0.725), in the two treatment groups. (B) But disease-free survival was significantly higher in hepatic resection (HR) group (P = 0.015). RFA, radiofrequency ablation.

Fig. 1 Overall (A) and disease-free survival (B) of all patients in the two treatment groups. (A) The overall survival were not significantly different (P = 0.725), in the two treatment groups. (B) But disease-free survival was significantly higher in hepatic resection (HR) group (P = 0.015). RFA, radiofrequency ablation. Fig. 2 Disease-free survival of patients with hepatocellular carcinoma (HCC ≤ 3 cm (A) and 3 cm < HCC ≤ 5 cm (B) in the two treatment groups. (A) Disease-free survival was significantly higher in resection group (P = 0.003). (B) Disease-free survival was higher in hepatic resection (HR) group but the difference did not reach statistical significance (P = 0.099). RFA, radiofrequency ablation. Fig. 3 Disease-free survival of patients with α-FP below 20 ng/mL and absence of portal hypertension in the two treatment groups: Disease-free survival was higher in hepatic resection (HR) group but the difference did not reach statistical significance (P = 0.228). RFA, radiofrequency ablation. Table 1 Characteristics of patients with HR and RFA Values are presented as number (%) or mean ± standard deviation. HR, hepatic resection; RFA, radiofrequency ablation. Table 2 Complications and mortality of HR and RFA HR, hepatic resection; RFA, radiofrequency ablation; PV, portal vein. Table 3 Recurrence of HCC after HR and RFA HCC, hepatocellular carcinoma; HR, hepatic resection; RFA, radiofrequency ablation. Table 4 Overall and disease-free survival of HR and RFA HR, hepatic resection; RFA, radiofrequency ablation. Table 5 Analysis of prognostic factors associated with overall survival

HR, hepatic resection; RFA, radiofrequency ablation; PV, portal vein. Table 3 Recurrence of HCC after HR and RFA HCC, hepatocellular carcinoma; HR, hepatic resection; RFA, radiofrequency ablation. Table 4 Overall and disease-free survival of HR and RFA HR, hepatic resection; RFA, radiofrequency ablation. Table 5 Analysis of prognostic factors associated with overall survival CI, confidence interval; HR, hepatic resection; RFA, radiofrequency ablation; ICG R-15, indocyanine green retention rate at 15 minutes. a)Hazard ratio. Table 6 Analysis of prognostic factors associated with disease-free survival CI, confidence interval; HR, hepatic resection; RFA, radiofrequency ablation; ICG R-15, indocyanine green retention rate at 15 minutes. a)Hazard ratio.

INTRODUCTION Since Phillipe Mouret of France performed the first laparoscopic cholecystectomy (LC) in 1987, multiport conventional LC (CLC) has become the gold standard for the treatment of gallbladder (GB) disease [1], with advantages of better cosmesis, less scar, less pain, and shorter hospitalization [2]. Surgeons have attempted to reduce number of ports and incisions with accumulation of experience and development of equipments for the past few decades. Single incision laparoscopic cholecystectomy (SILC) was first performed by Navarra et al. [3] in 1997, but did not regain much popularity since the development. However, the recent increase in use of SILC can be attributed to new surgical techniques and equipment, such as the articulating instruments and access ports capable of allowing several instrument to be inserted in a single ports [4,5,6]. Nowadays, the 3-channel method with multiport access is commonly used in SILC [7]. Despite the new techniques and exponential improvement of equipment, there still remains some limitations, such as difficulty in exposure of the Calot's triangle, narrow indications (exclusion criteria: high body mass index [BMI], previous abdominal surgery, acute cholecystitis with severe gallbladder [GB] inflammation), and higher bile duct injury rate with the 3-channel SILC [8,9]. For these reasons, adequacy and feasibility of SILC is still controversial. Previously, we had also performed 3-channel SILC with 2 instruments and a flexible telescope, but encountered similar limitations. Therefore, we have replaced our standard setting into a 4-channel SILC with an addition of a snake retractor for resolution of the aforementioned limitations. In this study, we hereby report an adequacy and feasibility of 4-channel single incision laparoscopic cholecystectomy using a snake retractor.

milar limitations. Therefore, we have replaced our standard setting into a 4-channel SILC with an addition of a snake retractor for resolution of the aforementioned limitations. In this study, we hereby report an adequacy and feasibility of 4-channel single incision laparoscopic cholecystectomy using a snake retractor. METHODS We have conducted retrospective review of 415 patients that underwent SILC between April 2010 and February 2013. From April 2010 through September 2012, 326 patients had been treated with 3-channel method using a handmade single port, a flexible telescope and two articulating instruments. In the early period, we excluded those who were older than 70 years of age with radiologic or pulmonologic comorbidities, or acute GB inflammation, but did not exclude patients with high BMI or history of abdominal surgery. After 50 cases, with accumulation of experience, the inclusion criteria of SILC was expanded to all the patients who would typically be considered for CLC, but excluded the patients with suspected early-staged GB malignancy [10]. After October 2012, we have modified our 3-channel method to a 4-channel SILC by adding a snake retractor for liver retraction which we later named as "modified Konyang standard method". Eighty-nine patients have been treated with the 4-channel SILC using a snake retractor, and the inclusion criteria for the 4-channel SILC had been applied equally.

dified our 3-channel method to a 4-channel SILC by adding a snake retractor for liver retraction which we later named as "modified Konyang standard method". Eighty-nine patients have been treated with the 4-channel SILC using a snake retractor, and the inclusion criteria for the 4-channel SILC had been applied equally. Instruments and port The handmade port consisted of a 10-mm size ALEXIS wound retractor (Applied Medical, Rancho Santa Margarita, CA, USA) and size 7 sterile glove in which three 5-mm ports and one 10-mm port (Laport, Sejong Medical, Paju, Korea) were prepared on the 1st, 2nd, 3rd, 5th tip of fingers to create a 4-working channel for the laparoscopic instruments (Fig. 1). The wound retractor was introduced through 2.5-cm transumbilical incision. The surgical glove was fixed to the outer ring of the wound retractor and then the CO2 pipe was connected to 10-mm port to create pneumoperitoneum. We used a 10-mm flexible telescope (Olympus Co., Tokyo, Japan), a 5-mm snake liver retractor for liver traction (Diamond-Flex Triangular Retractors, CareFusion, Waukegan, IL, USA), a long articulated Endo-Roticulator (Coviden, Mansfield, MA, USA) for traction and dissection of GB, and a suction-hook bovie (Endopath Probe Plus II Pistol Grip Handle, Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) for irrigation and coagulation. We ligated cystic duct and artery using 5-, 10-mm Hem-O-Lok clip (Weck Closure Systems, a division of Teleflex Inc., Wayne, PA, USA).

A) for traction and dissection of GB, and a suction-hook bovie (Endopath Probe Plus II Pistol Grip Handle, Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) for irrigation and coagulation. We ligated cystic duct and artery using 5-, 10-mm Hem-O-Lok clip (Weck Closure Systems, a division of Teleflex Inc., Wayne, PA, USA). Surgical technique The patients were placed in reverse Trendelenburg position (15-30 degrees) with right side up. A 2.5-cm transumbilical incision was made and the handmade port was inserted. After making pneumoperitoneum, a flexible telescope was inserted through 3rd finger channel and then snake retractor was inserted through 2nd finger below the telescope. The snake retractor was angulated and retracted the liver. The GB was retracted laterally with a grasper which was inserted through 5th finger and the anterior peritoneum surrounding the cystic duct was dissected by left hand using a dissector through 1st finger channel (Fig. 2). After that, the left hand performed cephalic traction of the infundibulum and exposed the posterior peritoneum of the cystic duct, and then the grasper held in the right hand carried out posterior peritoneal dissection. Isolation of the cystic duct and artery using 30-50 degrees angulated dissector held in the left hand was performed. After isolating the cystic duct, both the duct and the artery are clipped using 5-mm Hem-O-Lok clip held in the left hand and the cystic duct and artery were divided using scissors held in the left hand. After the cystic artery and duct were divided, the GB was pulled cephalad using the grasper held in the right hand and then the GB was dissected from the GB bed using the suction-hook bovie held in left hand. After irrigation by the right hand using the suction-hook bovie, the GB was removed through the Alexis wound retractor positioned at the umbilical incision without an endo-bag.

cephalad using the grasper held in the right hand and then the GB was dissected from the GB bed using the suction-hook bovie held in left hand. After irrigation by the right hand using the suction-hook bovie, the GB was removed through the Alexis wound retractor positioned at the umbilical incision without an endo-bag. RESULTS Preoperative clinical characteristics Among 415 SILC patients, there were 189 male (45.5%) and 226 female patients (54.5%). The mean age was 52.3 ± 14.0 years old, and the mean BMI was 25.7 ± 15.1 kg/m2. One hundred and nineteen patients (28.7%) had previous abdominal surgeries, and 10 of 119 patients had undergone upper gastrointestinal (GI)surgery. The mean operation time was 52.7 ± 24.4 minutes, and the mean hospital stay was 2.9 ± 3.0 days. Conversions to CLC that required additional ports were 9 cases (2.1%) (Table 1).

undred and nineteen patients (28.7%) had previous abdominal surgeries, and 10 of 119 patients had undergone upper gastrointestinal (GI)surgery. The mean operation time was 52.7 ± 24.4 minutes, and the mean hospital stay was 2.9 ± 3.0 days. Conversions to CLC that required additional ports were 9 cases (2.1%) (Table 1). Comparisons between 3- and 4-channel SILC Three hundred and twenty-six patients underwent 3-channel SILC, and 89 patients had the 4-channel SILC using a snake retractor. There were 143 male (43.9%) and 185 female patients (56.1%) in the 3-channel SILC group whereas 46 male (51.7%) and 43 female patients (48.3%) in the 4-channel SILC group. Previous operative history were present on 96 patients (29.4%) of which 7 cases had undergone upper GI operation vs. 23 cases (25.8%) with 3 cases of upper GI operation (P = 0.505). Mean BMI was 25.7 ± 17.0 kg/m2 vs. 25.2 ± 3.9 kg/m2 (P = 0.806), 30 patients (9.2%) vs. 23 patients (25.8%) were treated with percutaneous transhepatic gallbladder drainage (PTGBD) insertion before operation (P < 0.001), mean operating time was 53.0 ± 25.8 minutes vs. 51.9 ± 18.6 minutes (P = 0.709) and mean hospital stay was 3.0 ± 3.3 days vs. 2.6 ± 0.9 days (P = 0.043). There were total 9 cases (2.1%) of port addition, 6 cases (1.8%) in the 3-channel group and 3 cases (3.4%) in the 4-channel group (P = 0.411), due to cystic artery bleeding and bile leakage from the GB bed, but there were no open conversions. There was no statistically significant difference between the 3-channel SILC and the 4-channel SILC group except for PTGBD insertion (P < 0.001) and mean hospital stay (Table 2).

3.4%) in the 4-channel group (P = 0.411), due to cystic artery bleeding and bile leakage from the GB bed, but there were no open conversions. There was no statistically significant difference between the 3-channel SILC and the 4-channel SILC group except for PTGBD insertion (P < 0.001) and mean hospital stay (Table 2). Postoperative complications between 3- and 4-channel SILC Postoperative complications were observed in total of 7 patients, 6 cases in the 3-channel group and 1 case in the 4-channel group (Table 3). Of the 7 patients, 2 were major complications requiring additional treatments (1 bile duct injury and 1 duodenal perforation), and the remaining 5 were minor complications (4 wound infections and 1 incisional hernia). In the 4-channel SILC group, 1 wound infection was observed. There was no mortality. Bile duct injury occurred in a patient with severe GB inflammation, was determined to be type E by Strasberg's classification, detected at postoperative day 2, and was treated with hepaticojejunostomy. For the patient with duodenal perforation, there was severe adhesion between the duodenum and the liver from prior subtotal gastrectomy. The duodenal perforation had most likely occurred during dissection of the duodenum that was firmly adhered to the liver. Signs and symptoms of peritonitis were observed at postoperative day 2, and it was treated with laparoscopic primary repair of perforation site. The four patients with wound infections were treated with simple dressing. Incisional hernia occurred in a patient who was treated for wound infection after postoperative month 3, and herniorrhaphy was performed. All complications occurred in the 3-channel SILC group except for 1 simple wound infection.

Board's approval, from May 2005 to December 2011, 11 consecutive patients who underwent LE for benign or borderline malignant tumors of the pancreas were recruited into the current study. We retrospectively analyzed the medical rescords and this study conformed to the ethical guidelines of the Declaration of Helsinki. In all cases, ultrasonography (USG), CT, and MRI including magnetic resonance cholangiopancreatography (MRCP) were routinely performed before operation. The indications of LE were followed: (1) preoperative evaluations strongly suggesting benign or borderline malignant nature tumor, (2) no involvement of the main pancreatic duct, and (3) outwardly growing tumor with small tumor bed. For small benign or borderline malignant lesions (less than 2 cm), we recommended close observation. However, if the lesion had solid portion or if the patient strongly wanted surgery, we performed operation. Complete tumor removal with clear margins was the management principle in each case. The following characteristics were collected and analyzed on each patient: age, sex, body mass index (BMI), presentation, preoperative pancreatitis, preoperative diagnosis, tumor location, tumor size, final pathology, complication, and recent follow-up details. In addition, the perioperative outcomes such as operation time, blood loss, return to normal bowel movement, return to adequate oral intake, length of postoperative hospital stay, pancreatic fistula rate, overall postoperative mortality, and recurrence rate were analyzed. According to the International Study Group of Pancreatic Fistula (ISGPF) criteria, pancreatic fistula was defined as any measurable drainage from an operatively placed drain on or after postoperative day 3, with an amylase content greater than 3 times the upper limit of normal serum amylase levels [9].

rforation site. The four patients with wound infections were treated with simple dressing. Incisional hernia occurred in a patient who was treated for wound infection after postoperative month 3, and herniorrhaphy was performed. All complications occurred in the 3-channel SILC group except for 1 simple wound infection. DISCUSSION Since Phillipe Mouret of France performed the first LC in 1987 [1], the superiority of LC as the standard procedure for GB removal compared to the open cholecystectomy has not been questioned due to better cosmetic satisfaction, less scar, less pain, and shorter hospitalization [2]. Ever since the initial development of LC, surgeons had attempted to reduce the number and the size of ports. In these efforts, more challenging and innovative methods like natural orifice transluminal endoscopic surgery (NOTES) have been invented and developed. Since the first NOTES transvaginal cholecystectomy by Bessler et al. [11] of the United States in 2007, numerous NOTES cholecystectomies have been performed. However, some challenges still exist, including longer operating time, poor triangulation of instruments, difficulty in standardization of the procedure, and increased risks of leakage and fistula, which clearly indicates that improvement of the NOTES surgical techniques and instruments is much needed [7,11]. Nowadays, surgeons have switched their focus to single incision laparoscopic surgery as an alternative minimally invasive surgery to the NOTES. Since the first SILC by Navarra et al. [3] in 1997, various new techniques and instruments have been introduced and modified. SILC has become more popular, and several studies including review of over hundred cases or meta-analysis of the operative data have been reported [12,13,14,15,16]. The SILC certainly has superior cosmetic outcome compared to the CLC. However, a surgeon should not choose SILC solely based on superior cosmesis, patient' safety still remains as a major concern. Joseph et al. [8] reported that the bile duct injury rate in SILC (0.72%) was higher than CLC (0.2%). Trastulli et al. [16] reported a meta-analysis data including 13 randomized controlled trial studies comparing SILC vs. CLC, the failure rate was 8.4% vs. 0.7%, conversion rate to open was 0.2% vs. 0.2%, overall complication rate was 7.3% vs. 6.6% and a bile leakage rate was 0.4% vs. 0.7%. Sajid et al.

than CLC (0.2%). Trastulli et al. [16] reported a meta-analysis data including 13 randomized controlled trial studies comparing SILC vs. CLC, the failure rate was 8.4% vs. 0.7%, conversion rate to open was 0.2% vs. 0.2%, overall complication rate was 7.3% vs. 6.6% and a bile leakage rate was 0.4% vs. 0.7%. Sajid et al. [13] reported postoperative pain and complications, the hospital length of stay, cosmesis score, conversion rate, and ports addition rate were statistically similar between SILC and CLC in their meta-analysis study. Although there were various studies on SILC, the inconsistencies of results among studies ranged too wide to be certain of the safety in SILC. As we mentioned earlier, a major problem when comparing CLC and SILC is the difficulty in exposure of the Calot's triangle. Aprea et al. [17], Cao et al. [18], Edwards et al. [19], etc., many surgeons have used percutaneous anchorage with sutures and Lirici et al. [20] used needlescopic grasper for GB retraction and reducing complications. The most difficult problems of the 3-channel SILC in our department were similar to those reported from other institutes, which were inadequate visualization of the Calot's triangle and clash between the instruments and the telescope. In order to resolve these issues, we used a flexible telescope and articulating long instruments, and standardized our method, which was to retract the GB inferolaterally by right hand and to dissect the cystic duct and artery by left hand while positioning the flexible telescope at the left side of the working instruments [21]. Despite the standardization of our method, visualization of the Calot's triangle was still incomplete, especially when the GB was acutely inflamed. Thus, we incorporated a snake tractor to address the remaining issue. We had initially proposed that our modified 4-channel SILC wound have certain benefits, such as for better exposure of the Calot's triangle, and decrease in ports addition, conversion rate, and complication rate. We performed SILC in a selected patient population without severe comorbidities, or acute cholecystitis in the early period in the formerly published studies [8,22,23], but we expanded indications for SILC while increasing the number of the SILC cases, and performed 3- and 4-channel SILC on patients with major comorbidities, obesity, previous abdominal surgery, and acute cholecystitis pretreated with PTGBD, but excluded patients with possible early stage GB malignancy.

dies [8,22,23], but we expanded indications for SILC while increasing the number of the SILC cases, and performed 3- and 4-channel SILC on patients with major comorbidities, obesity, previous abdominal surgery, and acute cholecystitis pretreated with PTGBD, but excluded patients with possible early stage GB malignancy. A proportion of patients with acute cholecystitis, who treated with PTGBD before an operation, was 30 (9.2%) in 3-channel SILC and 23 (25.8%) in 4-channel SILC. This raises a possibility that the 4-channel SILC could be applicable for more patients with acute cholecystitis. There were total 9 cases of CLC conversion including 6 cases in the 3-channel SILC group and 3 cases in the 4-channel SILC group, due to the cystic artery bleeding. We recommended reducing this problem by ligating the cystic artery before the cystic duct ligation. There was only single wound infection case in the 4-channel SILC group and no major complication like the bile duct injury. However, there were some limitations in our study. One is the small sample size, and the other is a lower conversion and complication rate compared to other studies [13]. The latter is most likely due to the amount of experience by the surgeon who performed the 4-channel SILC, since he had previously performed over 2,000 cases of the CLC. Surely, we need larger sized samples and long-term follow-up studies. But we considered that the 4-channel SILC can become one of the primary treatments of benign GB disease in the future.

mount of experience by the surgeon who performed the 4-channel SILC, since he had previously performed over 2,000 cases of the CLC. Surely, we need larger sized samples and long-term follow-up studies. But we considered that the 4-channel SILC can become one of the primary treatments of benign GB disease in the future. In conclusion, 4-channel single incision laparoscopic cholecystectomy has certain advantages such as better visibility and accessibility for dissection of the Calot's triangle, and reproducible methods in experienced hands. 4-channel SILC is deemed safe and feasible; therefore, most benign diseases of GB could be treated with the 4-channel SILC using a snake retractor. No potential conflict of interest relevant to this article was reported. Fig. 1 The handmade port and instruments. Fig. 2 Placement of the snake retractor for liver traction. Table 1 Preoperative clinical characteristics of all patients undergoing SILC (n = 415) Values are presented as mean ± standard deviation or number (%). SILC, single incision laparoscopic cholecystectomy; PTGBD, percutaneous transhepatic gallbladder drainage; ASA, American Society of Anaesthesiologists. Table 2 Comparison between 3- and 4-channel SILC Values are presented as mean ± standard deviation or number (%). SILC, single incision laparoscopic cholecystectomy; PTGBD, percutaneous transhepatic gallbladder drainage. Table 3 Postoperative complication between 3- and 4-channel SILC SILC, single incision laparoscopic cholecystectomy.

INTRODUCTION Hilar cholangiocarcinoma (HCCA), also known as Klatskin's tumor, is a relatively rare tumor typically affecting the hepatic duct confluence. Complete surgical resection is the only therapeutic strategy offering the chance of a cure to patients with HCCA [1,2,3,4]. Recently, the use of aggressive surgical management, including major hepatectomy, has increased tumor resectability and has improved long-term results for patients [1,4]. HCCA is classified on the basis of the involvement of the hepatic confluence into four types according to Bismuth's scheme [5]. A type IV lesion is a combination of Bismuth type IIIa and IIIb lesions, in which the tumor invades the second-order bile duct tributaries of both hepatic ducts [6]. In the past, type IV lesions had been considered unresectable [7,8], with that opinion being included in the American Joint Committee on Cancer (AJCC) cancer staging manual (7th edition) [9]. Although extended liver resection may provide long-term survival in patients with HCCA, there are few reports on factors influencing resectability of Bismuth type IV HCCA. The aim of this study was to identify anatomical factors that predict curative-intended resection in patients with Bismuth type IV HCCA.

HCCA is classified on the basis of the involvement of the hepatic confluence into four types according to Bismuth's scheme [5]. A type IV lesion is a combination of Bismuth type IIIa and IIIb lesions, in which the tumor invades the second-order bile duct tributaries of both hepatic ducts [6]. In the past, type IV lesions had been considered unresectable [7,8], with that opinion being included in the American Joint Committee on Cancer (AJCC) cancer staging manual (7th edition) [9]. Although extended liver resection may provide long-term survival in patients with HCCA, there are few reports on factors influencing resectability of Bismuth type IV HCCA. The aim of this study was to identify anatomical factors that predict curative-intended resection in patients with Bismuth type IV HCCA. METHODS Patient selection With approval from Institutional Review Board of Seoul National University Hospital (IRB No. H-1112-025-388), data for 159 patients with Bismuth type IV HCCA who were evaluated at our institute between 2000 and 2010 were entered into a prospectively maintained database. Of the patients, 119 had unresectable disease including distant metastasis, extensive lymph node metastasis, or involvement of major vessels except ipsilateral involvement of hepatic artery or portal vein branch to the resected hepatectomy side. Of the remaining 40 patients, data for those patients who underwent the current standard treatment of HCCA (major hepatectomy plus extrahepatic bile duct resection and regional lymphadenectomy) were examined. Thirty-three patients who underwent major hepato-biliary resection with curative intent (CIR) were enrolled (Fig. 1). All of those patients were confirmed Bismuth type IV HCCA after pathologic examination.

ment of HCCA (major hepatectomy plus extrahepatic bile duct resection and regional lymphadenectomy) were examined. Thirty-three patients who underwent major hepato-biliary resection with curative intent (CIR) were enrolled (Fig. 1). All of those patients were confirmed Bismuth type IV HCCA after pathologic examination. Imaging analysis Imaging was performed before any intervention on the bile duct, with the exception of patients in whom biliary drains had been placed before referral (18/159, 11.3%). In all patients evaluated for inclusion, CT examinations had been performed on multidetector CT (MDCT) scanners [10,11]. MRI or MR cholangiopancreatography imaging was performed for 92 patients (57.9%) on a 1.5-T superconducting system [12]. Direct cholangiograms were obtained for 142 patients (89.3%) using endoscopic retrograde cholangiopancreatography or percutaneous transhepatic cholangiography [12]. We estimated the length of longitudinal tumor extent along the biliary tree by evaluating the extent of the irregular stricture on cholangiograms or by evaluating the extent of the bile duct wall thickening on MDCT or MRI images. Measurements of longitudinal tumor extent and anatomical variation are shown in Fig. 2. Measurements of longitudinal tumor extent and anatomical variation were reviewed by an experienced radiologist.

rregular stricture on cholangiograms or by evaluating the extent of the bile duct wall thickening on MDCT or MRI images. Measurements of longitudinal tumor extent and anatomical variation are shown in Fig. 2. Measurements of longitudinal tumor extent and anatomical variation were reviewed by an experienced radiologist. Definition of anatomical variation Huang et al. [13] proposed a system for bile duct variations (BDVs). Type A1 was defined as common (right and left hepatic duct junction), type A2 (hilar trifurcation type) as a common junction of right anterior hepatic duct, right posterior hepatic duct (RPHD), and left hepatic duct (LHD), type A3 as an aberrant drainage of RPHD to the left main duct, type A4 as an aberrant drainage of RPHD to the main hepatic duct, and type A5 as aberrant drainage of RPHD to the cystic duct [13]. In the present study, BDVs were grouped according to this classification. Also, we used the hepatic artery variation classification system proposed by Hiatt et al. [14]. In this classification scheme, type 1 was defined as common, type 2 as having a replaced or accessory left hepatic artery arising from the left gastric artery, type 3 as having a replaced or accessory right hepatic artery originating from the superior mesenteric artery, type 4 as having a double-replaced pattern, and type 5 as having the entire common hepatic artery originating as a branch of the superior mesenteric artery. Finally, our classification of portal venous variation was based on the Cheng classification [15], in which type I was defined as having a normal portal bifurcation, type II as having a portal trifurcation, type III as having the left portal vein originating from the right anterior portal branch, and type IV as having the right anterior portal branch originating from the left portal vein.

Cheng classification [15], in which type I was defined as having a normal portal bifurcation, type II as having a portal trifurcation, type III as having the left portal vein originating from the right anterior portal branch, and type IV as having the right anterior portal branch originating from the left portal vein. Surgical procedures After laparotomy and the exclusion of distant metastasis, all of the following surgical procedures included a regional lymphadenectomy at the right side of the celiac artery, and removal of all tissues in the hepatoduodenal ligament except the portal vein and the hepatic artery. The type of resection was determined by the relative location and extent of the tumor. When the tumor was predominantly located in the right- or left-perihilar bile ducts, or tumor involvement in the liver parenchyma, unilateral hepatic artery, or when portal vein was observed on the preoperative images, an extended right- or left-hemihepatectomy, or trisectionectomy including caudate lobectomy combined with bile duct resection was performed (Fig. 1). As commonly used, we defined R0 resection as having complete tumor removal, R1 resection as having microscopic residual ductal disease, and R2 resection as having macroscopic remnant ductal carcinoma. Intraoperative evaluation of the proximal (hepatic)-side and/or distal (duodenal)-side ductal margins was performed by using frozen sections in all patients. Operative specimens were submitted for permanent histopathology. When the distal-side ductal margin was positive, additional resection of the intrapancreatic bile duct or pancreatoduodenectomy was performed, as far as was possible in principle. When the proximal-side ductal margin was positive, additional resection of the hepatic duct was performed, if possible.

nent histopathology. When the distal-side ductal margin was positive, additional resection of the intrapancreatic bile duct or pancreatoduodenectomy was performed, as far as was possible in principle. When the proximal-side ductal margin was positive, additional resection of the hepatic duct was performed, if possible. Adjuvant treatment Except in patients with poor performance status or those who refused chemoradiotherapy (CRT), we performed adjuvant CRT with 5-fluorouracil (5-FU) radiosensitizer after patients were informed of the prognosis and of the effects of each treatment modality. None of the patients received chemotherapy alone as adjuvant treatment. Treatment consisted of a 40-Gy dose to the tumor given in 10 daily fractions (as intravenous bolus of 5-FU) over a 2-week period. In some cases, patients received 5-FU monthly over a period of 1 year after CRT [16]. Statistical analyses The data was analyzed using IBM SPSS Statistics ver. 19.0 (IBM Co., Armonk, NY, USA). Continuous and normally distributed variables are presented as the medians and range. Continuous parameters in each group were compared using the independent t test or the Mann-Whitney U test, and categorical parameters using the chi-square test or Fisher exact test. Survival curves were constructed using the Kaplan-Meier method and differences in survival were evaluated using the log-rank test. P-values of 0.05 or less were considered statistically significant.

independent t test or the Mann-Whitney U test, and categorical parameters using the chi-square test or Fisher exact test. Survival curves were constructed using the Kaplan-Meier method and differences in survival were evaluated using the log-rank test. P-values of 0.05 or less were considered statistically significant. RESULTS Clinicopathological analysis of CIR of Bismuth type IV HCCA Median cohort age was 60 years (range, 24-79 years) and the male to female ratio was 1.8:1. Twenty-one of 33 patients underwent R0 resection. Preoperative PVE was performed in 10 patients. The surgical procedures included right-sided resection (16/33) and left-sided resection (17/33). Median follow-up duration was 14.9 months (range, 0-51.0 months). Anatomical variation in patients with Bismuth type IV HCCAs The percentage of BDV in patients with CIR was significantly higher than in non-CIR patients. Among the variant BDV types, the rate of type A2 BDV in patients with CIR was higher than that in non-CIR patients. However, no significant differences were found between CIR and non-CIR patients in terms of hepatic arterial variations, or portal venous variations (Table 1).

gnificantly higher than in non-CIR patients. Among the variant BDV types, the rate of type A2 BDV in patients with CIR was higher than that in non-CIR patients. However, no significant differences were found between CIR and non-CIR patients in terms of hepatic arterial variations, or portal venous variations (Table 1). Analysis of length of hilum to second bile duct confluence and length of tumor infiltration The mean length from the hilum to the left second bile duct confluence and the length of tumor infiltration over the ipsilateral second bile duct confluence in right-sided CIR patients were significantly shorter than those in left-sided CIR patients (Table 2). Similarly, the proportion of left-sided CIR patients with tumor infiltration of <5 mm over the right second confluence was greater than that in right-sided CIR patients, but the difference was only of marginal significance (P = 0.061) (Table 3).

ere significantly shorter than those in left-sided CIR patients (Table 2). Similarly, the proportion of left-sided CIR patients with tumor infiltration of <5 mm over the right second confluence was greater than that in right-sided CIR patients, but the difference was only of marginal significance (P = 0.061) (Table 3). Survival analysis of Bismuth type IV HCCAs Overall survival of CIR and non-CIR patients with Bismuth type IV HCCA was determined. Median survival duration and 3-year survival rate of CIR and non-CIR patients were 16 months and 28.0% vs. 12 months and 6.1%, respectively (P = 0.006) (Fig. 3). Survival after surgical resection was significantly better in CIR patients with adjuvant CRT than in those without CRT (Table 4). There were no significant differences in survival on the basis of tumor invasion (AJCC T category), lymph node metastasis, histologic differentiation, presence of perineural invasion, combined portal vein resection, preoperative portal vein embolization (PVE), type of operation, or resection status (Table 4). DISCUSSION Even though diagnosis of Bithmuth type IV HCCA has markedly improved with advanced imaging modalities, patients with Bithmuth type IV HCCA have not been considered as candidates for curative resection [7,17,18]. However, recent reports have suggested that certain patients with Bismuth type IV HCCA are able to undergo curative resection [8,17,18]. In the present study, 33 of 159 patients (20.8%) underwent CIR. Among those, most patients (21/33) had negative surgical margins (R0 resection).

ates for curative resection [7,17,18]. However, recent reports have suggested that certain patients with Bismuth type IV HCCA are able to undergo curative resection [8,17,18]. In the present study, 33 of 159 patients (20.8%) underwent CIR. Among those, most patients (21/33) had negative surgical margins (R0 resection). The proportion of CIR patients with BDV types A2 to A4 (especially, A2 hilar trifurcation BDV) was markedly higher than that in patients with common bile ducts (type A1) (Table 1). A2 BDV has typically short lengths of first-order bile duct compared to type A1 BDV. As a result, Bismuth type IV HCCA with A2 type BDV is actually similar to Bismuth types IIIa or IIIb, right- or left- sided hepatic resection as CIR could be possible.

r than that in patients with common bile ducts (type A1) (Table 1). A2 BDV has typically short lengths of first-order bile duct compared to type A1 BDV. As a result, Bismuth type IV HCCA with A2 type BDV is actually similar to Bismuth types IIIa or IIIb, right- or left- sided hepatic resection as CIR could be possible. In the present study, the distance from the hilum to the left second bile duct confluence and the extent of tumor infiltration over the left second bile duct confluence in right-sided CIR patients were significantly shorter than those lengths in left-sided CIR patients (Table 2). Also, the proportion of left-sided CIR patients with tumor infiltration of less than 5 mm over the right second bile duct confluence was marginally larger than that in right-sided CIR (Table 3). This result may be because the relatively short length of the first-order bile duct makes the anatomical characteristics of Bismuth type IV similar to those of Bismuth types IIIa or IIIb. Thus, we suggest that basing the selection of the operative procedure on of the length of the first-order bile duct and on the tumor extension over the second confluence along the bile duct is crucial for patients with Bismuth type IV HCCA.

racteristics of Bismuth type IV similar to those of Bismuth types IIIa or IIIb. Thus, we suggest that basing the selection of the operative procedure on of the length of the first-order bile duct and on the tumor extension over the second confluence along the bile duct is crucial for patients with Bismuth type IV HCCA. With regard to vascular variation, we assumed that not only some type of hepatic artery variation, such as types 2, 3, or 4, but also some type of portal venous variation, such as type III or IV, had potential benefit for performing CIR due to the relatively close anatomical proximity between tumor and vasculatures. However, presently there were no significant differences in CIR rate among vascular variations (Table 1). This might be due to our relatively small study cohort or to there being no actual contribution of those variables to the resectability of Bismuth type IV HCCA. As a result, we suggest that further study is needed to determine the diagnostic usefulness of vascular variation. Several reports including our previous report indicate that adjuvant CRT might be useful in patients with HCCA [19,20,21,22]. In the present study, there was a survival gain in patients who received adjuvant CRT compared to non-CRT patients (Table 4). Thus, we believe that adjuvant CRT after surgical resection can be beneficial in Bismuth type IV HCCA patients.

rt indicate that adjuvant CRT might be useful in patients with HCCA [19,20,21,22]. In the present study, there was a survival gain in patients who received adjuvant CRT compared to non-CRT patients (Table 4). Thus, we believe that adjuvant CRT after surgical resection can be beneficial in Bismuth type IV HCCA patients. Recent studies have established that the important prognostic factors for long-term survival in HCCA patients are negative surgical margins, lymph node status, and tumor differentiation grade [3,20,21,23,24]. Among these, the most consistently reported independent determinant for long-term survival after HCCA resection is the surgical margin status of the resected bile duct [3,20,21,23,24]. In the present study, there was no significant difference in survival related to resection status (Table 4). However, patients who underwent CIR showed more prolonged survival than that in non-CIR patients (Fig. 3). This result can be explained because surgical resection with a positive margin has a better prognosis if adjuvant treatment, such as CRT, is combined with surgical resection [19,21,22].

resection status (Table 4). However, patients who underwent CIR showed more prolonged survival than that in non-CIR patients (Fig. 3). This result can be explained because surgical resection with a positive margin has a better prognosis if adjuvant treatment, such as CRT, is combined with surgical resection [19,21,22]. To obtain a negative resection margin, a more extensive hepatic resection is essential in HCCA. Some authors suggest that an extensive hepatic resection, such as performing a right or left trisectionectomy with caudate lobectomy, may be an effective surgical procedure that can achieve a low mortality rate and high pathological curability for HCCA [25,26]. However, in-hospital deaths from postoperative hepatic failure have been the greatest contributor to poor survival rates [2,25]. As a partial solution to this poor survival rate, preoperative PVE is widely used to minimize the risk of liver failure when extensive liver resection is anticipated [4,7]. Here, however, there was no indication of a survival gain with implementation of preoperative PVE (Table 4). As a result, we suggest that preoperative PVE should be selectively used, perhaps in patients with an expected fingerling future liver remnant.

liver failure when extensive liver resection is anticipated [4,7]. Here, however, there was no indication of a survival gain with implementation of preoperative PVE (Table 4). As a result, we suggest that preoperative PVE should be selectively used, perhaps in patients with an expected fingerling future liver remnant. This study has several limitations. The first is the existence of inaccuracies in the performance of imaging analyses. Imaging analysis was performed in 18 patients after placing a drainage catheter in the bile duct. The presence of such a catheter may have limited the accurate evaluation of the enhancing or intraluminal lesion secondary to luminal collapse or there may be some interfering effect related to tube's presence. Second, although modern imaging techniques provide sufficient details to identify clearly the longitudinal and radial extents of the tumor [27,28], a subset of patients had unexpectedly extensive tumor infiltration along the biliary tree. This may be related to a submucosal extension along the bile duct, as is often observed in the periductal-infiltrating and nodular-infiltrating types of HCCA [10]. In contrast, there was overestimation of tumor extent from preoperative imaging modalities in some patients. Periductal fibroplastic and inflammatory reactions may cause such overestimation, particularly if adjacent to a major vascular structure, as the cicatrizing effect may lead to strictures without adventitial invasion [29,30]. For further evaluation of this potential source of limitation, we will analyze an ongoing prospective study of longitudinal tumor extent when it is assessed by preoperative imaging and pathologic examination.

ajor vascular structure, as the cicatrizing effect may lead to strictures without adventitial invasion [29,30]. For further evaluation of this potential source of limitation, we will analyze an ongoing prospective study of longitudinal tumor extent when it is assessed by preoperative imaging and pathologic examination. With careful selection, patients with Bismuth type IV HCCA can be considered as candidates for CIR with an expectation of prolonged survival. Presence of type A2 BDV, the length of the hilum to the contralateral second bile duct confluence, and the extent of tumor infiltration over the second confluence of right- or left-dominant Bismuth type IV HCCA were the important factors for selection of a CIR procedure. ACKNOWLEDGEMENTS This study was supported by a grant from the National R&D Program for Cancer Control, Ministry of Health & Welfare, Republic of Korea (No. 1120310). The authors thank Dr. Kyung-Sik Ahn, Department of Radiology, Korea University College of Medicine, Seoul, Korea, for imaging analysis. No potential conflict of interest relevant to this article was reported. Fig. 1 Patients with Bismuth type IV hilar cholangiocarcinoma selected for curative-intended resection. Fig. 2 Longitudinal measure of tumor extent in bile duct variation type A1. BDV, bile duct variation. Fig. 3 Survival rate at follow-up in patients with Bismuth type IV hilar cholangiocarcinomas. CIR, major hepato-biliary resection with curative intent. Table 1 Comparison of anatomical variations between CIR and non-CIR patient CIR, major hepato-biliary resection with curative intent.

Fig. 2 Longitudinal measure of tumor extent in bile duct variation type A1. BDV, bile duct variation. Fig. 3 Survival rate at follow-up in patients with Bismuth type IV hilar cholangiocarcinomas. CIR, major hepato-biliary resection with curative intent. Table 1 Comparison of anatomical variations between CIR and non-CIR patient CIR, major hepato-biliary resection with curative intent. Table 2 Length of hilum to 2nd bile duct confluence and extent of tumor infiltration in CIR patients CIR, major hepato-biliary resection with curative intent; PHA, proper hepatic artery; RHA, right hepatic artery; LHA, left hepatic artery; MPV, main portal vein; RPV, right portal vein; LPV, left portal vein; NS, not significant. Table 3 Length of tumor infiltration over 2nd bile duct confluence in CIR patients CIR, major hepato-biliary resection with curative intent. Table 4 Survival analysis in patients with Bismuth type IV hilar cholangiocarcinomas who underwent curative-intended resection PVE, portal vein embolization; *NC, not calculated (Three in-hospital mortality [two hepatic failure and one pulmonary embolism]) were excluded; †papillary or well-differentiated/moderate- or poorly differentiated.

INTRODUCTION Cholangiocarcinoma is a relatively rare tumor with a poor prognosis and few long-term survivors [1]. Surgical resection remains the only potentially curative treatment, but many patients develop tumor recurrence [2]. Another biliary cancer, that is, multiple biliary cancer, have been found rarely after surgical treatment of cholangiocarcinoma, rather than recurrence. Some multiple gastrointestinal cancers have been reported. However, multiple cancers in the extrahepatic bile duct (EHBD) have not been reported frequently. While synchronous multiple biliary cancers occur in 3.7%-7.4% of all surgically resected biliary tumors, metachronous multiple biliary cancers have not been reported frequently [3,4,5]. Moreover, treatment or outcome of metachronous biliary cancer has not been found precisely. Local recurrence following resection of extrahepatic bile duct cancer is generally regarded as incurable, and secondary curative surgery as virtually impossible. However, metachronous biliary cancers with about 10 cases reported in the world literature were treated with curative resection [6,7,8]. Thus few studies have addressed the surgical treatment of secondary periampullary carcinoma after resection of the extrahepatic bile duct cancer and the role of this reresection is not well-documented or established. This study was conducted to examine the feasibility and effect of secondary curative surgery for metachronous periampullary cancer in the extrahepatic bile duct.

Local recurrence following resection of extrahepatic bile duct cancer is generally regarded as incurable, and secondary curative surgery as virtually impossible. However, metachronous biliary cancers with about 10 cases reported in the world literature were treated with curative resection [6,7,8]. Thus few studies have addressed the surgical treatment of secondary periampullary carcinoma after resection of the extrahepatic bile duct cancer and the role of this reresection is not well-documented or established. This study was conducted to examine the feasibility and effect of secondary curative surgery for metachronous periampullary cancer in the extrahepatic bile duct. METHODS Between October 1995 and December 2011, 455 patients with EHBD cancer underwent surgical resection in a tertiary institution. The EHBD cancers in the present study did not include gallbladder (GB) cancer or distal common bile duct (CBD) cancer. Lymph node dissection was performed for at least the hepatoduodenal ligament in all EHBD cancers. We excluded 40 patients who underwent palliative surgery for EHBD cancer in this study. Among the 415 patients who underwent surgical resection with curative intent for EHBD cancer, 245 patients (59%) had recurrence, including local recurrences (n = 104), intrahepatic metastases (n = 61), and systemic metastases (n = 80). Instances of local recurrence occurred in the following areas: hepaticojejunostomy site (n = 34), hepatic pedicle lymphadenectomy area (n = 43), liver resection margin (n = 15) and periampullary region (n = 12). In two of the 12 patients with periampullary recurrence, local recurrences consequently revealed duodenal cancer of primary origin, regardless of biliary tract involvement. Those two patients underwent palliative surgery, such as gastrojejunostomy, due to aggressive vascular invasion. Ten patients underwent pancreaticoduodenectomy (PD) for secondary periampullary cancer following EHBD cancer resection.

ly revealed duodenal cancer of primary origin, regardless of biliary tract involvement. Those two patients underwent palliative surgery, such as gastrojejunostomy, due to aggressive vascular invasion. Ten patients underwent pancreaticoduodenectomy (PD) for secondary periampullary cancer following EHBD cancer resection. Follow-up studies after EHBD cancer resection included routine laboratory tests, serum CA 19-9, and abdominal CT in the first month after surgery and every 3-6 months for 2 years after surgery, every 6 months until 5 years, and then annually thereafter. All periampullary lesions were first detected with abdominal CT during follow-up for EHBD cancer resection. We checked preoperative magnetic resonance imaging scans and PET to evaluate resectability and seek evidence of distant metastasis. The criteria for resectability for secondary periampullary tumor were as follows; (1) absence of distant metastasis on imaging scans, (2) absence of intrahepatic metastasis, and (3) absence of clinically and/or radiologically evident lymphadenopathy in the para-aortic region.

ty and seek evidence of distant metastasis. The criteria for resectability for secondary periampullary tumor were as follows; (1) absence of distant metastasis on imaging scans, (2) absence of intrahepatic metastasis, and (3) absence of clinically and/or radiologically evident lymphadenopathy in the para-aortic region. We reviewed medical records, including surgeon's notes, radiologic images and pathology reports retrospectively. A pathologic examination was performed for all of the resected specimens. Preoperative interventions such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasonography (EUS) and esophagogastroduodenoscopy (EGD) were performed to confirm preoperative pathologic status. Intraoperative frozen biopsy was performed to confirm margin status. The diagnosis of periampullary cancer was based on the histology obtained from the postoperative biopsy of the resected specimen. Time to metachronous disease was calculated from the date of EHBD cancer resection to the date when metachronous tumor was first diagnosed with interventional biopsy or imaging studies.

tus. The diagnosis of periampullary cancer was based on the histology obtained from the postoperative biopsy of the resected specimen. Time to metachronous disease was calculated from the date of EHBD cancer resection to the date when metachronous tumor was first diagnosed with interventional biopsy or imaging studies. Tumor stage was based on criteria from the 7th edition of the American Joint Committee on Cancer (AJCC) cancer staging manual for ampulla of Vater (AoV) cancer, distal CBD cancer and hilar cholangiocarcinoma. Curative resection (R0 resection) was defined as no-residual-tumor status, whereas microscopic (R1 resection) and macroscopic residual tumor (R2 resection) were defined as noncurative resection. Postoperative pancreatic fistula was classified by definition of the International Study Group of Pancreatic Fistula [9]. The cumulative survival rates were calculated using the Kaplan-Meier method.

, whereas microscopic (R1 resection) and macroscopic residual tumor (R2 resection) were defined as noncurative resection. Postoperative pancreatic fistula was classified by definition of the International Study Group of Pancreatic Fistula [9]. The cumulative survival rates were calculated using the Kaplan-Meier method. RESULTS Clinicopathologic classification of the 10 extrahepatic bile duct cancers The study group included 7 men and 3 women of mean age 61 years (range, 45-70 years). The EHBD cancers were 7 hilar cholangiocarcinomas, 2 middle CBD cancers, and one cystic duct cancer. In accordance with tumor location, 5 patients with hilar cholangiocarcinoma underwent hepatectomy with caudate lobectomy; 4 patients with hilar cholangiocarcinoma and middle CBD cancer and one with cystic duct cancer underwent bile duct segmental resection with hepaticojejunostomy. The TNM classifications and tumor stages of the EHBD cancers, based on the AJCC cancer staging manual, are shown in Table 1. Lymph node involvement was observed in only one patient. Perineural invasion was noted in 4 patients (40%). An R0 resection was achieved in 9 patients and an R1 resection in one. No patient underwent adjuvant therapy following EHBD cancer resection.

ancers, based on the AJCC cancer staging manual, are shown in Table 1. Lymph node involvement was observed in only one patient. Perineural invasion was noted in 4 patients (40%). An R0 resection was achieved in 9 patients and an R1 resection in one. No patient underwent adjuvant therapy following EHBD cancer resection. Clinicopathologic characteristics of the metachronous periampullary cancers Clinical features of the 10 patients who underwent PD are shown in Table 1. Only in patient number 6, who had hilar cholangiocarcinoma, was margin status of the distal bile duct positive after EHBD resection, i.e., with focal high grade dysplasia. After 25.8 months, however, the metachronous cancer in this patient was detected in the AoV, not in the remnant bile duct. Resection margins at the first operation were free of tumor in 9 patients. Preoperative CA 19-9 before PD was high in 5 patients with 4 hilar cholangiocarcinomas and in one with middle CBD cancer. The metachronous cancers included 8 distal CBD cancers and 2 AoV cancers. Interventional biopsies using ERCP, EUS, and EGD were preoperatively performed in 6 patients and cancer was confirmed. Following detection of the metachronous cancer progression, 10 patients underwent PD, including 6 Whipple procedures and 4 pylorus-preserving pancreaticoduodenectomies. In the 10 patients who underwent PD, the mean number of lymph nodes harvested was 6 (range, 0-13) while the mean number of lymph nodes involved was 0.8 (range, 0-6). The volume of blood loss was 586 ± 243 mL (range, 300-1150 mL). No patient underwent homologous blood transfusion during the perioperative period. The postoperative complications after PD included delayed gastric emptying in 2 patients and pancreatic fistula as grade B and C in 2 others. There were no intra- or postoperative deaths in this series. The mean interval between extrahepatic bile duct cancer resection and detection of the metachronous periampullary cancer was 20.6 months (range. 3.4-36.6 months). The follow-up period after PD ranged from 8.5 to 120.5 months. Five of the 10 patients died during the follow-up period. Patients No. 2 and 3 died as cancer progression with multiple metastases to the lymph nodes, detected at 35 and 17 months after PD, respectively. Patients No. 5, 6, and 10 died through systemic recurrence with hepatic metastasis and peritoneal seeding, detected at 3, 5, and 16 months after PD, respectively. Patient No.

Patients No. 2 and 3 died as cancer progression with multiple metastases to the lymph nodes, detected at 35 and 17 months after PD, respectively. Patients No. 5, 6, and 10 died through systemic recurrence with hepatic metastasis and peritoneal seeding, detected at 3, 5, and 16 months after PD, respectively. Patient No. 3 and 5, who had positive nodal disease, underwent adjuvant chemotherapy (5-fluorouracil based regimens). Patient No. 10, who also had positive node status, refused treatment with adjuvant chemotherapy. Palliative radiotherapy was administered to Patient No. 2 due to local recurrence around the hepaticojejunostomy site 35.5 months after the second operation. Comparison of the histopathological findings The histologic types, cell differentiation and gross types between the EHBD cancer and the metachronous periampullary cancer were compared in Table 2. The degrees of cell differentiation were identical in the primary and secondary cancers of 9 patients but not in the cancers of Patient No. 6. Among the 10 patients, the gross tumor types were papillary in 4 patients. Mean distance from the resection margin of distal bile duct to the EHBD cancer was 1.7 cm (range, 1.0-2.5 cm) except in one case in which the resection margin was positive for tumor. Survival Median survival after EHBD cancer resection including the survival period after PD was 56.1 months (range, 18.6-152.7 months). Median survival after PD was 44.6 months (range, 8.5-120.5 months) (Fig. 1).

Comparison of the histopathological findings The histologic types, cell differentiation and gross types between the EHBD cancer and the metachronous periampullary cancer were compared in Table 2. The degrees of cell differentiation were identical in the primary and secondary cancers of 9 patients but not in the cancers of Patient No. 6. Among the 10 patients, the gross tumor types were papillary in 4 patients. Mean distance from the resection margin of distal bile duct to the EHBD cancer was 1.7 cm (range, 1.0-2.5 cm) except in one case in which the resection margin was positive for tumor. Survival Median survival after EHBD cancer resection including the survival period after PD was 56.1 months (range, 18.6-152.7 months). Median survival after PD was 44.6 months (range, 8.5-120.5 months) (Fig. 1). DISCUSSION Surgical resection is the only accepted curative treatment for cancer of the EHBD. Nagakawa et al. [10] reported the resection rate and the curative rate for bile duct cancer as 67.0% and 30.4%, respectively. Multiple cancers in the EHBD have not been found frequently. In many such instances, there are double cancers of the CBD and the GB [3,6]. But, double cancers of the CBD are rare. Although the actual incidence of multiple malignant tumors in the bile duct is unknown, it is reported to occur in approximately 5%-10% of bile duct cancers [4,5]. When metachronous cancers are identified, the distinction between secondary primary cancer and recurrence is often clinically difficult. Warren and Gates [11] proposed the three still generally accepted criteria that had to be met in order to consider malignant tumors as multiple primary tumors rather than recurrence: (1) each tumor must present a definite picture of malignancy, (2) each tumor must be distinct, (3) the possibility of one being a metastasis of the other must be ruled out. Gertsch et al. [5] suggested that the criteria for double primary cancer in the biliary tract was their location at separate sites with normal intervening tissue, together with histologic evidence sufficient to rule out submucosal to periductal lymphatic spread. Kobayashi et al. [12] demonstrated that multicentric adenocarcinoma of the biliary tract is more likely to be early cancer and papillary carcinoma with extensive dysplastic epithelium and is less likely to have lymph node metastasis.

histologic evidence sufficient to rule out submucosal to periductal lymphatic spread. Kobayashi et al. [12] demonstrated that multicentric adenocarcinoma of the biliary tract is more likely to be early cancer and papillary carcinoma with extensive dysplastic epithelium and is less likely to have lymph node metastasis. In the present study, the sites of metachronous cancers in 2 patients were the AoV, not biliary tract. Conceivably, those two AoV cancers may be regarded as metachronous multiple tumors or derived by intraluminal tumor implantation rather than recurrence. Local recurrence usually originates from residual cancer cells at the surgical margins [13]. Based on evidence from pathologic reviews, all of the primary tumors in this study were more than 1.0 cm distant from the distal resection margin except in one case. Although histologic types and grades in the primary and secondary tumors of 8 patients were matched, we could not rule out the occurrence of multiple malignant tumors solely on the following evidence: (1) negative resection margins of distal bile duct in fist pathology, (2) distance from primary tumor to resection margin, (3) secondary tumor sites in remnant distal bile duct being far from original resection margin. Moreover, as stated by Joo et al. [8] and Kobayashi et al. [12], the bile duct cancer resembled a primary tumor from evidence of dysplastic changes near the main mass. Extensive dysplasia in the biliary tract suggests that multicentric adenocarcinomas might arise from the carcinogenetic background epithelial dysplasia. Metachronous tumors of 5 patients in this study developed within 2 years following EHBD resection. In view of the recurrence, it should be noted that the remnant bile duct recurrence developed in a patient with synchronous multicentric cancer despite negative resection margin. This recurrence might be considered to be metachronous tertiary cancer even though it developed within 2 years after the prior surgery [12].

In view of the recurrence, it should be noted that the remnant bile duct recurrence developed in a patient with synchronous multicentric cancer despite negative resection margin. This recurrence might be considered to be metachronous tertiary cancer even though it developed within 2 years after the prior surgery [12]. The cause of multiple biliary cancers has not been defined, but it is generally accepted that the anomalous pancreaticobiliary duct union (APBDU) plays an important role in the development of multiple biliary cancers. Previous studies describe the occurrence of multiple malignant tumors in association with APBDU [6,8,14,15,16,17]. It is reported that about 50% of cases of synchronous double biliary cancers were associated with APBDU [6]. The presence of APBDU was not evaluated in this series. Others have speculated that familial and genetic factors are associated with occurrence of multiple malignant tumors [7]. Three of the patients in this study had family histories of cancer; and two of these cancers involved gastrointestinal tissues, suggesting genetic predisposition. Upper biliary tract cancers and metachronous double biliary cancers might have a strong genetic predisposition such as loss of heterozygosity, point mutation of k-ras oncogene, or overexpression of the tumor suppressor gene p53 [3,8,18]. Multiple malignant tumors are rare, hence it is proposed that bile duct cancers are usually advanced by the time of diagnosis, and that when surgery is possible with curative intent, this should be performed with a wide surgical margin [7,19]. Papillary carcinomas of the EHBD tend to grow multiply and spread fairly long distances superficially, and appear to have better prognosis than do other types of EHBD cancer [12,20,21,22]. Kobayashi et al. [12] reported that early papillary adenocarcinoma in the biliary tract were associated with multicentric cancer. Although 4 of the tumors in this study were grossly of papillary type, we would not conclude from this that papillary carcinomas of bile duct are more likely than ductal adenocarcinomas to develop metachronous cancer after surgical resection. Moreover, 4 of 5 survivors in this study had papillary carcinomas according to the gross tumor type and this may have contributed to the favorable survival rates observed.

rom this that papillary carcinomas of bile duct are more likely than ductal adenocarcinomas to develop metachronous cancer after surgical resection. Moreover, 4 of 5 survivors in this study had papillary carcinomas according to the gross tumor type and this may have contributed to the favorable survival rates observed. Similar cases of metachronous bile duct cancer are reported [6,7,8,12]. In all of those reported cases, the metachronous bile duct cancers were treated successfully by surgery. Jung et al. [23] reported median overall survival after biliary tract cancer resection as 48.8 months. These results are similar with our results, although we observed longer median survival after the bile duct cancer resection. Previous studies report five-year survival rates of 11.0%-28.6% for hilar or superior bile duct cancer [24,25,26] and 21.0%-32.7% for middle and distal bile duct cancer after resection [2,27,28,29]. Median survival times after EHBD resection and the secondary operations were 56.1 and 44.6 months, respectively, in the present study. Based on these results, our suggestion is that development of surgical treatment permitting long-term survival for metachronous periampullary cancer is both feasible and necessary.

ere associated with demographic and clinical factors, we found no statistical significance with age, BMI, smoking history, existence of comorbidity, operation time and NNIS risk factors, while there was a significant difference with the length of hospital stay (16.6 ± 7.1 days vs. 11.8 ± 2.1 days, P = 0.004) (Table 5). Assessments of wound healing For the postoperative evaluation of wound healing until day 30, seroma occurred most frequently in 147 patients, with a cumulative occurrence rate of 18.51% (95% CI, 15.98-21.39), and tenderness (12.10%), erythema (6.42%) and wound dehiscence (4.91%) followed in decreasing order. Purulent discharge had the lowest rate with six patients (0.76%) (Table 6). For most variables, the occurrence rate changed between day 3 and day 7 after the operation, while showing no distinct difference between day 7 and day 30. Each wound healing assessment alone had no direct association with actual cases of SSI occurrence, except for purulent discharge. In patients suspected of SSI with signs such as tenderness, edema, erythema, or heating, the surgeons temporarily opened the incised area to check whether it was true or not. In those cases, most patients had noninfective fluid such as seroma or fat necrosis.

29]. Median survival times after EHBD resection and the secondary operations were 56.1 and 44.6 months, respectively, in the present study. Based on these results, our suggestion is that development of surgical treatment permitting long-term survival for metachronous periampullary cancer is both feasible and necessary. There is a wide variation in practice patterns between individuals and institutions, because no studies have compared high- versus low-intensity surveillance in patients after surgical resection for EHBD cancer. Follow-up management after EHBD cancer resection may contribute to prolonged survival. Triphasic CT scan of the liver (abdomen and pelvis) was performed as the usual follow-up imaging modality every 3-6 months for the first 2 years after resection and every 6 months thereafter. As for the follow-up of those patients enough to have a prolonged survival after surgical resection for metachronous periampullary cancer, we suggest an intensive role for CT scanning, especially in papillary carcinoma of the EHBD. Based on the overall survival rate after EHBD cancer resection in this series, follow-up duration should be maintained for at least 5 years. Analysis for factors related to long-term survival was limited by the small number of patients in our study. However, the findings support the hypothesis that PD for secondary periampullary cancer, although a relatively aggressive treatment, may potentially extend patient survival.

There is a wide variation in practice patterns between individuals and institutions, because no studies have compared high- versus low-intensity surveillance in patients after surgical resection for EHBD cancer. Follow-up management after EHBD cancer resection may contribute to prolonged survival. Triphasic CT scan of the liver (abdomen and pelvis) was performed as the usual follow-up imaging modality every 3-6 months for the first 2 years after resection and every 6 months thereafter. As for the follow-up of those patients enough to have a prolonged survival after surgical resection for metachronous periampullary cancer, we suggest an intensive role for CT scanning, especially in papillary carcinoma of the EHBD. Based on the overall survival rate after EHBD cancer resection in this series, follow-up duration should be maintained for at least 5 years. Analysis for factors related to long-term survival was limited by the small number of patients in our study. However, the findings support the hypothesis that PD for secondary periampullary cancer, although a relatively aggressive treatment, may potentially extend patient survival. In conclusion, because local recurrence after EHBD cancer resection is common, to achieve long-term survival in patients with extrahepatic bile duct cancer, and papillary carcinoma in particular, a second curative surgery should be considered. In metachronous periampullary cancer, following resection of the extrahepatic bile duct cancer, PD may provide a feasible and acceptable treatment.

common, to achieve long-term survival in patients with extrahepatic bile duct cancer, and papillary carcinoma in particular, a second curative surgery should be considered. In metachronous periampullary cancer, following resection of the extrahepatic bile duct cancer, PD may provide a feasible and acceptable treatment. This paper was presented at the Oral Session in the 22nd World Congress of the International Association of Surgeons, Gastroenterologists and Oncologists, IASGO 2012 (December 7, 2012). No potential conflict of interest relevant to this article was reported. Fig. 1 Overall survival rates (A) after extrahepatic bile duct resection and (B) after pancreaticoduodenectomy for secondary periampullary cancer. Table 1 Clinical profiles of 10 patients who underwent pancreaticoduodenectomy CBD, common bile duct; AoV, ampulla of Vater; CC, cholangiocarcinoma; HGD, high grade dysplasia. a)Based on the American Joint Committee on Cancer 7th ed. b)Distal bile duct resection margin after primary resection. c)Interval between primary treatment and detection of the metachronous periampullary cancer. d)Follow-up period after pancreaticoduodenectomy. e)Bismuth classification of the hilar cholangicarcinoma. Table 2 Comparison of pathologic finding for extrahepatic bile duct cancers and subsequent periampullary cancers DAC, ductal adenocarcinoma; M/D, moderately differentiated; AoV AC, ampulla of Vater adenocarcinoma; CBD, common bile duct; IPC, intraductal papillary adenocarcinoma; W/D, well-differentiated. a)Distance from distal resection margin.

INTRODUCTION Traditionally, benign or borderline malignant pancreatic tumors have been treated by major standard resections such as pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) with or without splenectomy [1]. Although these procedures can be performed with low morbidity and mortality rate, resection of a large amount of normal pancreas can be associated with an increased risk of endocrine or exocrine insufficiency [2]. In this matter, some authors reported that enucleation can be considered as an alternative surgical procedure [3,4,5]. Compared with major resections, enucleation is charaterized by extensive parenchymal preservation, less operation time, and faster recovery [6]. With the advancement of laparoscopic techniques and instruments, laparoscopic approach for pancreatic lesions has become an increasingly used procedure. Although prospective randomized controlled study is absent, several reports documented the feasibility, safety, and effectiveness of laparoscopic enucleation (LE) in benign or borderline malignant pancreatic tumors [1,5,7,8]. However, these reports included case reports and small series. Therefore, the purpose of this study was to present the surgical experience in our institution and to analyze the postoperative outcome of LE for benign or borderline malignant tumors of the pancreas.

e were analyzed. According to the International Study Group of Pancreatic Fistula (ISGPF) criteria, pancreatic fistula was defined as any measurable drainage from an operatively placed drain on or after postoperative day 3, with an amylase content greater than 3 times the upper limit of normal serum amylase levels [9]. All patients underwent regular follow-up examinations postoperatively every 6 months for 5 years and annually thereafter. The mean follow-up period was 44.3 ± 23.9 months. This included a clinical examination, blood tests, CT of the abdomen, and chest radiography. Medical records and survival data were obtained for all patients. LE procedure After general anesthesia patients were placed in a right semilateral decubitus position. Under preparing and drapping in the usual sterile manner, the surgeon, the camera assistant, and the scrub nurse were positioned to the right side of the patient, and the first assistant stood to the left side of the patient. A 12-mm balloon trocar (telescope route) was first inserted through an infraumbilical minilaparotomy wound and pneumoperitoneum (12 mmHg) was achieved by CO2 insufflation. Under the laparoscopy-providing vision, three other trocars were inserted into the following locations: the epigastrium (5 mm) for the left hand of the surgeon; the midclavicular line below the costal arch (12 mm) for the right hand of the surgeon; the left flank (5 mm) for assistance (Fig. 1).

ved by CO2 insufflation. Under the laparoscopy-providing vision, three other trocars were inserted into the following locations: the epigastrium (5 mm) for the left hand of the surgeon; the midclavicular line below the costal arch (12 mm) for the right hand of the surgeon; the left flank (5 mm) for assistance (Fig. 1). The gastrocolic ligament was divided for entrance to the pancreas using harmonic scalpel (Ethicon, Cincinnati, OH, USA) and electrocautery. Laparoscopic USG probe was used through a 12-mm trocar and applied directly to the anterior surface of the pancreas to confirm the location of the tumor and identify its relationship to the splenic vessels and main pancreatic duct. Pancreatic dissection was performed using harmonic scalpel and bleeding between tumor and normal parenchyma was controlled by a 5-mm bipolar electrocoagulation instrument (Ethicon). The specimen was then placed in a LapBag (SJM, Paju, Korea) and removed through a minimally extended umbilical port incision. One closed suction drain was placed in the site of the enucleation. Statistical analysis Data are presented as the mean ± standard deviation. Comparisons among the groups were performed using the Mann-Whitney U test or chi-square test where appropriate. Statistical evaluation was performed using the SPSS ver. 14.0 (SPSS Inc., Chicago, IL, USA) program for Windows. A P-value less than 0.05 was considered statistically significant.

e mean ± standard deviation. Comparisons among the groups were performed using the Mann-Whitney U test or chi-square test where appropriate. Statistical evaluation was performed using the SPSS ver. 14.0 (SPSS Inc., Chicago, IL, USA) program for Windows. A P-value less than 0.05 was considered statistically significant. RESULTS During the study period, 11 patients underwent LE (Table 1). There were 10 women (91%) and 1 man (9%) with a mean age of 43.1 ± 11.9 years, and the mean BMI was 25.1 ± 6.4 kg/m2. The most common presentation was incidental finding (n = 8, 73%), followed by abdominal pain (n = 2, 18%), and abdominal mass (n = 1, 9%). Also, there were no patients with preoperative pancreatitis. The tumors that had no symptoms (incidental finding) were detected by routine health checkup. All 11 patients who underwent LE were completed laparoscopically without conversion. In two patients (case 7 and case 9), cystic fluid was spilled during operation. The tumors were located in the body (n = 5, 45%) and tail (n = 6, 55%) of the pancreas. The mean operation time was 97.4 ± 16.6 minutes, and mean blood loss was 35.9 ± 11.9 mL. The final histopathological diagnoses included 4 mucinous cystadenomas, 4 serous cystadenomas, 1 solid pseudopapillary neoplasm (SPN), 1 simple cyst, and 1 Castleman disease. The mean diameter of the resected tumors was 4.0 ± 3.3 cm. One patient (9%) developed postoperative complication. This patient had pancreatic fistula and recovered with conservative management. The mean length of postoperative hospital stay was 5.5 ± 1.7 days, and the mean follow-up period was 44.3 ± 23.9 months. All of the patients are alive and disease-free (Table 2).

.3 cm. One patient (9%) developed postoperative complication. This patient had pancreatic fistula and recovered with conservative management. The mean length of postoperative hospital stay was 5.5 ± 1.7 days, and the mean follow-up period was 44.3 ± 23.9 months. All of the patients are alive and disease-free (Table 2). DISCUSSION With the introduction of newer sophisticated abdominal imaging techniques, benign or borderline pancreatic tumors such as pancreatic cystic neoplasms are being detected with increasing frequency [4]. Although most of these lesions are tumors benign in nature, they have malignant potential [3]. Thus, many surgeons have been performing major standard resections such as PD and DP with or without splenectomy [1]. Although these procedures can now be performed with low morbidity and mortality rates, resection of a large amount of normal pancreas can be associated with increasing risk of endocrine or exocrine insufficiency [2]. Especially, DP can induce diabetes when pancreatic resection exceeds 75% [1]. For these reasons, parenchyma-sparing procedures such as enucleation or central pancreatectomy have been performed with increasing frequency [1,3,4,5,6].

creas can be associated with increasing risk of endocrine or exocrine insufficiency [2]. Especially, DP can induce diabetes when pancreatic resection exceeds 75% [1]. For these reasons, parenchyma-sparing procedures such as enucleation or central pancreatectomy have been performed with increasing frequency [1,3,4,5,6]. Enucleation of pancreatic tumors is a well established parenchyma-sparing and function-preserving surgical procedure for pancreatic lesions such as endocrine tumors, serous or mucinous cystadenomas, and SPN [3,4,5,6,7,8]. Moreover, several reports documented the feasibility, safety, and effectiveness of LE in benign or borderline malignant pancreatic tumors [1,7,8]. The current study included 4 mucinous cystadenomas, 4 serous cystadenomas, 1 SPN, 1 simple cyst, and 1 Castleman disease. All 11 patients who underwent LE were completed laparoscopically without conversion and no recurrences were recorded after surgery. Although further evaluation should be conducted, our study shows that LE is a clinically safe and effective procedure for benign or borderline malignant pancreatic tumors. Preoperatively and intraoperatively, the following fators should be considered for performing LE: localization of the tumor, malignancy potential of the tumor, distance between a lesion and the main pancreatic duct, and growing pattern of the tumor.

Enucleation of pancreatic tumors is a well established parenchyma-sparing and function-preserving surgical procedure for pancreatic lesions such as endocrine tumors, serous or mucinous cystadenomas, and SPN [3,4,5,6,7,8]. Moreover, several reports documented the feasibility, safety, and effectiveness of LE in benign or borderline malignant pancreatic tumors [1,7,8]. The current study included 4 mucinous cystadenomas, 4 serous cystadenomas, 1 SPN, 1 simple cyst, and 1 Castleman disease. All 11 patients who underwent LE were completed laparoscopically without conversion and no recurrences were recorded after surgery. Although further evaluation should be conducted, our study shows that LE is a clinically safe and effective procedure for benign or borderline malignant pancreatic tumors. Preoperatively and intraoperatively, the following fators should be considered for performing LE: localization of the tumor, malignancy potential of the tumor, distance between a lesion and the main pancreatic duct, and growing pattern of the tumor. One of the most important concerns during LE is the localization of the tumor. With the advancement of preoperative imaging techniques and intraoperative localization with laparoscopic USG, open exploration with bimanual palpation of the pancreas may not be absolutely necessary [8]. Recent reports on the use of laparoscopic USG have shown a success rate of 80% to 100% in localizing and outlining the margins of pancreatic tumors [10,11]. In our study, laparoscopic USG was routinely performed and pancreatic lesions were localized in all 11 cases.

of the pancreas may not be absolutely necessary [8]. Recent reports on the use of laparoscopic USG have shown a success rate of 80% to 100% in localizing and outlining the margins of pancreatic tumors [10,11]. In our study, laparoscopic USG was routinely performed and pancreatic lesions were localized in all 11 cases. The malignant potency of pancreatic cystic tumors is another issue of concern. Preoperative noninvasive imaging techniques such as USG, CT, and MRI are unreliable to accurately distinguish among the different pancreatic cysts [4]. Recently, endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) has been suggested as a method to differentiate between benign and malignant lesions [3,4,12]. However, EUS guided FNA has the risk of malignant cell spillage into the peritoneum with subsequent seeding and reduced survival [4]. For these reasons, our institution does not recommend preoperative EUS guided FNA. Intraoperative frozen-section examination is an important method to obtain the information on the nature of cystic mass [5]. So, in our institution, we routinely used frozen-section examination to clarify a preoperative confusing diagnosis.

these reasons, our institution does not recommend preoperative EUS guided FNA. Intraoperative frozen-section examination is an important method to obtain the information on the nature of cystic mass [5]. So, in our institution, we routinely used frozen-section examination to clarify a preoperative confusing diagnosis. The distance between a lesion and the main pancreatic duct has been considered to affect the risk of main duct damage and pancreatic leak [1,5,6]. Some authors suggested that, for enucleation to be performed safely, the lesion should be at least 2-3 mm from the main pancreatic duct and not too deep in the parenchyma [1,5]. Preoperative MRCP can measure the distance between a lesion and the main pancreatic duct and assists in the decision to perform enucleation. In the current study, MRCP was routinely performed and the patients were considered candidates for enucleation if their lesion did not involve the main pancreatic duct and had a pattern of growing outwardly with a small tumor bed.

a lesion and the main pancreatic duct and assists in the decision to perform enucleation. In the current study, MRCP was routinely performed and the patients were considered candidates for enucleation if their lesion did not involve the main pancreatic duct and had a pattern of growing outwardly with a small tumor bed. Pancreatic fistula is the most serious complication in all pancreatic surgeries. The incidence of pancreatic fistula after open enucleation has been reported to range from 18.2% to 50% [3,4,5,6]. However, the reported incidence of pancreatic fistula after LE was lower (range, 9.1%-13%) than that reported after open enucleation [1,13]. Dedieu et al. [1] suggested that this improvement in pancreatic duct control could be explained by the slower and more meticulous pancratic enucleation. In the current study, 1 patient (9%) had pancreatic fistula according to the definition of ISGPF, and this patient recovered with conservative management. This results in precise selection of patients, which includes a superficial lesion that does not involve the main pancratic duct and has an outgrowing aspect with small tumor bed.

study, 1 patient (9%) had pancreatic fistula according to the definition of ISGPF, and this patient recovered with conservative management. This results in precise selection of patients, which includes a superficial lesion that does not involve the main pancratic duct and has an outgrowing aspect with small tumor bed. Short operation time, less blood loss, and more rapid recovery are often cited as the prominant advantages of enucleation [6]. Especially, extensive preservation of the normal pancreatic tissues is an another merit of enucleation. Reported data show that pancreatic enucleation preserve pancreatic exocrine and endocrine function [5]. In our study, there was no evidence of new-onset exocrine and endocrine insufficiency. Also, when compared to LDP group (from July 2007 to February 2012, 41 patients underwent LDP in our institution for benign or borderline malignant tumor of the pancreas), the LE group had statistically significant shorter postoperative hospital stays with short operation time and less blood loss (Table 3).

sufficiency. Also, when compared to LDP group (from July 2007 to February 2012, 41 patients underwent LDP in our institution for benign or borderline malignant tumor of the pancreas), the LE group had statistically significant shorter postoperative hospital stays with short operation time and less blood loss (Table 3). In conclusion, the results of this study show that LE in patients with a benign or borderline malignant tumor of the pancreas is a safe and effective procedure. On the basis of our results and considering the general advantages of laparoscopic surgery, LE should be considered as a treatment option for benign or borderline malignant pancreatic lesions that do not involve the main pancratic duct and have an outgrowing aspect with small tumor bed. But, our study has some limitations. It was a retrospective study and LE group was only 11 patients, which is relatively small. So, further evaluation, including prospective randomized clinical trials are needed to confirm these results. ACKNOWLEDGEMENTS This work was supported by Soonchunhyang University Research Fund. This work was supported by IN-SUNG Foundation for Medical Research. No potential conflict of interest relevant to this article was reported. Fig. 1 Trocar placement for laparoscopic enucleation. Table 1 Clinical feature and characteristics of the laparoscopic enucleation group BMI, body mass index. Table 2 Pathologic summary and follow-up data of the laparoscopic enucleation group NED, no evidence of disease. Table 3 Comparison of perioperative outcomes between LE and LDP group

Fig. 1 Trocar placement for laparoscopic enucleation. Table 1 Clinical feature and characteristics of the laparoscopic enucleation group BMI, body mass index. Table 2 Pathologic summary and follow-up data of the laparoscopic enucleation group NED, no evidence of disease. Table 3 Comparison of perioperative outcomes between LE and LDP group Values are presented as mean ± standard deviation or number (%). LE, laparoscopic enucleation; LDP, laparoscopic distal pancreatectomy; NS, not significant.

INTRODUCTION Pancreatic surgery is associated with a high rate of complications because of distinctive features of the pancreas (the tissue is soft and exerts an exocrine function). The resection field is usually both extensive and destructive because the pancreas lies deep and is in close proximity to surrounding organs [1]. Therefore, a correct differential diagnosis is important to avoid unnecessary operations on patients with benign pancreatic diseases, such as pancreatitis and pancreatic tuberculosis, which can be confused with pancreatic malignancies. If a pancreatic lesion is obscure, a biopsy is usually performed via fine-needle aspiration (FNA) guided by endoscopic ultrasound (EUS). However, biopsy interpretation may be hindered by the small sample size and the presence of inflammatory changes that mask or mimic neoplasms [2,3]. Thus, the utility of biopsies in the making of medical decisions on surgery is rather limited. Many researchers have sought to identify biomarkers that accurately distinguish pancreatic cancer from benign pancreatic lesions [4]. MicroRNAs (miRNAs) have been widely investigated as potential biomarkers for several malignancies [5,6,7,8]. Pancreatic ductal adenocarcinoma has a unique miRNA signature that may help differentiate pancreatic cancer from other diseases [9,10,11,12,13,14]. However, the potential application of these markers to preoperative evaluation of pancreatic lesions has not yet been investigated extensively.

eral malignancies [5,6,7,8]. Pancreatic ductal adenocarcinoma has a unique miRNA signature that may help differentiate pancreatic cancer from other diseases [9,10,11,12,13,14]. However, the potential application of these markers to preoperative evaluation of pancreatic lesions has not yet been investigated extensively. In the present work, we obtained the miRNA expression profiles of freshly collected aspirates to explore the feasibility of miRNA expression profiling of pancreatic cancer in small biopsy samples. METHODS Tissue collection Surgical specimens from 11 consecutive patients who had undergone resection for pathologically confirmed pancreatic ductal adenocarcinoma, from January 2013 through August 2013, were subjected to miRNA profiling. FNA (2-5 needle passes per patient; mean, 3.5) using 20- to 23-gauge needles was performed separately on cancer masses and adjacent normal pancreatic tissue immediately after operation. This procedure was the same as that of diagnostic FNA, which is performed during preoperative evaluation of a pancreatic mass in a clinical setting. We also obtained tissue sections of pancreatic ductal adenocarcinomas from another 19 patients, and cryopreserved these samples for comparative analysis. This study was approved by the Institutional Review Board of the Catholic University of Korea College of Medicine, and all patients gave informed consent in the manner prescribed by the Declaration of Helsinki. All tissues were anonymized, and analyses were performed in parallel to avoid batch effects.

METHODS Tissue collection Surgical specimens from 11 consecutive patients who had undergone resection for pathologically confirmed pancreatic ductal adenocarcinoma, from January 2013 through August 2013, were subjected to miRNA profiling. FNA (2-5 needle passes per patient; mean, 3.5) using 20- to 23-gauge needles was performed separately on cancer masses and adjacent normal pancreatic tissue immediately after operation. This procedure was the same as that of diagnostic FNA, which is performed during preoperative evaluation of a pancreatic mass in a clinical setting. We also obtained tissue sections of pancreatic ductal adenocarcinomas from another 19 patients, and cryopreserved these samples for comparative analysis. This study was approved by the Institutional Review Board of the Catholic University of Korea College of Medicine, and all patients gave informed consent in the manner prescribed by the Declaration of Helsinki. All tissues were anonymized, and analyses were performed in parallel to avoid batch effects. RNA extraction RNA was extracted using Ambion RecoverAll Total Nucleic Acid Isolation Kits (Ambion, Austin, TX, USA). In short, tissue samples were ground and subjected to protease digestion in RNAse-free tubes. RNA was captured on glass-fiber filters and eluted into 60-mL amounts of nuclease-free water after washing in ethanol. RNA levels were quantified using a NanoDrop 8000 spectrophotometer (NanoDrop, Wilmington, DE, USA). FNA specimens from normal pancreatic tissues yielded 1.2-41 mg of total RNA (mean, 15.8 µmg). FNA specimens from cancer tissues yielded considerably less RNA, ranging from 1.0 to 32 µg (mean, 5.9 µg). RNA was extracted as follows: After vigorous manual shaking, each sample was centrifuged for 5 minutes at room temperature to remove debris. The supernatant was removed, 0.2-mL chloroform per 1 mL of TRIzol added, and incubation for 2-5 minutes at room temperature followed (after vigorous shaking). All samples were centrifuged for 15 minutes at 4℃ at no more than 12,000 × g, yielding a lower red phenolchloroform phase, an interphase, and a colorless upper aqueous phase containing all of the RNA. This phase was transferred to a fresh tube and RNA precipitated by addition of 500-µL isopropanol. All samples were centrifuged again for 15 minutes at 4℃ and the RNA precipitate formed a gel-like pellet on the sides and bottom of the tube. Ethanol (0.25 mL per 1 mL of TRIzol) was added and the sample applied directly to an RNeasy column and then washed with buffer to remove impurities. RNA was eluted in a final volume of 15 µL.

ere centrifuged again for 15 minutes at 4℃ and the RNA precipitate formed a gel-like pellet on the sides and bottom of the tube. Ethanol (0.25 mL per 1 mL of TRIzol) was added and the sample applied directly to an RNeasy column and then washed with buffer to remove impurities. RNA was eluted in a final volume of 15 µL. MicroRNA profiling Fresh samples from 11 pancreatic ductal adenocarcinomas and 11 matched adjacent normal pancreatic tissues were analyzed using the miRCURY LNA Array platform (Exiqon, Woburn, MA, USA). In each case, 750-ng amounts of test and control total RNA were labeled with Hy3 and Hy5 fluorescent materials, respectively, using mercury LNA microRNA Hi-Power Labeling Kits, Hy3/Hy5 (Exiqon, Vedbaek, Denmark) following the procedure described by the manufacturer. Each Hy3-labeled test sample and Hy5-labeled reference sample were mixed and hybridized to the seventh-generation array, which features capture probes targeting all human, mouse, and rat miRNAs registered in miRBASE 16.0. Hybridized chips were washed, processed to detect biotin-containing transcripts (using the streptavidin-Alexa647 conjugate), and scanned on an Axon 4000B microarray scanner (Axon Instruments, Sunnyvale, CA, USA). We next analyzed miRNA expression using miRCURY LNA Arrays containing Tm-normalized capture probes for 3,100 miRNAs, including all known and registered miRNAs, and human miRPlus sequences not yet annotated in miRBase.

47 conjugate), and scanned on an Axon 4000B microarray scanner (Axon Instruments, Sunnyvale, CA, USA). We next analyzed miRNA expression using miRCURY LNA Arrays containing Tm-normalized capture probes for 3,100 miRNAs, including all known and registered miRNAs, and human miRPlus sequences not yet annotated in miRBase. Quantitative real-time PCR (to quantify the levels of eight selected miRNAs) Real-time RT-PCR was performed on all samples to validate miRNA profiling results; we used an ABI 7500 Fast Real-time PCR platform (Applied Biosystems, a division of Thermo Fisher Scientific Inc., Waltham, MA, USA) to this end. We selected eight miRNAs identified as of interest by miRNA microarray profiling (upregulated: miR-21, miR-27a, miR-146a, miR-200a, and miR-196a; downregulated: miR-217, miR-20a, and miR-96). Reverse transcription was performed using species-specific primers (Applied Biosystems) (Table 1). Data were analyzed with the aid of ABI Prism 7700 SDS software (Applied Biosystems).

iRNA microarray profiling (upregulated: miR-21, miR-27a, miR-146a, miR-200a, and miR-196a; downregulated: miR-217, miR-20a, and miR-96). Reverse transcription was performed using species-specific primers (Applied Biosystems) (Table 1). Data were analyzed with the aid of ABI Prism 7700 SDS software (Applied Biosystems). Statistical and bioinformatic analysis Data from each FNA specimen were analyzed as follows. The miRNA levels measured on the chips were converted into discrete variables by splitting the samples into two classes (highand low-level expression) using the mean miRNA expression level as a threshold. On expression analysis, P-values were calculated using Student t-test after adjustment using Benjamini and Hochberg multiple testing. The confidence levels of the chosen means were 95%. All calculations were performed with the aid of R/bioconductor (principally the limma package). miRNA profiling identified a subset of 99 top miRNAs (miRNAs associated with P-values less than 0.05) of all miRNAs targeted by the Array that were differentially expressed in cancer and normal tissues. Next, all samples were subjected to quantitative RT-PCR (qRT-PCR) to amplify each of eight selected miRNA species. miRNA expression levels in pancreatic cancer samples were calculated and compared to those of normal pancreatic tissues. Relative expression levels were analyzed using the cycle threshold (Ct) method. The expression level of each miRNA was normalized to that of U6sn RNA (an internal control). Control amplification of the small endogenous RNA U6 (a housekeeping gene) was performed on all samples. The postamplification thresholds for all samples were set to be identical, to allow the Ct values of each miRNA to be compared. Mean Ct values were calculated for each specimen and normalized to those of RNA U6 in the same samples. Thus: miRNA expression levels were normalized by subtracting the Ct value of the U6sn RNA internal control from that of each miRNA (Ct miRNA minus Ct U6sn). All data are presented as such normalized Ct values, and miRNA expression levels in controls (paraneoplastic normal pancreatic tissues) were set to 1.0.

e samples. Thus: miRNA expression levels were normalized by subtracting the Ct value of the U6sn RNA internal control from that of each miRNA (Ct miRNA minus Ct U6sn). All data are presented as such normalized Ct values, and miRNA expression levels in controls (paraneoplastic normal pancreatic tissues) were set to 1.0. RESULTS The clinical and pathological features of 11 FNA and 19 cryopreserved specimens are summarized in Table 2. All malignant specimens were pathologically confirmed to exhibit pancreatic ductal adenocarcinoma, and all paraneoplastic normal pancreatic tissues were found to be free of malignant cells upon retrospective review of pathologists' reports. Expression profiling of miRNAs miRNAs differentially expressed in pancreatic cancers and matched paraneoplastic normal pancreatic tissues were identified using the miRNA microarray. Fig. 1 shows a heat map and hierarchical clustering data revealing the overall expression patterns of the miRNAs. Red represents an expression level higher than normal, and green lower than normal. Microarray analysis identified 158 differentially expressed miRNAs; 51 were overexpressed and 107 underexpressed in pancreatic cancer compared to normal pancreatic tissue. Of these miRNAs, the top 10 differentially expressed miRNAs (up or down) are shown in Table 3.

evel higher than normal, and green lower than normal. Microarray analysis identified 158 differentially expressed miRNAs; 51 were overexpressed and 107 underexpressed in pancreatic cancer compared to normal pancreatic tissue. Of these miRNAs, the top 10 differentially expressed miRNAs (up or down) are shown in Table 3. qRT-PCR of selected miRNAs We performed quantitative real-time PCR on individual samples to confirm the microarray data. We chose eight miRNAs (exhibiting at least a threefold change in expression level) for further analysis based on the miRNA profiling data described above, and literature data [15,16,17]. These were five overexpressed (miR-21, miR-27a, miR-146a, miR-200a, and miR-196a) and three underexpressed (miR-217, miR-20a, and miR-96) miRNAs. In other words, these miRNAs were expressed to greater and lesser levels in cancer compared to control tissue, respectively. The levels of all of miR-21, miR-27a, miR-146a, and miR-196a were significantly higher in FNA specimens from cancer tissue relative to matched control tissue in all samples, and, in more than half of the samples, the level was >10 folds greater. However, the expression level of miR-200a varied, in contrast to what we expected, considering the high level of integration of the microarray data (Figs. 2, 3). Compared to the levels in control tissue, the expression levels of miR-217, miR-20a, and miR-96 were significantly downregulated in almost all pancreatic cancer tissues (Figs. 2, 3).

level of miR-200a varied, in contrast to what we expected, considering the high level of integration of the microarray data (Figs. 2, 3). Compared to the levels in control tissue, the expression levels of miR-217, miR-20a, and miR-96 were significantly downregulated in almost all pancreatic cancer tissues (Figs. 2, 3). In addition, the mean expression levels of the eight species of miRNAs were assessed by qRT-PCR in 19 cryopreserved sections of pancreatic cancer compared with 11 control tissues. The results were similar to those described above: The expression levels of miR-21, miR-27a, miR-146a, miR-200a, and miR-196a were significantly higher, and those of miR-217, miR-20a, and miR-96 significantly lower, in cancer specimens than controls (Fig. 4). The reproducibility of the qRT-PCR assay showed that miRNAs can be efficiently extracted from fresh FNA specimens, allowing data from multiple samples to be compared.

-200a, and miR-196a were significantly higher, and those of miR-217, miR-20a, and miR-96 significantly lower, in cancer specimens than controls (Fig. 4). The reproducibility of the qRT-PCR assay showed that miRNAs can be efficiently extracted from fresh FNA specimens, allowing data from multiple samples to be compared. DISCUSSION It is essential to develop sensitive and specific biomarkers for diagnosis of pancreatic cancer because most patients are asymptomatic at early stages, and the disease may be inoperable at diagnosis. The differential diagnosis of pancreatic cancer from benign conditions including pancreatitis and pancreatic tuberculosis is also a major problem. The potential morbidity and mortality associated with needless radical resection, frequently accompanied by serious complications, must be avoided [18,19,20]. Conventional diagnostic methods such as imaging (enhanced CT or MRI), serum tumor marker analysis (of CA19-9, CA-125, and CEA levels), and other modalities, do not always aid in differential diagnosis, and are sometimes poorly effective [20,21]. Thus, an objective molecular test preoperatively discriminating pancreatic cancer from benign pancreatic disease would be clinically valuable.

, serum tumor marker analysis (of CA19-9, CA-125, and CEA levels), and other modalities, do not always aid in differential diagnosis, and are sometimes poorly effective [20,21]. Thus, an objective molecular test preoperatively discriminating pancreatic cancer from benign pancreatic disease would be clinically valuable. miRNAs have received considerable attention as potential biomarkers of human malignancies [6,7,12]. miRNAs are 18- to 24-nucleotide noncoding RNA molecules exhibiting remarkable evolutionary conservation. The principal functions of miRNAs are regulation of the stability and translation of nuclear mRNA transcripts. In general, miRNAs negatively regulate the expression of genes involved in many biological processes, including development, differentiation, and apoptosis. Acting posttranscriptionally, the molecules may fine-tune the expression levels of as many as 30% of all mammalian proteinencoding genes. To date, more than 700 human miRNAs have been identified [5]. Aberrant miRNA expression has been implicated in the initiation and progression of certain diseases, including various cancers. Approximately half of all human miRNA genes are located in fragile chromosomal regions affected in various human cancers [15]. The classic view of cancer as a genetic disease influenced by expression of oncogenes or tumor suppressor genes that code for proteins is now expanding to include miRNAs. Abnormal miRNA expression in cancer suggests that the miRNAs may be used as diagnostic signatures. Further, a molecular signature derived from about 200 miRNAs could be superior in terms of cancer classification in comparison to mRNA expression profiles of over 20,000 genes. Another technical advantage is the small size of miRNAs, reducing susceptibility to degradation not only in frozen but also formalin-fixed paraffin-embedded tissues, allowing for wider application of miRNA profiling in readily available clinical samples [13,22,23].

ison to mRNA expression profiles of over 20,000 genes. Another technical advantage is the small size of miRNAs, reducing susceptibility to degradation not only in frozen but also formalin-fixed paraffin-embedded tissues, allowing for wider application of miRNA profiling in readily available clinical samples [13,22,23]. Considerable evidence has accumulated showing that miRNAs influence the course of numerous cancers. Thus, miR-21, miR-92am, and miR-200c are involved in colorectal cancer; let- 7 and miR-16 in nonsmall cell lung cancer; upregulation of miR-142 in diffuse large B-cell lymphomas; miR-146a and miR-222 in thyroid cancer; and miR-222 and miR-29a in breast cancer [24]. Pancreatic ductal adenocarcinoma has a unique miRNA signature featuring significantly higher expression of miR-21, miR-10b, miR-15b, miR-27a, miR-155, miR-146a, miR-210, miR-100, miR-200a, and miR-196a; and decreased expression of miR-217, miR-375, miR-30a, miR-20a, and miR-96, compared to the miRNA profiles of nonneoplastic pancreatic tissue [9,10,11,12,13,14]. However, miRNA profiling of pancreatic cancer has hitherto used experimental cell lines or paraffin/formalinpreserved pancreatic cancer tissues from surgical specimens. Consequently, although preclinical promise has been shown, no miRNA profiling method is yet recommended for clinical application in the management of patients with pancreatic lesions, not even for the preoperative differential diagnosis of pancreatic cancer from benign lesions.

c cancer tissues from surgical specimens. Consequently, although preclinical promise has been shown, no miRNA profiling method is yet recommended for clinical application in the management of patients with pancreatic lesions, not even for the preoperative differential diagnosis of pancreatic cancer from benign lesions. In the present study, we sought to develop miRNA profiling of pancreatic cancer as a diagnostic tool. Current diagnosis and staging of pancreatic cancer are based on a combination of traditional radiological imaging and histological or cytological diagnosis using small amounts of tissue retrieved via EUSguided FNA, which requires the assistance of an experienced pathologist. Even the use of advanced imaging techniques followed by histological evaluation by a proficient pathologist sometimes fails to differentiate benign from malignant pancreatic lesions. Up to 6% of the cases suspected as malignant turn out to be benign at surgery, and the patients suffer needless postsurgical complications [21].

e use of advanced imaging techniques followed by histological evaluation by a proficient pathologist sometimes fails to differentiate benign from malignant pancreatic lesions. Up to 6% of the cases suspected as malignant turn out to be benign at surgery, and the patients suffer needless postsurgical complications [21]. If the preoperative diagnosis of a pancreatic lesion is ambiguous, how might treatment be planned? We performed miRNA analysis on pancreatic FNA samples obtained from surgically resected specimens, not via biopsy. EUS-guided FNA is rather invasive and the amount of tissue retrieved is very small. The use of this procedure for research purposes, and not for practical diagnosis of a patient, would be unethical and therefore impossible. FNA of fresh surgical specimens immediately following resection reproduces the preoperative diagnostic procedure in current clinical practice, in the absence of ethical concerns. This approach also allowed us to compare miRNA profiles between a cancerous lesion and paraneoplastic normal pancreatic tissue from the same individual. To our knowledge, this is a unique feature of our present study.

he preoperative diagnostic procedure in current clinical practice, in the absence of ethical concerns. This approach also allowed us to compare miRNA profiles between a cancerous lesion and paraneoplastic normal pancreatic tissue from the same individual. To our knowledge, this is a unique feature of our present study. Our immediate objective was to determine whether it was feasible to collect miRNA microarray and qRT-PCR data from very small amounts of fresh tissue obtained via diagnostic FNA. We assessed miRNA expression profiles in freshly collected materials obtained immediately after resection using separate needles to aspirate cancer and adjacent normal tissue. A total of 158 miRNAs was differentially expressed in the two tissues, as revealed by the miRCURY LNA Array platform. Consistent with earlier data on immortalized pancreatic cancer cell blocks and banked cancer tissue [12,13,16,22], we found that the expression levels of miR-21, miR-27a, miR-146a, miR-200a, and miR-196a were higher, and those of miR-217, miR-20a, and miR-96 lower, in FNA samples of cancers. Comparative qRT-PCR analysis of the expression levels of miR-21, miR-27a, miR-146a, miR-200a, and miR-196a in FNAs from 11 pancreatic cancers showed that all were expressed at significantly higher levels, in almost all samples, compared to normal tissue. In contrast, the expression levels of miR-217, miR-20a, and miR-96 were significantly lower in all samples.

sion levels of miR-21, miR-27a, miR-146a, miR-200a, and miR-196a in FNAs from 11 pancreatic cancers showed that all were expressed at significantly higher levels, in almost all samples, compared to normal tissue. In contrast, the expression levels of miR-217, miR-20a, and miR-96 were significantly lower in all samples. In conclusion, we have shown that it is feasible to perform miRNA profiling of very small pancreatic cancer specimens obtained using FNA. The work may yield an important preoperative diagnostic tool, especially in terms of lesion resection. We found that the amount of tissue in most FNA samples sufficed for quantitative analysis of miRNA expression. Differentially regulated miRNAs observed in cryopreserved resection specimens of pancreatic cancer were also identified in freshly collected FNA materials. No potential conflict of interest relevant to this article was reported. Fig. 1 A heat map and hierarchical clustering showing the overall expression patterns of microRNAs. Red represents an expression level higher than that of the normal control, and green lower expression. Fig. 2 Comparative expression analysis of miR-21 (A), miR-27a (B), miR-146a (C), miR-200a (D), miR-196a (E), miR-217 (F), miR-20a (G), and miR-96 (H) levels in 11 fine-needle aspiration specimens from cancer relative to matched normal control tissue, as estimated by quantitative RT-PCR. The expression levels in control paraneoplastic normal pancreatic tissues were set to 1.0 in terms of log2 values.

iR-200a (D), miR-196a (E), miR-217 (F), miR-20a (G), and miR-96 (H) levels in 11 fine-needle aspiration specimens from cancer relative to matched normal control tissue, as estimated by quantitative RT-PCR. The expression levels in control paraneoplastic normal pancreatic tissues were set to 1.0 in terms of log2 values. Fig. 3 Box plot showing the overall expression levels of eight species of microRNAs (miRNAs) as revealed by quantitative RT-PCR (qRT-PCR) in 11 fine-needle aspiration specimens from cancer compared to control tissue. The expression levels in control paraneoplastic normal pancreatic tissues were set to 1.0 in terms of log2 values. Fig. 4 Box plot showing the expression levels of eight species of microRNAs (miRNAs), assessed using quantitative RT-PCR (qRT-PCR), in 19 cryopreserved sections of pancreatic cancer tissue compared with 11 control tissues. The expression levels in control paraneoplastic normal pancreatic tissues were set to 1.0 in terms of log2 values. Table 1 Primers for reverse transcription-polymerase chain reaction miRNA, microRNA. Table 2 The clinical and pathological features of 11 FNAretrieved and 19 cryopreserved pancreas ductal adenocarcinoma samples FNA, fine-needle aspiration. Table 3 The top 10 differentially expressed (up or down) miRNAs in pancreatic cancer compared with normal pancreatic tissue miRNA, microRNA. a)Average Hy3 signal intensity. b)Log2 (-fold change) when the miRNA expression levels of test and control samples were compared.

INTRODUCTION Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract [1]. It is well known that GISTs arise from the interstitial cells of Cajal or their common stem cell, and that activating mutations of the KIT or PDGFRA proto-oncogenes are related to the oncogenic development of GISTs [2,3]. The most common symptom of gastric GIST is bleeding, and other symptoms that may be present include dyspepsia, abdominal pain or discomfort, obstructive jaundice, and mass palpation. However, most patients are asymptomatic and are diagnosed incidentally during endoscopy [4]. GISTs represent less than 1% of all gastrointestinal (GI) tract malignancies. The most common location of GISTs is the stomach (70%), but they can occur in all parts of the GI tract, such as the small intestine (20%-30%), colon/rectum (10%), and rarely the omentum, esophagus, and appendix [5]. The annual incidence is 7-14 cases per million in Western countries. The median age is 63 years at the time of diagnosis, and a slight male predominance has been reported [4,6,7]. However, GISTs are reported at any age and their incidence varies according to race and country [4]. The standard treatment for primary localized GIST is surgical resection, to achieve tumor-free margins and an intact tumor capsule. The clinical behavior of GIST after surgical resection is extremely variable. Some tumors follow a benign, indolent course, but others show aggressive clinical courses despite adequate oncologic resection. The prognosis in reported series also varies widely [8,9,10].

ieve tumor-free margins and an intact tumor capsule. The clinical behavior of GIST after surgical resection is extremely variable. Some tumors follow a benign, indolent course, but others show aggressive clinical courses despite adequate oncologic resection. The prognosis in reported series also varies widely [8,9,10]. Recently, gastric GISTs have attracted interest because of relative higher incidence than that of other GI tract organs, and advances in laparoscopic techniques, which have allowed the minimally invasive resection of tumors [9]. There have only been a few large-scale studies about clinical features and prognosis of surgically treated gastric GISTs. Here, we report a multicenter, retrospective study of 406 cases of gastric GIST patients who underwent curative surgical resection. METHODS Patients This study was conducted at four tertiary referral university hospitals (Daegu Catholic University Medical Center, Kyungpook University Hospital, Keimyung University Dongsan Medical Center, and Yeungnam University Medical Center) in Daegu, Korea. We performed a retrospective study on 406 consecutive patients who underwent curative resection for localized gastric GIST between March 1998 and March 2012. No tumor rupture or spillage occurred during operation. All patients were confirmed as gastric GISTs by immunohistochemical staining for CD117(ckit), CD34, or both.

performed a retrospective study on 406 consecutive patients who underwent curative resection for localized gastric GIST between March 1998 and March 2012. No tumor rupture or spillage occurred during operation. All patients were confirmed as gastric GISTs by immunohistochemical staining for CD117(ckit), CD34, or both. The retrospectively collected medical records were reviewed with respect to clinical parameters, including age, gender, tumor location, the surgical approach, pathological characteristics, and recurrence. Pathological parameters were assessed, including tumor size, mitotic count, cell type (pure spindle, mixed spindle and epithelioid, pure epithelioid), cellularity, and mucosal invasion. Tumor size was measured and the largest dimension was taken into account. The mitoses were counted on 50 high power fields (HPFs) (×400). Preoperative diagnostic studies included esophagogastroduodenoscopy and CT. Endoscopic ultrasonography was performed selectively to identify the nature and location of tumors. The study design was approved by the institutional review boards of each hospital. Follow-up clinical study For the follow-up clinical studies, history taking, physical examination, chest x-ray, gastroduodenoscopy, and abdominal CT scans were carried out biannually until the second postoperative year; after that, annual follow-up was performed. If necessary, abdominal ultrasonography, chest CT scans, and PET scans were performed. Recurrences were investigated retrospectively using the medical records. The median follow-up period was 42.9 months (2-166 months).

ried out biannually until the second postoperative year; after that, annual follow-up was performed. If necessary, abdominal ultrasonography, chest CT scans, and PET scans were performed. Recurrences were investigated retrospectively using the medical records. The median follow-up period was 42.9 months (2-166 months). Statistical analysis Summaries of demographic and clinicopathological characteristics were performed using descriptive statistics. The values of means and standard deviations (SDs) are presented for quantitative variables and values of frequency and percent for qualitative variables. Comparisons between groups (open and laparoscopic) were performed using the chi-square test for qualitative variables and two-sample t-test with normality for quantitative variables. All tests were two-sided and P-values less than 0.05 were considered to indicate statistical significance. The IBM SPSS Statistics ver. 19.0 (IBM Co., Armonk, NY, USA) was used for analyses.

re performed using the chi-square test for qualitative variables and two-sample t-test with normality for quantitative variables. All tests were two-sided and P-values less than 0.05 were considered to indicate statistical significance. The IBM SPSS Statistics ver. 19.0 (IBM Co., Armonk, NY, USA) was used for analyses. RESULTS Patient characteristics The clinicopathological characteristics of all patients are shown in Table 1. There were 157 males (38.7%) and 249 females (61.3%), with a mean age of 60.8±10.8 (SD) years. Of the 406 tumors, 200 (49.3%), 122 (30.0%), and 84 (20.7%) were located in the upper, middle, and lower portion of the stomach, respectively. Immunohistochemistry showed that 380 tumors (96.6%) were positive for CD117 and 334 (82.3%) were positive for CD34. Tumor sizes were ≤ 2 cm in 51 patients (12.6%), 2 cm < tumor size ≤ 5 cm in 248 (61.1%), 5 cm < tumor size ≤ 10 cm in 79 (19.5%), and >10 cm in 28 (6.9%), with a mean size of 4.9 cm (range, 0.3-29.0 cm). Mitotic counts (per 50 HPF) were ≤ 5 in 306 patients (75.4%), 5 < mitotic count ≤ 10 in 91 (22.4%), and > 10 in 9 (2.2%). We classified the patients by risk group according to both of the National Institute of Health (NIH) criteria and the American Joint Committee on Cancer (AJCC) staging system. According to the NIH criteria, 15.0% of patients were classified in the very low risk group, 43.6% were in low risk group, 20.9% were intermediate risk, and 20.4% were high risk. According to AJCC staging, 70.9% of patients were stage I, 18.0% were stage II, and 11.1% were stage III.

ee on Cancer (AJCC) staging system. According to the NIH criteria, 15.0% of patients were classified in the very low risk group, 43.6% were in low risk group, 20.9% were intermediate risk, and 20.4% were high risk. According to AJCC staging, 70.9% of patients were stage I, 18.0% were stage II, and 11.1% were stage III. Operative method Complete surgical resection was performed for all 406 patients with tumor-free resection margins. No intraoperative tumor rupture or spillage event occurred. Laparoscopic wedge resections were performed for 156 patients (38.4%) and conventional open surgical resections for 250 patients (61.6%). The laparoscopic wedge resection was first performed in 2004, and the proportion of the laparoscopic approach increased annually, reaching 85% in 2012 (Fig. 1). A comparison of the characteristics of open resection group and laparoscopic resection group is shown in Table 2. Compared with open resection group, patients who underwent laparoscopic resection had smaller tumors (3.45 cm vs. 5.46 cm, P < 0.001). There was no significant difference in tumor location or mitotic count. Recurrence occurred in 11 patients who underwent open resection, while no recurrence was observed in laparoscopic resections (P = 0.008).

tion group, patients who underwent laparoscopic resection had smaller tumors (3.45 cm vs. 5.46 cm, P < 0.001). There was no significant difference in tumor location or mitotic count. Recurrence occurred in 11 patients who underwent open resection, while no recurrence was observed in laparoscopic resections (P = 0.008). Recurrence The median follow-up period was 42.9 months (2-166 months) and there were 11 recurrence patients (2.7%). Clinicopathological characteristics of the recurrent cases after curative resection are shown in Table 3. Nine of the eleven recurrent cases were in the high-risk group according to the NIH criteria. Recurrence sites were the liver in nine cases, and peritoneal recurrences were observed in two. All recurrent patients were treated with imatinib mesylate (Gleevec). DISCUSSION We analyzed 406 consecutive patients retrospectively who had undergone resection of gastric GISTs at four centers between March 1998 and March 2012. In previous studies by Miettinen et al. [4] and Tran et al. [7], median age of GIST patients at the diagnosis was 63 and there was a slight male predominance. However, our study showed a female predominance, with mean age of 60.8 years. Several studies in Korean populations have reported female predominance [11,12]. The stomach is the most common site of GISTs, 52%-60% of cases, with the proximal stomach involved in about two-thirds of those patients [13,14]. Similarly, in our study, the upper third was the most common site, involved in 49.3% of patients.

ral studies in Korean populations have reported female predominance [11,12]. The stomach is the most common site of GISTs, 52%-60% of cases, with the proximal stomach involved in about two-thirds of those patients [13,14]. Similarly, in our study, the upper third was the most common site, involved in 49.3% of patients. A consensus conference held at the National Institutes of Health in 2001 provided the first practical scheme for the assessment of risk in the clinical course of GISTs. The risk categorization was based on an evaluation of the size and mitotic count (per 50 HPF) of tumors [2]. The NIH criteria have been used widely for risk assessment of GISTs in the clinical field. In 2010, the AJCC TNM staging system included GISTs in an attempt to assist in the management and surveillance of GISTs [15]. Distributions of the risk groups according to both NIH criteria and AJCC 7th staging in our study were similar to previous large-scale studies of gastric GISTs [16,17].

Ts in the clinical field. In 2010, the AJCC TNM staging system included GISTs in an attempt to assist in the management and surveillance of GISTs [15]. Distributions of the risk groups according to both NIH criteria and AJCC 7th staging in our study were similar to previous large-scale studies of gastric GISTs [16,17]. The primary goal of treatment for localized gastric GISTs is surgical resection with negative margins. In the past, it was said that a 1- to 2-cm margin was necessary for adequate resection [4,18]. However, recent studies suggested that extensive resection to obtain wide margin was not necessary and did not improve outcome [14,19]. Thus, it is now accepted that the surgical goal for GIST is complete resection with a negative margin only. Lymphadenectomy is also not indicated generally because of the rarity of lymphatic spread of GISTs [9,10]. For this reason, the laparoscopic wedge resection for gastric GISTs is now used more frequently with the advantages of a small incision, less pain, and oncologic safety [19,20,21].

ion with a negative margin only. Lymphadenectomy is also not indicated generally because of the rarity of lymphatic spread of GISTs [9,10]. For this reason, the laparoscopic wedge resection for gastric GISTs is now used more frequently with the advantages of a small incision, less pain, and oncologic safety [19,20,21]. In Europe, the recommendations of the GIST consensus conference in 2004 were that the laparoscopic approach should be limited to small GISTs (<2 cm) [1] and the Japanese guidelines suggested that the laparoscopic approach was acceptable for lesions smaller than 5 cm and only when performed by skilled surgeons [22]. However, no absolute indication for laparoscopic surgery for GISTs has yet been established. In our study, laparoscopic wedge resections were performed in 156/406 patients (38.4%). We first performed laparoscopic wedge resections in 2004 and the proportion increased annually (Fig. 1). The median tumor size of the patients who underwent laparoscopic wedge resection was 3.45 cm (0.4-8.5 cm), which was significantly smaller than that of open surgery, 5.46 cm (0.3-29 cm). Comparing open and laparoscopic surgery groups, the risk group distribution was also significantly different, but there was no significant difference in mitotic count. Although no definite indication or guideline for laparoscopic surgery was used in our study, tumor size may be a factor that affects the decisions of surgeons as to whether to perform open or laparoscopic surgery.

p distribution was also significantly different, but there was no significant difference in mitotic count. Although no definite indication or guideline for laparoscopic surgery was used in our study, tumor size may be a factor that affects the decisions of surgeons as to whether to perform open or laparoscopic surgery. Although there has been no prospective randomized trial comparing results of laparoscopic and open surgery, several studies have reported the feasibility and oncologic safety of laparoscopic surgery for GISTs [12,19]. In our study there was no recurrence in patients who underwent laparoscopic wedge resection, whereas there were 11 recurrences with open surgery. We also suggest that laparoscopic wedge resection is feasible to treat gastric GISTs for selected patients. However the difference of recurrence rates between open resection and laparoscopic resection groups does not represent oncological safety or superiority of laparoscopic resection. Because tumor size of laparoscopic resection group was significant smaller than open resection group, lower recurrence rate of laparoscopic resection group might be affected by smaller tumor size.

resection and laparoscopic resection groups does not represent oncological safety or superiority of laparoscopic resection. Because tumor size of laparoscopic resection group was significant smaller than open resection group, lower recurrence rate of laparoscopic resection group might be affected by smaller tumor size. The recurrence rates of gastric GISTs after surgery in previous studies ranged from 17% to 24% [23,24]. In this study, although most of our patients who underwent surgical resection were at very low or low risk group, according to the NIH criteria (238/406, 58.6%), we had a lower recurrence rate (11/406, 2.7%) in our series than those in other Western reports [23,24]. Tumor recurrence tends to be intra-abdominal and it usually occurs in the liver, the peritoneum, or both [9], similar to our results (Table 3). In this study, the most common site of recurrence was the liver (9 patients, 81.8%) followed by the peritoneum (2 patients, 18.2%). In recurrent gastric GISTs, some reports demonstrated that a combination of surgery and targeted therapy may reduce the development of recurrence or decrease the risk of disease progression [5,25]. In this study, imatinib mesylate was administrated to all patients with recurrence, 8/11 (72.7%) of whom showed partial responses to treatment.

GISTs, some reports demonstrated that a combination of surgery and targeted therapy may reduce the development of recurrence or decrease the risk of disease progression [5,25]. In this study, imatinib mesylate was administrated to all patients with recurrence, 8/11 (72.7%) of whom showed partial responses to treatment. Unfortunately, in this study, due to limitations of retrospective study and the small number of recurrence events, we could not assess risk factors affecting recurrence. It is difficult to compare results between previous studies directly, because of wide variety of patient characteristics among the studies. We think possible reasons for the discrepancies in prognosis between prior studies and ours include that we conducted this study only for gastric GISTs, which have a more favorable prognosis than that of intestinal GISTs. There was no intraoperative rupture or spillage of tumors. Also, previous studies included a greater number of large tumors than ours [4,13,14,26].

n prognosis between prior studies and ours include that we conducted this study only for gastric GISTs, which have a more favorable prognosis than that of intestinal GISTs. There was no intraoperative rupture or spillage of tumors. Also, previous studies included a greater number of large tumors than ours [4,13,14,26]. Recently, with advances in operative methods and early diagnoses, several studies have reported better oncological outcome of gastric GIST undergoing curative resection, especially in Korea and Japan. There are high incidences of gastric cancer in Korea and Japan, so there may be more of a possibility of the early detection of gastric GISTs because diagnostic studies, such as gastroduodenoscopy, are performed more often for the diagnosis and screening of gastric cancer. Furthermore, most gastric GISTs patients in these countries may undergo surgery by a surgeon who specializes in gastric cancer surgery. In Korea, Yang et al. [27] reported that 6 of 105 gastric GIST patients (5.7%) who underwent curative resections had recurrences. Kim et al. [12] also studied gastric GIST patients who underwent curative resection; there were 5 recurrences (4.8%) after surgery. In Japan, Honda et al. [28] reported that only 1 recurrence (1.3%) developed in 78 patients who underwent laparoscopic surgery for gastric GISTs.

rwent curative resections had recurrences. Kim et al. [12] also studied gastric GIST patients who underwent curative resection; there were 5 recurrences (4.8%) after surgery. In Japan, Honda et al. [28] reported that only 1 recurrence (1.3%) developed in 78 patients who underwent laparoscopic surgery for gastric GISTs. In conclusion, there was a lower recurrence rate of gastric GISTs after curative resection in our series than in other Western reports. Laparoscopic gastric wedge resection is feasible to treat gastric GISTs in selected patients and further efforts are necessary to conduct a prospective randomized study to prove the oncological safety and establish a clear indication of this procedure. No potential conflict of interest relevant to this article was reported. Fig. 1 Yearly changes in the proportion of open resection and laparoscopic resection for gastric gastrointestinal stromal tumors (GISTs). There showed an increasing tendency to perform laparoscopic resections for gastric GISTs. Table 1 Clinicopathological characteristics of 406 gastric GIST patients GIST, Gastrointestinal stromal tumor; IHC, Immuno-histo-chemistry; NIH, National Institute of Health; AJCC, American Joint Committee on Cancer, 7th ed. Table 2 Comparison of open resection group and laparoscopic resection group for patients of gastric GISTs GIST, Gastrointestinal stromal tumor; NIH, National Institute of Health; AJCC, American Joint Committee on Cancer, 7th ed. Values are presented as mean ± standard deviation or number (%). *Statistically significant with P < 0.05.

Table 2 Comparison of open resection group and laparoscopic resection group for patients of gastric GISTs GIST, Gastrointestinal stromal tumor; NIH, National Institute of Health; AJCC, American Joint Committee on Cancer, 7th ed. Values are presented as mean ± standard deviation or number (%). *Statistically significant with P < 0.05. Table 3 Recurrences in patient underwent surgical resection for gastric GISTs GIST, gastrointestinal stromal tumor; HPF, high power field; NIH, National Institute of Health.

INTRODUCTION Because gastric submucosal tumors (SMTs) have a potential for malignancy, and it is difficult to obtain histological confirmation through a preoperative biopsy, surgical resection is their main treatment [1]. Local tumor resection with negative surgical margins has become accepted as standard treatment because of the rarity of lymph node metastasis with these lesions. Laparoscopic gastric wedge resection is commonly used for treating gastric SMTs, but operative methods have varied depending on the location and size of the lesion [2,3]. In the past, open gastrectomy was generally performed in patients with gastric SMT, but recent advances in surgical skills and instruments have led to important innovations in laparoscopy. Interest in minimally invasive surgery has increased, and many surgeons are attempting laparoscopic approaches [4,5]. Identifying the location of lesions during laparoscopy is problematic, however, unlike with open surgery where simple tactile sense can be used. This is especially true for small endophytic gastric SMTs, for which intraoperative esophagogastroduodenoscopy (EGD) is frequently required because of the difficulty of determining adequate surgical margins.

ons during laparoscopy is problematic, however, unlike with open surgery where simple tactile sense can be used. This is especially true for small endophytic gastric SMTs, for which intraoperative esophagogastroduodenoscopy (EGD) is frequently required because of the difficulty of determining adequate surgical margins. Conventional laparoscopic exogastric wedge resection has several disadvantages in that a large amount of stomach must be resected, including normal gastric tissue. Several intragastric studies to identify and resect these tumors under direct visualization for EGD or laparoscopy have been reported, but they have not been widely used. There are only rare reports of laparoscopic intragastric tumor resection through a single incision. Here, we review our experiences with single-incision intragastric resection of gastric SMTs. We describe the outcomes and some characteristic findings.

laparoscopy have been reported, but they have not been widely used. There are only rare reports of laparoscopic intragastric tumor resection through a single incision. Here, we review our experiences with single-incision intragastric resection of gastric SMTs. We describe the outcomes and some characteristic findings. METHODS Patients This study was designed with single-arm, retrospective, case-series study. From January 2010 to December 2013, a total of 21 consecutive patients with gastric SMTs underwent single-incision intragastric resection in the Department of Surgery, Pusan National University Hospital. All patients were diagnosed with gastric SMTs based on preoperative endoscopic ultrasonography results. In each case, the location and type of tumor was confirmed with abdominal computed tomography. A single experienced surgeon skilled in laparoscopic gastric resection performed all the operations. The sex, age, hospital stay, comorbidities, body mass index (BMI), American Society of Anesthesiologists (ASA) score, tumor location, operating time, postoperative complications, and clinicopathologic data were analyzed. Variables were collected retrospectively and were reviewed with regard to the patients' demographics, perioperative data, clinicopathological data, and postoperative course. Cases that met any of the following criteria were excluded: (1) tumor size > 5 cm; (2) exophytic or dumbbell-type growth pattern; (3) tumor located in the lower third of the stomach including the angle.

ed with regard to the patients' demographics, perioperative data, clinicopathological data, and postoperative course. Cases that met any of the following criteria were excluded: (1) tumor size > 5 cm; (2) exophytic or dumbbell-type growth pattern; (3) tumor located in the lower third of the stomach including the angle. Surgical procedure Under general anesthesia, the patient was placed in the supine position. The operator was on the right side of the patient. A split leg position was used for the first assistant to stand between the patient's legs. After making a vertical, approximately 3-cm umbilical incision with unwrinkling of the natural fold (Fig. 1), we applied a 6-cm diameter Alexis wound retractor (extra small; Applied Medical, Rancho Santa Margarita, CA, USA) to the umbilical incision. We identified the location of the stomach and made a 3-cm incision to the lower body, greater curvature side (Fig. 2A). A second Alexis wound retractor was applied to this gastrostomy. Because the stomach is mostly in an upward position from umbilicus, we incised it by pulling down on it, with the stomach being grasped with a Babcock forceps (Fig. 2B). After a surgical glove was applied to the second Alexis wound retractor, a 12-mm port and two 5-mm ports were inserted through first, third, and fourth fingers of the glove (Fig. 3). A direct gaseous inflation of the stomach was performed using a carbon dioxide pressure of up to 12 mmHg. Rigid laparoscopes of 5 mm, 30 cm, and 30o were used for the operation. The tumor was resected with a 45-mm laparoscopic linear stapler (Endo-GIA, Covidien, Elancourt, France) (Fig. 4A-C). We checked for any bleeding along the staple line. Active bleeding was controlled by electrocautery or metal clipping (Fig. 4D). The resected specimen was extracted through the umbilical incision. After removing the second Alexis wound retractor, the gastrostomy was closed with continuous absorbable monofilament suture material or with a 100-mm linear stapler (GIA, Covidien). We then removed the first Alexis wound retractor and closed the peritoneum, fascia, and skin layer by layer.

rough the umbilical incision. After removing the second Alexis wound retractor, the gastrostomy was closed with continuous absorbable monofilament suture material or with a 100-mm linear stapler (GIA, Covidien). We then removed the first Alexis wound retractor and closed the peritoneum, fascia, and skin layer by layer. RESULTS Patient demographics The patients consisted of nine men and 12 women with a mean age of 51.9 ± 12.9 years (22-69 years) and mean BMI of 22.6 ± 2.0 kg/m2. Comorbidities were as follows: hypertension in five, diabetes mellitus in three, asthma in one, ureteral stricture in one, old tuberculosis in one. The ASA scores were all <2. Clinicopathologic data The mean tumor size was 2.4 ± 0.7 cm. The anatomic distribution of the tumors were as follows: three were in the esophagogastric junction, Thirteen in the fundus, three in the upper body, and two in the lower body (Fig. 5). Sixteen of the tumors were diagnosed as gastrointestinal stromal tumors (GISTs). According to the US National Institutes of Health classification for risk of malignant potential, one was very low risk, three was low risk, seven were intermediate risk, and five were high risk. In addition, according to the American Joint Committee on Cancer (AJCC), four were classified as stage IA, one as stage IB, ten as stage II, and one as stage IIIB. Patient demographics and clinicopathologic data of each case are presented in Table 1.

was low risk, seven were intermediate risk, and five were high risk. In addition, according to the American Joint Committee on Cancer (AJCC), four were classified as stage IA, one as stage IB, ten as stage II, and one as stage IIIB. Patient demographics and clinicopathologic data of each case are presented in Table 1. Perioperative data The mean operating time was 68.6 ± 12.0 minutes. There were no conversions to open surgery or major intraoperative complications. The mean time to resumption of water intake was 1.4 ± 0.5 days. The mean hospital length of stay was 4.9 ± 1.7 days. Postoperative intragastric bleeding occurred in two patients, who underwent endoscopy and were each given a blood transfusion. There were no recurrences or deaths during the mean 19-month follow-up period (Table 2). DISCUSSION Gastric SMTs account for about 2% of all neoplasms of the stomach. They arise from the submucosa or muscle propria layer of the gastric wall [6]. Gastric SMTs are classified as myogenic tumors (e.g., leiomyoma, leiomyosarcoma), neurogenic tumors (e.g., schwannomas, neurofibromas), or GISTs, the latter being most common [7]. Because of less invasiveness and the rarity of regional lymph node metastases, lymph node dissection is unnecessary. Thus, local resection with negative margins is recommended as appropriate treatment [8].

leiomyosarcoma), neurogenic tumors (e.g., schwannomas, neurofibromas), or GISTs, the latter being most common [7]. Because of less invasiveness and the rarity of regional lymph node metastases, lymph node dissection is unnecessary. Thus, local resection with negative margins is recommended as appropriate treatment [8]. Although conventionally open laparotomy has been performed as standard treatment for gastric SMTs, recent improvements in laparoscopic surgical skills and instruments have allowed expansion of the surgical options [4,5]. De Vogelaere et al. [8] reported that laparoscopic surgery was feasible for gastrointestinal tumors > 2 cm. In a large-scale study, Novitsky et al. [9] demonstrated that the laparoscopic approach produced good surgical results and a long-term disease-free survival of 92% in patients with variously sized tumors (1.0-8.5 cm).

gelaere et al. [8] reported that laparoscopic surgery was feasible for gastrointestinal tumors > 2 cm. In a large-scale study, Novitsky et al. [9] demonstrated that the laparoscopic approach produced good surgical results and a long-term disease-free survival of 92% in patients with variously sized tumors (1.0-8.5 cm). Laparoscopic gastric wedge resection has been recommended as effective, safe treatment of gastric SMTs, although the surgical approach varied according to the growth type and the location of the tumor [2]. Especially in the case of endophytic gastric SMT, it is not easy to determine an adequate resection margin because of the difficulty of confirming the tumor's location. When an endophytic gastric SMT is located on the cardia or prepylorus, partial or total gastrectomy might be needed because complications such as stricture may occur after gastric wedge resection. In such cases, an additional procedure to create an anastomosis might be required to maintain the continuity of the gastric route. Also, when the endophytic gastric SMT is located on the posterior wall, extended dissection may be necessary to obtain a good operative view. Conventional exogastric wedge resection in these patients requires massive resection of normal gastric tissue [3]. Sasaki et al. [2] noted the need for tailored gastric resections based on the varying tumor characteristics of SMTs.

he posterior wall, extended dissection may be necessary to obtain a good operative view. Conventional exogastric wedge resection in these patients requires massive resection of normal gastric tissue [3]. Sasaki et al. [2] noted the need for tailored gastric resections based on the varying tumor characteristics of SMTs. Song et al. [10] and Huguet et al. [11] suggested a transgastric approach as an alternative method for these endophytic tumors. It is novel technique that can preserve normal gastric tissue with a safe resection margin and can identify the tumor location under a direct laparoscopic view. However, the procedure requires incision of the stomach, which can give rise to contamination by gastric juice or tumor dissemination into the peritoneal cavity. Also, intraoperative EGD is often required to confirm the exact location of the gastrostomy. The intragastric approach we have described has several advantages over the transgastric approach. Although the tumor is small, our method facilitates exact, minimum gastric resection because the operator can readily identify the tumor's location. Also, the risk of intra-abdominal tumor seeding is relatively low because peritoneal spillage of gastric contents rarely occurs during the operation.

ransgastric approach. Although the tumor is small, our method facilitates exact, minimum gastric resection because the operator can readily identify the tumor's location. Also, the risk of intra-abdominal tumor seeding is relatively low because peritoneal spillage of gastric contents rarely occurs during the operation. Various methods of intragastric wedge resection have been reported. Tagaya et al. [12] introduced an intragastric approach during which the stomach is inflated by airflow via oral endoscopy. After elevating the gastric anterior wall using a double straight needle device, two or three laparoscopic ports were placed in the stomach. Intragastric resection was then performed under endoscopic view with endoscopic linear staplers. Specimens were retrieved through the oral route. Li et al. [13] reported a similar intragastric approach. They inserted two 5-mm trocars and a 12-mm trocar into the stomach. Then, without intraoperative EGD, they resected the tumor through the laparoscopic view. Retrieved tissues were extracted through the 12-mm trocar. Privette et al. [3] and Sahm et al. [14] also reported a hybrid operation to resect the tumor after inserting a trocar into the stomach under an endoscopic view.

e stomach. Then, without intraoperative EGD, they resected the tumor through the laparoscopic view. Retrieved tissues were extracted through the 12-mm trocar. Privette et al. [3] and Sahm et al. [14] also reported a hybrid operation to resect the tumor after inserting a trocar into the stomach under an endoscopic view. In the present study, we performed intragastric resection of the endophytic mass located on the upper and mid portion of the stomach through a single umbilical hole without multiple gastric entry holes. The gastrostomy can be easily extended using the wound retractor. Thus, the resected specimen was extracted more safely and easily than when using other intragastric approaches in which the resected specimen was removed via the oral route or through a 12-mm laparoscopic trocar. Recently, laparoscopic and endoscopic cooperative surgery (LECS) has been accepted as a good treatment choice for gastric SMTs. This technique was also introduced by Tsujimoto et al. [15] as a hybrid operation using endoscopic submucosal dissection and laparoscopic resection. It is obvious that LECS has several advantages in terms of exact identification of the tumor location and facilitating the minimum gastric resection. But LECS needs an experienced endoscopist and takes longer operative time (157.0 ± 68.4 minutes) than our intragastric approach.

al dissection and laparoscopic resection. It is obvious that LECS has several advantages in terms of exact identification of the tumor location and facilitating the minimum gastric resection. But LECS needs an experienced endoscopist and takes longer operative time (157.0 ± 68.4 minutes) than our intragastric approach. We could perform meticulous resection without intraoperative EGD under the good laparoscopic view, preserving normal gastric tissue like LECS. This simplicity-avoiding intraoperative EGD and closing the single gastrostomy without additional trocars-helps decrease the operating time. Also, the small skin incision provides a better cosmetic effect by maintaining the natural fold of the umbilicus. The mean operating time was 68.6 ± 12.0 minutes, which is not significantly different from that required for our open gastric wedge resection, reported elsewhere (62.7 ± 14.0 minutes) [16]. It is also acceptable result compared to other conventional exogastric wedge resection. In an analysis of the operating time for the individual cases, we were unable to confirm a significant correlation of the surgeon's experience with the length of the operation, which ranged between approximately 40 and 80 minutes. This finding indicates that our intragastric resection is an accessible technique that can be performed without a learning curve if the operator has some experience with laparoscopic surgery.

correlation of the surgeon's experience with the length of the operation, which ranged between approximately 40 and 80 minutes. This finding indicates that our intragastric resection is an accessible technique that can be performed without a learning curve if the operator has some experience with laparoscopic surgery. The pathology reports showed that the tumors were GISTs in sixteen cases, leiomyomas in two, schwannoma in one and others in two. There were no recurrences during the mean 19-month follow-up period. However, long-term follow-up is needed to confirm disease progress because the patient data did include some high-risk tumors according to the National Institute of Health classification and stage IIIB tumors according to AJCC staging. Postoperative intragastric bleeding occurred in two patients, who recovered after preventive blood transfusion with no other specific intervention. Lesser and greater curvature of stomach have high vascularity which can lead to postoperative bleeding, however, the all bleeding complications in our study occurred on fundus during the early operative period. Although postoperative intragastric bleeding may be often minor complication not to progress to fatal course, if it is concerned, hemostasis with electrocautery, metal clipping or suture on resection line is enough to prevent them. Actually, there was no further bleeding complication after we performed such meticulous manipulations.

perative intragastric bleeding may be often minor complication not to progress to fatal course, if it is concerned, hemostasis with electrocautery, metal clipping or suture on resection line is enough to prevent them. Actually, there was no further bleeding complication after we performed such meticulous manipulations. Although there was some conflict between laparoscopic instruments in the narrow operative field-a characteristic of single-port surgery-we were able to perform singleport laparoscopic surgery comfortably without additional instruments. If forceps that enabled articulation were available, we could perform an easier, safer operation. As it is easy to damage the gastric mucosa by the forceps because of the narrow operative field, cautious manipulation is required under a direct visual field. A mean of 2.2 ± 0.9 laparoscopic linear staplers were used, indicating little difference from the number used during conventional exogastric wedge resection. If tumor traction was easy or the tumor base was not wide, we could resect the tumor without difficulty using one or two laparoscopic linear staplers. If not, we needed more.

2 ± 0.9 laparoscopic linear staplers were used, indicating little difference from the number used during conventional exogastric wedge resection. If tumor traction was easy or the tumor base was not wide, we could resect the tumor without difficulty using one or two laparoscopic linear staplers. If not, we needed more. The single-port method in this study did not require pneumoperitoneum to explore the abdominal cavity because of direct gastric inflation with carbon dioxide gas. Tagaya et al. [17] introduced a jejunal clamping method with bowel clamp forceps and inserted a balloon catheter orally into the duodenum to prevent gaseous distension of the intestine during an intragastric approach. Our patients did not experience any complications related to postoperative intestinal gas after pneumoperitoneum of 12 mmHg. If this is a concern, it may be sufficient to insert a Levin tube for a day after the operation.

into the duodenum to prevent gaseous distension of the intestine during an intragastric approach. Our patients did not experience any complications related to postoperative intestinal gas after pneumoperitoneum of 12 mmHg. If this is a concern, it may be sufficient to insert a Levin tube for a day after the operation. The study has some limitations. First, there were no large endophytic gastric SMTs. The mean tumor size was 2.4 cm (range, 1.0-4.4 cm). Large tumors were excluded from this study because of the difficulty of manipulating them and the risk of tumor rupture. In the Japanese Clinical Practice Guideline, gastric SMTs < 5 cm are included in the indications for laparoscopic surgery [18]. Hence, we used the cutoff of tumors ≥ 5 cm because we had no experience with them regarding intragastric resection. Although excellent longterm survivals are reported for patients with relatively large gastric SMTs, there is still a lack of long-term survival reported after intragastric resection. Thus, a judicious approach was needed. The second limitation is the location of the tumor. Our procedure was valuable for resecting endophytic tumors located on the esophagogastric junction, gastric fundus, and body.

large gastric SMTs, there is still a lack of long-term survival reported after intragastric resection. Thus, a judicious approach was needed. The second limitation is the location of the tumor. Our procedure was valuable for resecting endophytic tumors located on the esophagogastric junction, gastric fundus, and body. The cases in which surgery was performed on the angle and antrum of the stomach (not included in this study) posed several tiresome problems, such as extreme narrowing of the operative field or limited articulation of the linear stapler caused by the gastric structure. These restrictions made the procedure more difficult. Therefore, we think that a different approach should be attempted for lesions distal to the gastric angle. Also, as the gastrostomy is made on the gastric anterior wall, all laparoscopic instruments were controlled in the direction from the anterior wall to the posterior wall of the stomach. Therefore, this procedure would not be appropriate for an anterior tumor that is not high-lying. We think that the eversion technique, suggested by Hyung et al. [19], is more effective for these tumors. Single-incision intragastric resection is feasible and safe procedure. It is especially efficient for removing small endophytic gastric SMTs located in the upper and mid portion of the stomach. Despite the small number of cases and lack of long-term follow-up data in our study, this procedure may be one of good treatment option for gastric SMTs, we think.

n is feasible and safe procedure. It is especially efficient for removing small endophytic gastric SMTs located in the upper and mid portion of the stomach. Despite the small number of cases and lack of long-term follow-up data in our study, this procedure may be one of good treatment option for gastric SMTs, we think. ACKNOWLEDGEMENTS This study was supported by a grant (0920050) from the National R&D Program for Cancer Control, Ministry for Health, Welfare, and Family Affairs, Republic of Korea. No potential conflict of interest relevant to this article was reported. Fig. 1 Umbilical incision. Fig. 2 (A) Gastric incision after inserting first wound retractor. (B) Pulling the stomach down by grasping with Babcock forcep. Fig. 3 (A) Single port with glove, trocar, and wound retractor. (B) Illustration of single port application. Fig. 4 (A) Endophytic mass was located at the apex of the fundus of the stomach. (B) Laparoscopic linear stapler was applied to the tumor. Tagging sutures were applied to pull up the tumor. (C) Remaining mass was resected with the second laparoscopic linear stapler. This procedure can be performed more easily through proper articulation of the stapler and tumor traction. (D) Resection line is observed. Bleeding control can be performed with sutures or electrocautery. Fig. 5 Distribution of submucosal tumors in various portions of the stomach. The number in each circle indicates the frequency. EGJ, esophagogastric junction; UB, upper body; LC, lesser curvature; PW, posterior wall; LB, lower body; E, esophagus; S, stomach; D, duodenum.

Fig. 4 (A) Endophytic mass was located at the apex of the fundus of the stomach. (B) Laparoscopic linear stapler was applied to the tumor. Tagging sutures were applied to pull up the tumor. (C) Remaining mass was resected with the second laparoscopic linear stapler. This procedure can be performed more easily through proper articulation of the stapler and tumor traction. (D) Resection line is observed. Bleeding control can be performed with sutures or electrocautery. Fig. 5 Distribution of submucosal tumors in various portions of the stomach. The number in each circle indicates the frequency. EGJ, esophagogastric junction; UB, upper body; LC, lesser curvature; PW, posterior wall; LB, lower body; E, esophagus; S, stomach; D, duodenum. Table 1 Patient demographics and clinicophathologic data (all patients) BMI, body mass index; NIH, National Institute of Health; AJCC, American Joint Committee on Cancer; EGJ, esophagogastric junction; N/A, not applicable; UB, upper body; LC, lesser curvature; PW, posterior wall; LB, lower body; GIST, gastrointestinal stromal tumor. Table 2 Perioperative data Values are presented as mean±standard deviation or number. SOW, sips of water. a)All cases were given a transfusion.

INTRODUCTION Surgical site infection (SSI) is still a frequent type of nosocomial infection, accounting for about 15% of the total number of nosocomial infections [1]. More specifically, it is reported that 4%-17% of midline laparotomy patients suffer from SSI [2,3]. Although many people underestimate SSI as something of minimal importance during wound healing, SSI may generate psychological, physical and financial stress to patients, and in some cases, even pose as a threat to their lives [4,5]. There have been strong efforts to reduce the rate of SSI. One of the major breakthroughs in SSI research is the appropriate use of antibiotics before and after operation [6]. As the use of prophylactic antibiotics has recently been proven to be effective in preventing SSI, these drugs are widely and increasingly used, and have contributed to decreasing the incidence of SSI along with the help of improved medical technology [7]. Despite the reduced rate of SSIs thanks to the proper utilization of antibiotics, many patients still suffer from SSIs. In recent years, in attempts to further reduce SSIs, researchers took a topical approach with a new focus on incisions. As most postoperative SSIs occur in incised areas [5], there have been several studies on using sutures coated with antibiotic materials. As a result, a triclosan-coated suture (Vicryl Plus, Ethicon Inc., Somerville, NJ, USA), which is antibacterial, was developed. Although the antibiotic effect of Vicryl Plus has been reported and recognized through in vitro experiments and animal testing [8,9], research studies involving human subjects have not been sufficient to make a case. Past studies with humans have mostly investigated different types of operations or involved a small number of subjects, making them insufficient to prove the efficacy of the sutures [10,11,12].

vitro experiments and animal testing [8,9], research studies involving human subjects have not been sufficient to make a case. Past studies with humans have mostly investigated different types of operations or involved a small number of subjects, making them insufficient to prove the efficacy of the sutures [10,11,12]. Gastric cancer surgery is one of the most frequently performed surgeries in Korea [13]. According to the classification of surgery wounds from the US Centers for Disease Control and Prevention (CDC), gastric cancer surgery falls into class II (clean-contaminated). In typical class II surgeries, SSI rates are reportedly 5%-15% [5,6]. In the case of a planned and prepared gastrectomy (i.e., laparotomy), the rate remarkably drops to lower than 5%. However, for cancer patients who suffer from SSIs, the infection can cause them more serious psychological and financial damage than it does to patients with other diseases, and can delay postoperative adjuvant therapy, bringing deadly outcomes to patients. In this light, researchers of this study took an objective approach to find the efficacy of triclosan-coated sutures in SSI after gastric cancer surgery via midline laparotomy, a commonly performed procedure in Korea.

Gastric cancer surgery is one of the most frequently performed surgeries in Korea [13]. According to the classification of surgery wounds from the US Centers for Disease Control and Prevention (CDC), gastric cancer surgery falls into class II (clean-contaminated). In typical class II surgeries, SSI rates are reportedly 5%-15% [5,6]. In the case of a planned and prepared gastrectomy (i.e., laparotomy), the rate remarkably drops to lower than 5%. However, for cancer patients who suffer from SSIs, the infection can cause them more serious psychological and financial damage than it does to patients with other diseases, and can delay postoperative adjuvant therapy, bringing deadly outcomes to patients. In this light, researchers of this study took an objective approach to find the efficacy of triclosan-coated sutures in SSI after gastric cancer surgery via midline laparotomy, a commonly performed procedure in Korea. METHODS Study group This prospective study enrolled a total of 916 patients who underwent curative radical gastrectomy for the treatment of gastric cancer at the Samsung Medical Center from December 2009 to September 2011. The number of target subjects was calculated based on the data released by the Korean Nosocomial Infection Surveillance System (KONIS); the overall rate of SSI in gastric surgery was about 4% according to the data [14]. The SSI rate of equivalence was expected on postoperative day 30, and the sample size of 825 patients was calculated with ±1.4% width of 95% confidence interval (CI). This number was increased to 916 patients in this study, taking into account an estimated rate of 10% loss of patients in screening.

ng to the data [14]. The SSI rate of equivalence was expected on postoperative day 30, and the sample size of 825 patients was calculated with ±1.4% width of 95% confidence interval (CI). This number was increased to 916 patients in this study, taking into account an estimated rate of 10% loss of patients in screening. Surgeries were performed by five experienced surgeons, who reached an agreement (protocol) on how to suture the abdominal wound. SSIs were detected through surveillance until day 30. The study was deliberated by the executive office of Institutional Review Board of Samsung Medical Center. All subjects participated in the study with prior written consent. Patients 18 years of age or older who were planning to receive surgery after being diagnosed with gastric cancer were eligible for enrollment. All patients were treated in compliance with the critical pathway (CP) of the hospital before and after the operation. According to the standards of the CP, patients received bowel preparation on the last day before the operation and were administered prophylactic antibiotics on the day of the operation and the next day after the operation. Cafotetan-the 2nd generation cephalosporin-was used as the prophylactic antibiotic. It was only injected once within one hour and once within 24 hours after the operation, in accordance with the guidelines of the US National Surgical Infection Prevention.

n the day of the operation and the next day after the operation. Cafotetan-the 2nd generation cephalosporin-was used as the prophylactic antibiotic. It was only injected once within one hour and once within 24 hours after the operation, in accordance with the guidelines of the US National Surgical Infection Prevention. The following cases were excluded from the study: (1) patients with wounds infected before the operation; (2) those who had to take other antibiotics during the follow-up period; (3) those with systemic diseases which might interfere with the clinician's judgment of the results of the clinical study (American Society of Anesthesiologists [ASA] score > 3); (4) those who were difficult to follow up; (5) those with a past medical history of abdominal surgery; and (6) those in whom the abdominal wound was closed by a different method other than the agreed technique.

cian's judgment of the results of the clinical study (American Society of Anesthesiologists [ASA] score > 3); (4) those who were difficult to follow up; (5) those with a past medical history of abdominal surgery; and (6) those in whom the abdominal wound was closed by a different method other than the agreed technique. Operative technique Prophylactic antibiotics were administered to all patients within one hour after the start of the operation. Surgical areas were shaved just before the operation only in required cases and were aseptically scrubbed with chlorhexidine (5%, soap). For the skin, an upper midline laparotomy was made with a scalpel, and the other layers down to the peritoneal cavity were incised by diathermy. During gastric cancer surgery, gentle handling was needed to prevent wounds from being infected by bowel contents. Triclosan-coated sutures (Vicryl Plus) were used to close the wound by a two-layer and a continuous technique. In doing so, interrupted sutures at the intervals of 3 to 5 cm helped to prevent continuous sutures from being weakened or from breaking. The skin, after stapling, was covered with an aseptic dressing. Prophylactic antibiotics were administered once more within 24 hours after the completion of surgery, while analgesics by intravenous injection were administered for a few days to reduce pain in the surgical area.

ures from being weakened or from breaking. The skin, after stapling, was covered with an aseptic dressing. Prophylactic antibiotics were administered once more within 24 hours after the completion of surgery, while analgesics by intravenous injection were administered for a few days to reduce pain in the surgical area. Data collection While patient-related factors including age, sex, weight, body mass index (BMI), smoking history, and underlying diseases were collected from past medical records or questionnaires during the preoperative period, surgery-related factors such as length of surgery, periods of hospitalization, SSI occurrence, and assessments of wound healing were collected prospectively.

weight, body mass index (BMI), smoking history, and underlying diseases were collected from past medical records or questionnaires during the preoperative period, surgery-related factors such as length of surgery, periods of hospitalization, SSI occurrence, and assessments of wound healing were collected prospectively. By definition, SSI is a type of infection that occurs in the surgical site within 30 days after operation or within one year if an implant is in place; SSI categorizes the infection into three groups (superficial and deep incisional SSIs and organspace SSI) according to the information from the US CDC [5]. The definition and classification of SSI are shown in Table 1. Patients in the present study were followed up postoperatively and observed up to day 30. In cases of poorly healed wounds and the presence of discharge for a long period, or in cases when proper antibiotics should have been used for treatment, bacterial cultivation was chosen. One of the major risk factors of SSIs is the National Nosocomial Infections Surveillance (NNIS) system risk index score. This index, which was developed by the CDC, predicts and scores the SSI risk for each type of surgery [15]. One point is given each to the case of an ASA score higher than 3, the case of wound class III and IV, and the case of surgery time longer than the standard time (T) for the type of surgery, making the total score in the range from 0 to 3. Standard surgery time is calculated based on the 75th percentile of the length of surgeries surveyed by NNIS for each type of surgery. For gastric surgery, the standard time is three hours. In this study, ASA scores ranged from 1 to 2, and all of patients fell into wound class II. Therefore, the NNIS risk index score was determined as either 0 or 1 in this cohort of patients.

entile of the length of surgeries surveyed by NNIS for each type of surgery. For gastric surgery, the standard time is three hours. In this study, ASA scores ranged from 1 to 2, and all of patients fell into wound class II. Therefore, the NNIS risk index score was determined as either 0 or 1 in this cohort of patients. For assessments of wound healing, the clinicians postoperatively evaluated erythema, edema, wound dehiscence, seroma, pus discharge, local heating and tenderness, which were recorded on each of the case report forms (answered with either "yes" or "no"). These results were reaffirmed by other surgeons to give objectivity. Efficacy outcomes The occurrence of SSI and assessments of wound healing were evaluated postoperatively by the clinicians and patients for a total of three times (on days 3, 7, and 30). Evaluation was made during hospitalization on days 3 and 7, and as an outpatient on day 30.

For assessments of wound healing, the clinicians postoperatively evaluated erythema, edema, wound dehiscence, seroma, pus discharge, local heating and tenderness, which were recorded on each of the case report forms (answered with either "yes" or "no"). These results were reaffirmed by other surgeons to give objectivity. Efficacy outcomes The occurrence of SSI and assessments of wound healing were evaluated postoperatively by the clinicians and patients for a total of three times (on days 3, 7, and 30). Evaluation was made during hospitalization on days 3 and 7, and as an outpatient on day 30. For the primary endpoint, we examined SSI rates up to day 30 after the operation. Evaluation was made under the categories of superficial and deep incisional SSIs and organspace SSI depending on the site and the extent of infection. When superficial and deep incisional SSIs were found together, they were categorized under deep incisional SSI. Thus, we postoperatively examined the number of infected patients and accumulated infection rates on days 3, 7, and 30 according to the SSI categorization. We also checked how the infected group and the noninfected group were associated with age, BMI, smoking history, existence of comorbidity, operation time, and length of hospital stay. As for the secondary endpoint, we examined the assessments of wound healing up to day 30 after the operation. For each variable of wound healing, frequency and accumulative rates were evaluated.

group were associated with age, BMI, smoking history, existence of comorbidity, operation time, and length of hospital stay. As for the secondary endpoint, we examined the assessments of wound healing up to day 30 after the operation. For each variable of wound healing, frequency and accumulative rates were evaluated. Statistical analysis For the subjects who were eliminated during the study, the Kaplan-Meier product limit method was used to calculate SSI rates and occurrence rates of wound healing variables. The cumulative occurrence rates until day 30 and 95% CI were calculated. In order to make comparisons between the group with infection and the group without infection, the Mann-Whitney test was applied for continuous variables, and the Fisher exact test for categorical variables. IBM SPSS Statistics ver. 20.0 (IBM Co., Armonk, NY, USA) was used for data analysis, and a significance level of 0.05 was used. RESULTS Patients The intention and purpose of this study were explained to the patients scheduled for gastric cancer surgery. The patients who voluntarily agreed to participate were collected for the study. Of the 916 patients, 122 were excluded by screening, and the remaining 794 patients were enrolled in the study. During postoperative surveillance on days 3, 7, and 30, eight patients dropped out (Table 2, Fig. 1).

r gastric cancer surgery. The patients who voluntarily agreed to participate were collected for the study. Of the 916 patients, 122 were excluded by screening, and the remaining 794 patients were enrolled in the study. During postoperative surveillance on days 3, 7, and 30, eight patients dropped out (Table 2, Fig. 1). Wound infections SSIs started to occur after postoperative day 3, and the cumulative number of infected patients until day 30 was 11. Out of the 11 patients, the numbers for the categories of superficial and deep incisional SSIs and organ-space SSI were 8, 2, and 1, respectively. In terms of surgery time of each category, there was no apparent association with infection, while the length of hospitalization was found to be longer in the infected group (Table 3). The cumulative infection rates for the superficial and deep incisional SSIs and organ-space SSIs were 1.01%, 0.25%, and 0.13%, respectively. Therefore, the total cumulative infection rate was 1.39% (95% CI, 0.77-2.50) (Table 4). Most of the ten patients with superficial and deep incisional SSIs were clinically diagnosed as they exhibited symptoms including pus, erythema, pain and fever. Meanwhile, one patient with organspace SSI was diagnosed by computerized tomography as the patient was suspected of intra-abdominal infection through the surgical site. Bacteria were cultivated from four patients among those with SSIs. As a result, causative organisms were isolated from two patients. Most patients improved through conservative treatment, while two patients with deep incisional SSI improved after second surgery for fascial defect.

l infection through the surgical site. Bacteria were cultivated from four patients among those with SSIs. As a result, causative organisms were isolated from two patients. Most patients improved through conservative treatment, while two patients with deep incisional SSI improved after second surgery for fascial defect. After examining whether the groups with and without infection were associated with demographic and clinical factors, we found no statistical significance with age, BMI, smoking history, existence of comorbidity, operation time and NNIS risk factors, while there was a significant difference with the length of hospital stay (16.6 ± 7.1 days vs. 11.8 ± 2.1 days, P = 0.004) (Table 5).

tual cases of SSI occurrence, except for purulent discharge. In patients suspected of SSI with signs such as tenderness, edema, erythema, or heating, the surgeons temporarily opened the incised area to check whether it was true or not. In those cases, most patients had noninfective fluid such as seroma or fat necrosis. Adverse events In this clinical study, a total of eight patients (0.87%) had adverse symptoms, four in postoperative day 3 and four during the surveillance period between day 3 and day 30, and they dropped-out from the study. These eight subjects required other antibiotics and additional treatment due to significant adverse symptoms, and had to be hospitalized for a longer time. Of the eight patients, six had respiratory problems such as atelectasis, pleural effusion and pneumonia, while two had noncomplicated fluid collection in the intra-abdominal cavity after the operation. However, all of these symptoms were caused by general anesthesia or gastrectomy. No symptom was directly related to triclosan-coated sutures. DISCUSSION Poor wound healing and SSI are among the most common complications of laparotomy. These are critical issues, as they not only increase medical costs due to the need of additional wound healing and antibiotics along with longer hospitalization, but also result in higher morbidity rates and death rates for high-risk patients [4,16]. In this regard, the focus of the present study was on the effect of triclosan-coated suture (Vicryl Plus) on SSIs and wound healing when it was used for abdominal suturing in gastric cancer surgery.

ong with longer hospitalization, but also result in higher morbidity rates and death rates for high-risk patients [4,16]. In this regard, the focus of the present study was on the effect of triclosan-coated suture (Vicryl Plus) on SSIs and wound healing when it was used for abdominal suturing in gastric cancer surgery. SSI is influenced by many intrinsic and extrinsic factors [4,5,15]. Patient related factors include age, sex, BMI, existence of comorbidity, medical history and habits (e.g., smoking). In addition, factors regarding surgery are depilation, skin sterilization, ventilation of the operation room, operation time, refined and aseptic operative techniques, and the proper use of antibiotics. As it is difficult to modify or standardize patient-related factors, past clinical studies on how to reduce SSIs have mainly been focused on surgery-related factors. One of the most frequently used methods involves the use of triclosan-coated sutures. There have been studies on sutures and SSI occurrence over the past several years. Sutures are known to increase the susceptibility of organs to infection and carry bacteria to surgical areas [17,18]. In other words, if bacteria, that are attached to the surface of the suture, first cause contamination, the local defense mechanisms of the surgical area will break down [19]. Precisely speaking, it is not the suture that causes infection. However, as bacteria can gather and proliferate on the suture, even a small number of bacteria on the suture is capable of causing infection [20]. For this reason, studies on antimicrobial sutures have been done in an effort to prevent sutures from causing infection. The study on the effect of triclosan-coated sutures on infections through in vitro experiements and animal testing found that triclosan-coated sutures were very effective in preventing bacteria from attaching to the suture [8,18]. Also, some recent clinical studies have reported that the antimicrobial coating of the suture helped to reduce postoperative inflammatory reactions and assisted in the wound healing process [21].

testing found that triclosan-coated sutures were very effective in preventing bacteria from attaching to the suture [8,18]. Also, some recent clinical studies have reported that the antimicrobial coating of the suture helped to reduce postoperative inflammatory reactions and assisted in the wound healing process [21]. This study was an investigator-driven prospective study, performed at a single center-Samsung Medical Center. Accordingly, every process starting from collection of patients and surgery to pre- and postoperative procedures was compiled with the protocol to obtain more objective SSI rates for the use of triclosan-coated sutures in midline laparotomy. As all the study participants were diagnosed with the same disease-gastric cancer-and had the NNIS risk index score in the range from 0 to 1, confounding variables were kept to a minimum in this study, which gave more reliability to the results of the SSI rates. Past studies indicated that SSIs increased the rate of morbidity, the length of hospitalization and, consequently, economic damages [16,22]. In this study, the increase of the length of hospitalization was found to be statistically significant in the group with infection and thought to result in financial losses. Not only that, but hospitals will have a lower inpatient turnover ratio and patients will lose working days (decreased productivity). So consequently, massive additional social costs can be incurred because of SSIs.

d to be statistically significant in the group with infection and thought to result in financial losses. Not only that, but hospitals will have a lower inpatient turnover ratio and patients will lose working days (decreased productivity). So consequently, massive additional social costs can be incurred because of SSIs. Although purulent drainage, bacterial culture and signs of infection (fever, pain or tenderness, swelling, redness and heating sense) are important in making a diagnosis of SSI, perceptive and accurate observation of them by a clinician is crucial. Therefore, diagnoses of SSI were reconfirmed by two more clinicians when it was uncertain. The results of this study indicated that the only single assessment (erythema, edema, wound dehiscence, seroma, local heating, and tenderness) had no direct association with SSIs, except for purulent discharge. As diagnosis by a clinician appears to be critical, surgeons should have enough knowledge and experience to be able to detect SSIs correctly. As a result of this study, because most SSIs were superficial and occurred between day 3 and day 7 after surgery, early detection and treatment of SSIs are considered really important.

gnosis by a clinician appears to be critical, surgeons should have enough knowledge and experience to be able to detect SSIs correctly. As a result of this study, because most SSIs were superficial and occurred between day 3 and day 7 after surgery, early detection and treatment of SSIs are considered really important. This prospective study had certain limitations. The biggest limitation is the one-armed study design. Nevertheless, our results are still significant as a preliminary study revealing that SSI rates using triclosan-coated sutures were greatly decreased to 1.39% in gastric cancer patients, compared with the historical data. Although this study can be shown to have better results than other studies due to low NNIS risk index scores of enrolled patients, the results of this study appear to be encouraging, especially when compared to the national reports such as NNIS and KONIS, in which the SSI rates of gastric surgery ranged from about 2.5% to 6.4% in the same NNIS scores [14,15]. Another limitation was the relatively small number of patients with infection, compared to the number of patients without infection, which made it difficult to perform a statistical analysis. Also, because the study relied too much on clinical diagnosis in patients with infection or those suspected of infection, the frequency of bacterial cultivation was low, and thus objective data from analysis of causative organisms, for example, were not sufficiently obtained. Although there are the aforementioned limitations in our study, those results are considered reliable and valuable because of the standardization of diseases and operative procedures in a relatively large number of patients together with the prospective trial.

ive organisms, for example, were not sufficiently obtained. Although there are the aforementioned limitations in our study, those results are considered reliable and valuable because of the standardization of diseases and operative procedures in a relatively large number of patients together with the prospective trial. We believe that this study presented an achievement by confirming that the use of triclosan-coated sutures (Vicryl Plus) in midline laparotomy can reduce SSIs. Triclosan-coated sutures may be one of the most effective antimicrobial agents developed to date and they are expected to greatly contribute to decreasing SSIs if combined with refined and aseptic surgery techniques and the proper use of prophylactic antibiotics. Furthermore, more studies are required to find the exact mechanisms between sutures and wound healing. Also, a wider range of studies on sutures will be needed due to the possibility of emergence of antimicrobial resistant bacteria in the future. In summary, this study shows that the use of triclosan-coated sutures for abdominal wall closure can reduce the number of SSIs in gastric cancer surgery. This might help to decrease the length of hospital stay for patients undergoing gastric cancer surgery. No potential conflict of interest relevant to this article was reported. Fig. 1 Flow chart of patients through the study. Table 1 Definition and classification of surgical site infection SSI, surgical site infection. Table 2 Demographics and medical history of 794 patients Values are presented as mean ± standard deviation or number (%).

No potential conflict of interest relevant to this article was reported. Fig. 1 Flow chart of patients through the study. Table 1 Definition and classification of surgical site infection SSI, surgical site infection. Table 2 Demographics and medical history of 794 patients Values are presented as mean ± standard deviation or number (%). Table 3 Frequency of surgical site infection and clinical data, according to type of infection (n = 794) Values are presented as mean ± standard deviation or number. SSI, surgical site infection; op., operation. a)The data are number of infected patients, excluding duplicated cases, on days 7, 30. Table 4 Cumulative surgical site infection rates during follow-up period, according to type of infection (n = 794) CI, confidence interval; SSI, surgical site infection. a)There was no infected patient in postoperative day 3. b)The total number of infected patients. Table 5 Comparable data between infected and noninfected group Values are presented as mean ± standard deviation or number (%). T75, 75th percentile of the average duration for the procedure, 3 hours for gastric surgery; NNIS, National Nosocomial infections Surveillance System. a)Comorbidity includes one or more of the diabetes, cardiovascular, and pulmonary disease. b)Duration of operation > T75 means NNIS risk index is one point. c)P-values are based on the Fisher exact test or Mann-Whitney test. Table 6 Incidence rates and actual occurrences of SSI for assessments of wound healing (n = 794) SSI, surgical site infection; CI, confidence intervals.

a)Comorbidity includes one or more of the diabetes, cardiovascular, and pulmonary disease. b)Duration of operation > T75 means NNIS risk index is one point. c)P-values are based on the Fisher exact test or Mann-Whitney test. Table 6 Incidence rates and actual occurrences of SSI for assessments of wound healing (n = 794) SSI, surgical site infection; CI, confidence intervals. a)The cases of temporarily opened were included. b)The data were expressed as an incidence (%) of actual infection in each of the wound healing assessments.

INTRODUCTION Many nations have been attempting to improve the management of patients with severe trauma, the main cause of death for young people worldwide [1]. It is well known that the mortality rate of severe trauma patients who are treated in specialized trauma centers equipped with a highly qualified trauma team and medical devices is significantly lower than that of patients treated in nontrauma centers [2,3]. In addition to being equipped with hardware, specialized trauma centers use effective and rapid management techniques, such as trauma team activation (TTA). TTA is initiated by some criteria and enable trauma surgeons (TSs) to perform a multidisciplinary approach [4,5,6,7]. Although the effects of use of TTA are tremendous, there is no best TTA protocol. Each trauma center must develop its own TTA protocol because the circumstances of each trauma center are unique.

(TTA). TTA is initiated by some criteria and enable trauma surgeons (TSs) to perform a multidisciplinary approach [4,5,6,7]. Although the effects of use of TTA are tremendous, there is no best TTA protocol. Each trauma center must develop its own TTA protocol because the circumstances of each trauma center are unique. Abdominal organs are vulnerable to trauma because of the lack of protection provided by bony structures. Some patients with major abdominal trauma develop life-threatening conditions that cause death. Accordingly, timely arrest of uncontrolled hemorrhage and control of contamination is clinically important for better results. Based on this knowledge, our hospital formed a trauma team and developed modified TTA criteria based on our unique circumstances. In addition, in 2012 two surgeons were designated to perform emergency laparotomy for major abdominal trauma exclusively, and have been doing so since. The goals of these actions are to shorten the time interval between emergency room (ER) arrival and definitive surgery and improve trauma intensive care unit management and overall outcomes. The purpose of this study was to evaluate the short-term outcomes of use of new TTA and the effectiveness of appointing a designated TS in the management of major trauma patients who underwent exploratory laparotomy.

arrival and definitive surgery and improve trauma intensive care unit management and overall outcomes. The purpose of this study was to evaluate the short-term outcomes of use of new TTA and the effectiveness of appointing a designated TS in the management of major trauma patients who underwent exploratory laparotomy. METHODS The medical records of trauma patients treated by the old TTA protocol (OT), which had been used from October 2010 to February 2012, and the new TTA protocol (NT), which had been used from March 2012 to August 2013, respectively, were retrospectively reviewed. Cases of prehospital death and of transfer to other hospitals were excluded from the analysis. The trauma team is composed of five emergency medicine (EM) physicians, two general surgeons whose subspecialty is hepatobiliary and vascular surgery, respectively, two cardiovascular surgeons, two neurosurgeons, and two anesthesiologists.

spital death and of transfer to other hospitals were excluded from the analysis. The trauma team is composed of five emergency medicine (EM) physicians, two general surgeons whose subspecialty is hepatobiliary and vascular surgery, respectively, two cardiovascular surgeons, two neurosurgeons, and two anesthesiologists. The main differences between OT and NT are the criteria of activation. Previously, an EM physician called the residents of each department according to the organ of injury, which was identified mainly by observation of patient symptoms and signs and focused assessment with sonography for trauma or CT. NT was developed according to the simplified criteria for TTA based on the field triage decision scheme outlined by American College of Surgeons Committee on Trauma [8]. NT is initiated very early in treatment based on assessment of vital signs, trauma mechanism, and injury type (Table 1). When a patient who meets the NT criteria arrives at the ER, Emergency Department resident initiates NT through the activation of electronic medical record (EMR) system. The EMR automatically texts data regarding the NT criteria, vital signs, mechanism of injury (MOI), and arrival time to three attending doctors-a general surgeon, a cardiovascular surgeon, and the trauma on-call neurosurgeon-who arrive at the ER within 15 minutes of receiving the text. After conducting a primary and secondary survey, the doctors decide on the necessity of performing preoperative CT scanning, which should be conducted within 30 minutes, and emergency surgery, which should be decided upon within 1 hour, at the ER.

urosurgeon-who arrive at the ER within 15 minutes of receiving the text. After conducting a primary and secondary survey, the doctors decide on the necessity of performing preoperative CT scanning, which should be conducted within 30 minutes, and emergency surgery, which should be decided upon within 1 hour, at the ER. The Chosun University Hospital Institutional Review Board approved this study, and the need to obtain informed consent was waived because of the study's retrospective nature. Statistical analysis was performed using IBM SPSS Statistics ver. 19.0 (IBM Co., Armonk, NY, USA). Comparisons between the two groups were performed using the Pearson chi-squared test and Student t-test and differences were considered statistically significant when P-value was less than 0.05.

dy's retrospective nature. Statistical analysis was performed using IBM SPSS Statistics ver. 19.0 (IBM Co., Armonk, NY, USA). Comparisons between the two groups were performed using the Pearson chi-squared test and Student t-test and differences were considered statistically significant when P-value was less than 0.05. RESULTS Of the 27,626 trauma patients admitted to the ER during the study period, 280 patients underwent exploratory laparotomy. Among them, 76 patients had an injury severity score (ISS) higher than 15. Thirty-five had been treated by OT and 41 by NT (Fig. 1). Of the 41 patients in the NT group, 32 were male. The mean age was 52.5 years. Thirty-eight had experienced blunt trauma, and 3 had experienced penetrating trauma. Twenty-seven had been transferred from the local hospital, and 14 had visited the ER primarily. Of the 38 patients who had undergone CT scanning in the local hospital, CT was reperformed in 18 patients (Table 2). Twelve had been traffic accident (TA) drivers, 5 TA motorcycle drivers, 3 TA passengers, 4 TA pedestrians, 1 TA cultivator (farm machine), and 1 TA bicyclist; 6 had been victims of physical assault; 5 had experienced falls; and 3 had experienced stab injuries. Nine had an injury in small intestine, 8 in liver, 6 in mesentery, 4 in spleen, 4 in blood vessel, 2 in pancreas and 1 in diaphragm, stomach, kidney, respectively (Table 3).

ltivator (farm machine), and 1 TA bicyclist; 6 had been victims of physical assault; 5 had experienced falls; and 3 had experienced stab injuries. Nine had an injury in small intestine, 8 in liver, 6 in mesentery, 4 in spleen, 4 in blood vessel, 2 in pancreas and 1 in diaphragm, stomach, kidney, respectively (Table 3). No statistically significant differences were found between the OT and NT groups regarding mean ISS, revised trauma score (RTS), Glasgow coma scale (GCS) score, systolic blood pressure, respiratory rate, and trauma and injury severity score (Table 4). The time interval between the accident and ER arrival, between ER arrival and CT scanning, between ER arrival and operating room (OR) presentation, and between the accident and OR presentation was found to be significantly shorter for the NT group compared to the OT group. The mean surgical duration for all patients was 198.6 minutes. Four combined operations were performed in each group. The mean ICU stay and hospital stay of all patients were 4.9 and 19.2 days, respectively. The mean mortality within 24 hours, within 1 month, and overall of all patients were 6%, 9%, and 9% respectively. Although use of NT was found to have decreased the time interval between ER arrival and OR presentation by 73 minutes and between accidents to OR presentation by 147 minutes, it was not found to yield any survival benefit compared to using OT (Table 5).

nth, and overall of all patients were 6%, 9%, and 9% respectively. Although use of NT was found to have decreased the time interval between ER arrival and OR presentation by 73 minutes and between accidents to OR presentation by 147 minutes, it was not found to yield any survival benefit compared to using OT (Table 5). DISCUSSION Use of TTA is considered a fundamental element in managing trauma patients, with a recent meta-analysis reporting a 15% reduction in mortality with the use of a trauma system [9]. While trauma centers use different activation methods and criteria, TTA notification is typically performed via light panel, beeper, or cell phone text. Many trauma centers are calling for modification of existing TTA protocol to achieve better outcomes. Such modification should be based on many revisions after short-term evaluation and in consideration of the resources available to provide trauma care. Compared to those in Western nations, most trauma centers in our nation have limited resources. The findings of this study regarding the short-term results of TTA modification are thus valuable, especially for trauma centers with resources similar to those of the hospital studied here.

available to provide trauma care. Compared to those in Western nations, most trauma centers in our nation have limited resources. The findings of this study regarding the short-term results of TTA modification are thus valuable, especially for trauma centers with resources similar to those of the hospital studied here. In the past, most TTA protocols were based on the organ of injury, the identification of which is confirmed mainly by CT scanning. While use of this anatomic indicator has improved the accuracy of major trauma activation and resulted in more cost-efficient resource use in terms of deployment of surgeons and other staff and use of the OR [10], it requires considerable time. Specifically, it requires that EM physicians decide which patients need CT scanning, which area of the body should be scanned, and which technique should be used to interpret the radiologic findings, and may require consultation with a radiologist. As TTA should be performed after completion of all these processes, it may result in the late involvement of the TS. As it is well known that early presence of a TS on the trauma team reduces resuscitation time and time to incision for emergency operations [11], many trauma centers are changing TTA protocol to promote earlier involvement of the TS. For this purpose, many current TTA protocols are based on more objective and simple criteria, such as presence of unstable vital signs, advanced age, GCS, MOI, and laboratory parameters.

me to incision for emergency operations [11], many trauma centers are changing TTA protocol to promote earlier involvement of the TS. For this purpose, many current TTA protocols are based on more objective and simple criteria, such as presence of unstable vital signs, advanced age, GCS, MOI, and laboratory parameters. The most commonly used simple TTA indicator is systolic hypotension, which has been found to be a valid indicator for TTA. One study of patients with prehospital hypotension found that nearly 50% required operative intervention and an additional 25% required ICU admission [12]. Advanced age may also be a TTA criterion, as elderly trauma patients, even those with minor or moderately severe injuries, have been found to have high mortality. Nevertheless, a significant number of elderly patients with severe injuries do not meet the standard criteria for TTA. It is thus suggested that age 70 years and over alone should be a criterion for TTA [13]. Prehospital GCS score is a reliable parameter for predicting hospital admission after motor vehicle collision (MVC). When obvious indicators, such as hypoxemia, multiple long bone fractures, or focal neurologic deficits, for TTA are lacking, prehospital GCS score may be used [14]. MOI has also been suggested for use as a criterion, regardless of physiologic indicators [15]. Use of these simple indicators may enable initiation of TTA earlier and more objectively such that even non-physicians can perform it [16].

cal neurologic deficits, for TTA are lacking, prehospital GCS score may be used [14]. MOI has also been suggested for use as a criterion, regardless of physiologic indicators [15]. Use of these simple indicators may enable initiation of TTA earlier and more objectively such that even non-physicians can perform it [16]. As expected, use of NT based on these simple criteria was found to have resulted in earlier TTA initiation and reduction in the time interval between ER arrival and CT scanning compared to use of OT compared to that reported by a study of TTA in a trauma center conducted at another university hospital in our nation, the time to CT scanning and emergency surgery was found to be statistically significantly shorter in the current study (Table 6) [17,18]. Moreover, use of NT was found to have decreased the time interval between ER arrival and emergency operation by 73 minutes compared to use of OT. However, use of NT was not found to have improved patient outcomes compared to use of OT. ICU stay, hospital stay, mortality within 24 hours, mortality within one month, and overall mortality found not have been improved at a statistically significant level (Table 6). These findings may be results of the heterogeneity of MOI, injured abdominal organs, accompanying injuries, and type of surgery between two groups. In particular, we enrolled the cases of abdominal injury requiring exploratory laparotomy only. We expect the outcomes of TTA would be better if we compared the results prospectively with the same study period and better design. Although use of NT was found to have decreased the time interval between ER arrivals and OR presentation, this interval is still longer than that of Western and Japanese trauma centers. This delay is not due to TTA defects but rather lack of trauma resources, such as on-call trauma surgeons, spare anesthesiologists, and OR availability. This delay thus cannot be reduced without incurring high costs, such as by hiring additional TS and increasing the number of ORs and trauma coordinators. However, hospitals unable to incur such costs may aim to decrease the interfacility transport time. Recently, the Ministry of Health and Welfare designated 35 major trauma-specified centers (MTSCs) and prepared a budget for preparing the trauma care resources. However, many teaching hospitals failed to be designated, as they can use the TTA protocols of MTSCs but cannot prepare the trauma resources necessary for designation.

, the Ministry of Health and Welfare designated 35 major trauma-specified centers (MTSCs) and prepared a budget for preparing the trauma care resources. However, many teaching hospitals failed to be designated, as they can use the TTA protocols of MTSCs but cannot prepare the trauma resources necessary for designation. Non-MTSCs need to develop effective interfacility transfer protocols in order to improve the nationwide outcomes of trauma patients [19]. While it is difficult to define the ideal time interval between ER arrival and emergency surgery, Western trauma centers generally define it as within 2 hours. A study of the Royal London Hospital found that the mean duration from ER arrival to emergency surgery was 56 minutes for blunt trauma and 37 minutes for penetrating trauma [20]. Another study using American College of Surgeons audit filters found that performance of laparotomy more than 2 hours after admission resulted in increased mortality and longer ICU and hospital stay [21]. This study faced several limitations that should be considered when reviewing the findings. First, the cohorts examined had different time period and resultant heterogeneity. Second, the long-term outcome after hospital discharge was not examined. Third, compared to use of anatomic indicators, use of simple TTA criteria poses the risk of over-triage. Although it is important issue regarding interfacility referral, the extent of over-triage was not examined. ACKNOWLEDGEMENTS Present study was supported by grants from the Clinical Medicine Research Institute at Chosun University Hospital, 2012.

This study faced several limitations that should be considered when reviewing the findings. First, the cohorts examined had different time period and resultant heterogeneity. Second, the long-term outcome after hospital discharge was not examined. Third, compared to use of anatomic indicators, use of simple TTA criteria poses the risk of over-triage. Although it is important issue regarding interfacility referral, the extent of over-triage was not examined. ACKNOWLEDGEMENTS Present study was supported by grants from the Clinical Medicine Research Institute at Chosun University Hospital, 2012. No potential conflict of interest relevant to this article was reported. Fig. 1 Patient enrollment process. ER, emergency room; ISS, injury severity score; OT, old trauma team activation protocol; NT, new trauma team activation protocol. Table 1 Criteria for new trauma team activation Table 2 Patient demographics Values are presented as number (%) or mean ± standard deviation. OT, old trauma team activation protocol; NT, new trauma team activation protocol; ER, emergency room. Table 3 Mechanism of injury and organ of major injury OT, old trauma team activation protocol; NT, new trauma team activation protocol; TA, traffic accident; NS, not significant. Table 4 Injury and trauma severity scores and physiological indicators Values are presented as mean ± standard deviation.

OT, old trauma team activation protocol; NT, new trauma team activation protocol; ER, emergency room. Table 3 Mechanism of injury and organ of major injury OT, old trauma team activation protocol; NT, new trauma team activation protocol; TA, traffic accident; NS, not significant. Table 4 Injury and trauma severity scores and physiological indicators Values are presented as mean ± standard deviation. OT, old trauma team activation protocol; NT, new trauma team activation protocol; ISS, injury severity score; RTS, revised trauma score; GCS, Glasgow coma scale; SBP, systolic blood pressure; RR, respiratory rate; TRISS, trauma and injury severity score. Table 5 Patient outcomes Values are presented as mean ± standard deviation or number (%). OT, old trauma team activation protocol; NT, new trauma team activation protocol; ER, emergency room; OR, operative room. Table 6 Comparison of the effectiveness of trauma team activation protocol ICU, intensive care unit.

INTRODUCTION Although local anesthesia for inguinal hernia repair has been described since the beginning of the last century, it was not until the 1950s that the routine use of local anesthesia for inguinal herniorrhaphy gained acceptance [1]. As the method of operation has changed over time, the anesthesia method has also varied. Although past reports have provided evidence of the safety and efficacy of local anesthesia for hernia [2,3], it is not widely performed. Sanjay and Woodward [3] reported that only 15% of doctors in Wales, United Kingdom usually perform hernia operations using local anesthesia. However, many hernia centers have reported that most operations are performed under local anesthesia [4,5,6]. In some reports that were published in Korea, the reported rate of hernia surgery using local anesthesia varies widely, from 0% to 100% [7,8,9,10,11] (Table 1). Specifically, although local anesthesia was reported to be effective for pain and safety, most of the subjects in those studies were either patients who had risk associated with general anesthesia or spinal anesthesia or were elderly. However, the choice of anesthetic technique should be based on the type and extent of the surgical procedure, concomitant medical disease and the effects of anesthetic agents on organ function [12]. The aim of this study was to analyze the feasibility and safety of routine use of the tumescent local anesthetic (TLA) technique.

the choice of anesthetic technique should be based on the type and extent of the surgical procedure, concomitant medical disease and the effects of anesthetic agents on organ function [12]. The aim of this study was to analyze the feasibility and safety of routine use of the tumescent local anesthetic (TLA) technique. METHODS The medical records of 146 patients who had undergone inguinal hernia repair operation by single surgeon (D.G.S.) at Seoul Medical Center between September 2009 and December 2013 were retrospectively reviewed, and the data were compared with 47 inguinal hernia operations performed under spinal anesthesia between 2004 and 2008. There was no definite indication for local anesthesia during inguinal hernia surgery. However, relative contraindications of local anesthesia during inguinal hernia surgery were (1) age <20 years old, (2) suspected strangulation, (3) multiple recurring inguinal hernias, (4) lack of patient cooperation (patient refused local anesthesia or was physically or mentally unstable), (5) a need or plan for other combined surgery, and (6) lidocaine allergy or severely decreased liver function.

gery were (1) age <20 years old, (2) suspected strangulation, (3) multiple recurring inguinal hernias, (4) lack of patient cooperation (patient refused local anesthesia or was physically or mentally unstable), (5) a need or plan for other combined surgery, and (6) lidocaine allergy or severely decreased liver function. Tumescent local anesthesia infiltration technique: Infiltration anesthesia was performed by the surgeon with 1% lidocaine skin infiltration to achieve rapid local anesthesia at the incision line. A 5-cm transverse skin incision was made, and the skin was opened. A TLA solution (2% lidocaine 10 mL + 0.5% bupivacaine 10 mL + 0.1% epinephrine HCl 0.1 mL mixed with 80-mL normal saline made 100-mL TLA) was prepared just before surgery by the scrub nurse and injected from the subcutaneous tissue to the fascia layer after skin anesthesia. Then TLA solution was then injected step by step. Sedation was provided with small doses of midazolam. Intraoperative monitoring of heart rate and blood pressure and verbal contact between the patient and the surgeon were maintained during local anesthesia.

subcutaneous tissue to the fascia layer after skin anesthesia. Then TLA solution was then injected step by step. Sedation was provided with small doses of midazolam. Intraoperative monitoring of heart rate and blood pressure and verbal contact between the patient and the surgeon were maintained during local anesthesia. Operation technique used: standardized surgical techniques were used according to the type of hernia. A high ligation was only performed in six young patients. Six cases of Bassini repair were performed for small indirect hernias. Lichtenstein repairs were performed for medium to large indirect inguinal hernias in 112 cases. Ten cases of modified plug-mesh repair were performed for direct and pantaloon hernias. Twelve cases of modified Kugel patch repairs were performed for large direct inguinal hernias. The size of the hernia defect was measured according to the surgeon's fingertip width. (small hernia, less than the one fingertip width; medium, one to two fingertip width; large, more than two fingertip width). We reviewed the patients' clinical characteristics (age, body mass index, type of hernia, direction, operation type, symptom duration and comorbidity state) and operative results. We conducted telephone interviews to collect information about recurrence.

Operation technique used: standardized surgical techniques were used according to the type of hernia. A high ligation was only performed in six young patients. Six cases of Bassini repair were performed for small indirect hernias. Lichtenstein repairs were performed for medium to large indirect inguinal hernias in 112 cases. Ten cases of modified plug-mesh repair were performed for direct and pantaloon hernias. Twelve cases of modified Kugel patch repairs were performed for large direct inguinal hernias. The size of the hernia defect was measured according to the surgeon's fingertip width. (small hernia, less than the one fingertip width; medium, one to two fingertip width; large, more than two fingertip width). We reviewed the patients' clinical characteristics (age, body mass index, type of hernia, direction, operation type, symptom duration and comorbidity state) and operative results. We conducted telephone interviews to collect information about recurrence. Regarding the statistical analysis, continuous variables (age, body mass index [BMI], symptom duration) were dichotomized using the mean value of each variable. The chi-square test or Fisher exact test and independent 2-tailed t-tests were used to compare the clinicopathological parameters and surgical outcomes between the spinal anesthesia group and the local anesthesia group wherever appropriate. Values were expressed as the mean (standard deviation, SD) or median (range) as appropriate. Probabilities of less than 0.05 were considered significant. All the data collected from the database were analyzed using SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA).

group and the local anesthesia group wherever appropriate. Values were expressed as the mean (standard deviation, SD) or median (range) as appropriate. Probabilities of less than 0.05 were considered significant. All the data collected from the database were analyzed using SPSS ver. 12.0 (SPSS Inc., Chicago, IL, USA). RESULTS A total of 146 adult hernia patients with 157 hernia repairs were examined. Four operations were performed for recurrent hernias. There was no conversion from local anesthesia to spinal or general anesthesia. The mean age was 62.5 ± 17.4 years. Data related to the general characteristics of the hernia patients (age, gender, BMI, type of hernia, direction, symptom duration and comorbidity) are presented in Tables 2, 3. Among the 146 cases, 111 (76%) were indirect-type hernias, 78 (53.4%) were right side, and 57 (39%) were left side. The most common comorbidities were hypertension (52 patients, 35.6%), benign prostate hyperplasia (45 patients, 30.8%), constipation (32 patients, 21.9%), diabetes mellitus (16 patients, 11%) and chronic lung disease (15 patients, 10.2%). At a mean follow-up of 24 ± 14 months, there were four recurrences (2.5%) among the 146 patients. The success rate of telephone contact was 87.6% (128/146 cases). The other patients (28 cases) were reviewed only via their outpatient follow-up chart records.

patients, 11%) and chronic lung disease (15 patients, 10.2%). At a mean follow-up of 24 ± 14 months, there were four recurrences (2.5%) among the 146 patients. The success rate of telephone contact was 87.6% (128/146 cases). The other patients (28 cases) were reviewed only via their outpatient follow-up chart records. The mean operation time was 61.4 ± 16.4 minutes, which was shorter than the operation time of the spinal anesthesia group (85.7 ± 25.5 minutes, P < 0.001). The mean length of hospital stay was 2.63 ± 1.8 days, which was also shorter than that of the spinal anesthesia group (4.9 ± 1.8 days, P < 0.001). A total of 32 postoperative complications occurred in 26 patients (17.8%). Wound problems were the most common postoperative complication. Twenty-seven events (wound pain, 14 cases; wound hematoma, 11 cases; wound seroma, 2 cases) occurred in 23 patients (15.7%). Other complications included scrotal swelling (3 cases, 2.1%) and postoperative voiding difficulty (2 cases, 1.4%). There was no case of wound infection. Postoperative voiding difficulty occurred significantly more frequently in the spinal anesthesia group (8 cases, 17%) compared with the local anesthesia group (2 cases, 1.4%; P < 0.001) (Table 4). The postoperative one-day mean ± SD visual analogue scale score was 3.88 ± 1.53; it significantly decreased to 1.69 ± 1.41 at seventh postoperative day (P < 0.001).

significantly more frequently in the spinal anesthesia group (8 cases, 17%) compared with the local anesthesia group (2 cases, 1.4%; P < 0.001) (Table 4). The postoperative one-day mean ± SD visual analogue scale score was 3.88 ± 1.53; it significantly decreased to 1.69 ± 1.41 at seventh postoperative day (P < 0.001). DISCUSSION After the tension-free technique was first introduced by Lichtenstein, diverse tension free surgical procedures for inguinal hernia evolved, including prolene hernia system repair, direct and indirect Kugel patch repair and laparoscopic herniorrhaphy. It is difficult to conclude which method is suitable for inguinal hernia treatment, but it seems to be easy and reasonable to discuss which anesthetic technique is suitable for open inguinal hernia surgery. Lawrence et al. [13] reported that laparoscopic hernia repair appears to be an expensive option; however, the local anesthesia technique has a short learning curve that requires simple training. The technique is easy to learn and apply, and it is an economic option for open anterior repairs. Therefore, every surgeon should be capable of not only performing current repair methods but also applying local anesthesia successfully in his/her daily practice.

has a short learning curve that requires simple training. The technique is easy to learn and apply, and it is an economic option for open anterior repairs. Therefore, every surgeon should be capable of not only performing current repair methods but also applying local anesthesia successfully in his/her daily practice. Previously established operative advantages of the local anesthesia technique include reduced bleeding (when adrenaline-containing solutions are used), easier dissection because of the separation of tissue planes by local anesthetic infiltration (hydrodissection) and the ability to assess the adequacy of the hernia repair by asking a conscious patient to perform a Valsalva maneuver if necessary [14].

de reduced bleeding (when adrenaline-containing solutions are used), easier dissection because of the separation of tissue planes by local anesthetic infiltration (hydrodissection) and the ability to assess the adequacy of the hernia repair by asking a conscious patient to perform a Valsalva maneuver if necessary [14]. The single surgeon selected the same anesthetic method (usually spinal anesthesia) that the other surgeons used when he started working at this hospital in 2004. Most of the inguinal hernia repairs performed under general or spinal anesthesia were performed between 2004 and 2008; we started to perform inguinal hernia surgery under local anesthesia for adult patients since 2008. However, we began performing inguinal hernia repair using the TLA solution technique in September 2009, when the single surgeon in this study returned to work after finishing studying abroad. From September 2009 to December 2013, we performed 146 consecutive adult inguinal hernia operations under local anesthesia using the TLA solution, with no conversion to spinal or general anesthesia and didn't experience any other side effect of the local anesthetic drugs. During that period, eight cases were performed under spinal or general anesthesia because of other combined surgeries (two cases), lack of patient cooperation (five cases) and recurrence case (one case who had already undergone both inguinal hernia operations twice).

any other side effect of the local anesthetic drugs. During that period, eight cases were performed under spinal or general anesthesia because of other combined surgeries (two cases), lack of patient cooperation (five cases) and recurrence case (one case who had already undergone both inguinal hernia operations twice). Recently, many local anesthetic techniques have evolved. Tumescent local anesthesia provides anesthesia over wide areas of skin and subcutaneous tissue via the direct infiltration of large volumes of dilute local anesthetic solution. Compare to conventional local anesthesia, it also provides excellent analgesia during surgery. Diluted anesthetics reduce the potential for lidocaine toxicity and it provides long-lasting analgesia postoperatively than conventional local anesthesia [15]. A step-by-step infiltration technique under direct surgical view seems to be safer than a percutaneous inguinal block for patients undergoing inguinal hernia repair because cadaveric dissection studies have suggested that inguinal block may cause femoral nerve injury [16,17].

ly than conventional local anesthesia [15]. A step-by-step infiltration technique under direct surgical view seems to be safer than a percutaneous inguinal block for patients undergoing inguinal hernia repair because cadaveric dissection studies have suggested that inguinal block may cause femoral nerve injury [16,17]. Gultekin et al. [18] reported that local anesthesia reduced postoperative pain but did not lengthen the operation time. In our study, we found that the operation time was significantly shorter in the local anesthetic (LA) group than in the spinal anesthetic (SA) group (SA: 85.7 ± 25.5 minutes vs. LA: 64.5 ± 17.6 minutes, P < 0.05). We experienced eight cases of hernia recurrence; four cases among 47 spinal anesthesia cases (8.5%) and four cases among 157 local anesthesia cases (2.5%, P < 0.05). However, most of the local anesthesia surgeries were performed in the latter half of the study period (2009 to 2013). We can guess that the increasing number of the surgeon's cases might have affected the differences in operation time and recurrence rate between the two groups. Sanjay and Woodward [3] reported that patients who underwent surgery under local anesthesia had lower postoperative analgesia requirements (P < 0.05) and a lower incidence of urinary retention compared with the general anesthesia (GA) group (GA: five patients, 2.4% vs. LA: two patients, 0.5%; P < 0.05). We also found that postoperative voiding difficulty was significantly more common in the SA group (eight patients, 17%) than in the LA group (two patients, 1.3%; P < 0.001).

wer incidence of urinary retention compared with the general anesthesia (GA) group (GA: five patients, 2.4% vs. LA: two patients, 0.5%; P < 0.05). We also found that postoperative voiding difficulty was significantly more common in the SA group (eight patients, 17%) than in the LA group (two patients, 1.3%; P < 0.001). In the past, we did not perform hernia repair under local anesthesia. As we have reported, general anesthesia was performed for 25 cases (20.6%), and spinal anesthesia was used for 97 cases (79.5%) among the 122 adult hernia patients in 2004 [7]. However, after 2008, we began to perform hernia surgery under local anesthesia, and the TLA solution injection technique has been used since September 2009. The mean length of hospital stay for this hospital was reduced from 6.8 days in 1989 to 4.8 days in 2004, and in this study, we found that the mean length of hospital stay was only 2.7 ± 1.5 days in the LA group. In the past, the patient was usually admitted before the operation day, and we started feeding on postoperative day one. Patients who underwent spinal anesthesia had to stay in bed for one day; if they could walk on postoperative day two, they could be discharged. Thus, a typical hospital stay lasted three to five days. However, during the local anesthetic method era, patients were admitted just before the operation started and were usually able to eat just after surgery. There were no strict discharge criteria for inguinal hernia patients. We always ask about the patient's intentions after surgery, and if the patient agrees, he or she can be discharged on the operation day. However, most patients want to be discharged on postoperative day one. That is one reason why the mean length of hospital stay is shorter when the local anesthesia method is used compared with spinal or general anesthesia.

tions after surgery, and if the patient agrees, he or she can be discharged on the operation day. However, most patients want to be discharged on postoperative day one. That is one reason why the mean length of hospital stay is shorter when the local anesthesia method is used compared with spinal or general anesthesia. Regarding medical costs, there are many reports about the cost-effectiveness of local anesthesia during hernia surgery in Western countries [19,20,21]. In our study, we found that the total mean ± standard deviation fee-for-service charge for the local anesthesia group was lower compared with the spinal anesthesia group (SA: 923,310 ± 269,847 Korean won [KRW] vs. LA: 786,963 ± 236,721 KRW, P < 0.001; Data not shown here). Although local anesthesia is believed to be beneficial in many regards, some patient characteristics make it dangerous to perform; for example, if the patient has a lidocaine allergy, uncontrolled (no pacemaker) arrhythmias, psychological problems or fear of surgery or is too young to endure the surgical stress. Additionally, if strangulation is suspected or in some complicated cases, local anesthesia is not indicated. As Amid et al. [22] has reported, bilateral inguinal hernia repair under local anesthesia is a safe procedure. In our study, there were 11 bilateral inguinal hernia cases in the LA group, and the mean operation time was 98.6 ± 13.5 minutes. This time was slightly longer than for unilateral repair (64.5 ± 17.6 minutes), but there were no intra- or postoperative complications in the bilateral inguinal hernia repair group.

cedure. In our study, there were 11 bilateral inguinal hernia cases in the LA group, and the mean operation time was 98.6 ± 13.5 minutes. This time was slightly longer than for unilateral repair (64.5 ± 17.6 minutes), but there were no intra- or postoperative complications in the bilateral inguinal hernia repair group. Kehlet and Bay-Nielsen [23] reviewed the Danish Hernia Database of approximately 43,123 patients between 1998 and 2005. The data were analyzed in relation to the type of inguinal hernia and whether it was repaired in a public hospital or by private hernia surgeons. The use of local anesthesia was followed by higher reoperation rates compared with general or regional anesthesia after the repair of direct, but not indirect, hernias in hospitals. However, reoperation rates after both direct and indirect hernia repairs were lower among private hernia surgeons with the uniform use of local anesthesia compared with reoperations following primary surgery in hospitals. Thus, the authors concluded that surgical experience and hernia type may be important factors for reoperation independent of the type of anesthesia used. However, the authors mentioned that when inguinal hernia repair is performed in general hospitals, local anesthesia may be a risk factor for recurrence after the primary repair of a direct hernia. Although local anesthesia provides maximum comfort for the patients in selected institutions, its use may result in discomfort to the patient and surgeon when the procedure is not performed properly. Inexperience with the local anesthetic technique can cause both discomfort to patients and an increased recurrence rate.

Although local anesthesia provides maximum comfort for the patients in selected institutions, its use may result in discomfort to the patient and surgeon when the procedure is not performed properly. Inexperience with the local anesthetic technique can cause both discomfort to patients and an increased recurrence rate. These findings indicate that before selecting the type of anesthetic method to use for inguinal hernia repair, it is necessary to have more evidence about which type of hernia repair technique is safer, offers a lower recurrence rate and is less affected by surgical skill. With that information, we can apply the proper anesthetic technique to that surgery. Each surgical technique and anesthetic method may have its advantages and disadvantages. In conclusion, if local anesthesia using TLA solution is used appropriately in open anterior inguinal hernia repair by a skilled surgeon, it may reduce operation time and hospital stay and decrease postoperative complications. No potential conflict of interest relevant to this article was reported. Table 1 Comparison of the anesthetic methods reported in the references Values are presented as number (%) unless otherwise indicated. Only adult inguinal hernia cases are included. Table 2 Comparison of the demographics between the SA and LA groups of inguinal hernia patients Values are presented as a number (%) unless otherwise indicated. SA, spinal anesthetic; LA, local anesthetic; BMI, body mass index; SD, standard deviation. a)Tissue repair includes high ligation, Bassini repair and McVay repair. Table 3 Patient comorbidities

Table 2 Comparison of the demographics between the SA and LA groups of inguinal hernia patients Values are presented as a number (%) unless otherwise indicated. SA, spinal anesthetic; LA, local anesthetic; BMI, body mass index; SD, standard deviation. a)Tissue repair includes high ligation, Bassini repair and McVay repair. Table 3 Patient comorbidities Values are presented as a number (%). SA, spinal anesthetic; LA, local anesthetic; CVA, cerebrovascular accident; DM, diabetes mellitus; HTN, hypertension; BPH, benign prostate hyperplasia. Table 4 Postoperative complications Values are presented as number (%). SA, spinal anesthetic; LA, local anesthetic. a)We defined wound pain as pain that lasted more than one week and required analgesics. b)Postoperative ileus occurred.

INTRODUCTION Fibromatosis (desmoid tumors) are rare soft tissue tumors of mesenchymal origin that arise from musculoaponeurotic structures. Generally, the locations of fibromatosis are categorized as extra-abdominal (extremities), abdominal wall, and intra-abdominal (the bowel wall and mesentery). Intra-abdominal fibromatosis (IAF) may arise sporadically or in association with familial adenomatous polyposis (FAP). Fibromatosis tumors exhibit slow-growth, benign histological features, and aggressive local invasion without metastasis [1]. Surgery remains a reasonable first treatment for operable tumors but may lead to high rates of morbidity and recurrence. Therefore, some cases of FAP-associated fibromatosis may be treated with drugs as a first option. However, gastric cancer-associated fibromatosis are very rare, difficult to diagnosis, and difficult to treat given the choice between surgical or pharmacological interventions. Komatsu et al. [2] first reported IAF after gastrectomy for gastric cancer. Herein, we report 2 cases of complete excision of IAF after gastrectomy for gastric cancer.

ssociated fibromatosis are very rare, difficult to diagnosis, and difficult to treat given the choice between surgical or pharmacological interventions. Komatsu et al. [2] first reported IAF after gastrectomy for gastric cancer. Herein, we report 2 cases of complete excision of IAF after gastrectomy for gastric cancer. Case Report Case 1 A 50-year-old man was admitted after nonpalpable intra-abdominal masses were detected by CT. This patient had received radical subtotal gastrectomy with gastrojejunostomy and jejunojejunostomy 2 years prior to admission. The histologic type was poorly differentiated adenocarcinoma and the stage was pT1N1M0 according to the American Joint Committee on Cancer, 7th edition. At the time of gastrectomy, no other intra-abdominal masses were found. After curative resection without adjuvant chemotherapy, he was checked routinely via biannual CT and annual endoscopy. Two years after gastrectomy, 2 jejunal mesenteric masses were detected by CT. The sizes were approximately 5 and 6 cm in diameter. Exploratory laparotomy was performed to confirm the pathological characteristics of the masses and to determine whether the masses were reflective of recurrent gastric cancer or of benign tumors (e.g., gastrointestinal stromal tumors [GISTs]). One mass detected in the jejunal mesentery near the gastrojejunostomy site was excised completely with the jejunal segment (Fig. 1). Additional gastrojejunostomy was performed because the previous gastrojejunostomy site was involved in the resected segment. Another tumor was detected in the jejunal mesentery 100 cm below the gastrojejunostomy site and was excised completely with the jejunal segment (Figs. 2, 3). Pathologically, the 2 tumors were diagnosed as mesenteric fibromatosis. No recurrence or metastasis had occurred during the 5-year follow-up period.

cted segment. Another tumor was detected in the jejunal mesentery 100 cm below the gastrojejunostomy site and was excised completely with the jejunal segment (Figs. 2, 3). Pathologically, the 2 tumors were diagnosed as mesenteric fibromatosis. No recurrence or metastasis had occurred during the 5-year follow-up period. Case 2 A 60-year-old man was admitted with a nonpalpable abdominal mass. This patient had undergone radical total gastrectomy for advanced gastric cancer 23 months prior to admission. The histologic type was mucinous adenocarcinoma and the stage was pT2N2M0. Additionally, peritoneal seeding or intra-abdominal masses were not detected during an initial laparotomy. Adjuvant chemotherapy was performed. He was checked routinely via biannual CT and an upper gastrointestinal series. Twenty-three months after surgery, a 4.2-cm-sized mass was detected in the periumbilical region by CT (Fig. 4). The radiologist recommended 18F-fluorodeoxyglucose PET/CT, which revealed a mild hypermetabolic mass in the periumbilical region that appeared to be metastatic (Fig. 5). Exploratory laparotomy was performed and the tumor was detected 30 cm above the ileocecal valve in the ileal mesentery. This mass was excised completely with the ileal segment. Macroscopically, the tumor was poorly demarcated and firm, measuring 6.0 cm × 5.8 cm × 2.3 cm (Fig. 6). Microscopically, the tumor showed proliferation of spindle-shaped cells with uniform cytologic features and focal dense collagen deposition (Fig. 7). Immunohistochemically, the tumor cells showed diffuse b-catenin nuclear staining (Fig. 8), but negative reactivity for CD34 and CD117. The tumor was diagnosed as a mesenteric fibromatosis. The patient recovered without complication and no recurrence or metastasis had occurred during the 3 month follow-up period.

g. 7). Immunohistochemically, the tumor cells showed diffuse b-catenin nuclear staining (Fig. 8), but negative reactivity for CD34 and CD117. The tumor was diagnosed as a mesenteric fibromatosis. The patient recovered without complication and no recurrence or metastasis had occurred during the 3 month follow-up period. DISCUSSION Fibromatosis refers to a group of rare soft tissue tumors of fibroblastic origin that can occur in sites including the extremities, abdominal wall, and intestines. Based on location, fibromatosis can be subdivided into extra-abdominal, abdominal wall, and IAF. The pathogenesis of IAF is unclear but may involve germline mutations of the APC gene, sex hormones, and traumatic injuries, including surgery. Although IAF can occur sporadically in rare cases, about 68%-86% of IAF and abdominal wall fibromatosis in FAP occur after abdominal surgery [3]. The incidence of fibromatosis is higher in females and may be attributable to the abnormal metabolism of estrogen, which has been implicated in the pathogenesis of sporadic fibromatosis [4]. CT is most commonly used to investigate IAF, which may appear as a hypervascular soft tissue mass that resembles a GIST. However, IAF can be differentiated from GIST on a CT image by ovoid or irregular contours, homogeneous enhancement, and an absence of central necrosis [5]. Magnetic resonance imaging is considered to be a more advantageous method in assessing extra-abdominal fibromatosis.

ascular soft tissue mass that resembles a GIST. However, IAF can be differentiated from GIST on a CT image by ovoid or irregular contours, homogeneous enhancement, and an absence of central necrosis [5]. Magnetic resonance imaging is considered to be a more advantageous method in assessing extra-abdominal fibromatosis. The appropriate treatment of IAF remains a subject of controversy. In asymptomatic patients, simple observation may be a suitable choice. Unfortunately, complete resection may be difficult in many cases due to deep infiltration and the absence of a capsule. However, treatment is required for symptomatic patients and/or those with tumors that display a rapid growth pattern. Surgery remains the first treatment option for patients with locally circumscribed fibromatosis [6]. Radiotherapy after surgery or radiotherapy alone has been used for improvement of local control. In fact, a meta-analysis of 22 studies reported that radiotherapy after surgery demonstrated significantly better control after both R0 and R1 resections [7].

option for patients with locally circumscribed fibromatosis [6]. Radiotherapy after surgery or radiotherapy alone has been used for improvement of local control. In fact, a meta-analysis of 22 studies reported that radiotherapy after surgery demonstrated significantly better control after both R0 and R1 resections [7]. Nonsurgical modalities for the treatment of unresectable IAF include nonsteroidal anti-inflammatory drugs (NSAIDs), antiestrogens (tamoxifen or toremifene), and cytotoxic chemotherapy. Sulindac is the most commonly used drug for the treatment of FAP-associated fibromatosis and the results of 1 study demonstrated an overall response rate of 57% in 14 FAP patients [4]. The efficacy of NSAIDs has been demonstrated in small cases, however, most cases showed variable responses [4]. The incidence of IAF increases during and after pregnancy and this natural history of the disease forms the basis for antihormonal therapy. Janinis et al. [8] reported that antihormonal therapy in fibromatosis resulted in stable disease or regression. The use of cytotoxic agents for the treatment for IAF is supported by the efficacy of doxorubicin combined with other agents (dacarbazine or cyclophosphamide and vincristine). The overall response rate is approximately 40%-50%, although severe side effects such as cardiotoxicity or myelotoxicity have been reported [4]. As a result, cytotoxic chemotherapy is reserved for those that are nonoperable or nonresponsive to other treatments. IAF is often mistaken for GIST or other spindle cell neoplasms, as they are all macroscopically solid localized tumors that originate in the mesentery. However, they can be distinguished pathologically, as GISTs are found to be immunopositive for CD114, CD34, and DOG-1, while IAF are found to be immunopositive for b-catenin mutations restricted to exon 3 of CTNNB1 [9].

l neoplasms, as they are all macroscopically solid localized tumors that originate in the mesentery. However, they can be distinguished pathologically, as GISTs are found to be immunopositive for CD114, CD34, and DOG-1, while IAF are found to be immunopositive for b-catenin mutations restricted to exon 3 of CTNNB1 [9]. In conclusion, we experienced 2 cases of mesenteric fibromatosis resembling GIST or metastatic tumors. All tumors were excised completely and no recurrence occurred. Although some cases of FAP-associated fibromatosis may be treated initially with drugs, gastric cancer-associated fibromatosis are very rare, difficult to diagnosis, and without consensus regarding a preferred treatment approach (surgery or pharmacotherapy). Therefore, exploratory laparotomy followed by complete excision may be an appropriate strategy for those patients with a mesenteric mass detected after gastrectomy for gastric cancer. No potential conflict of interest relevant to this article was reported. Fig. 1 First tumor in the mesentery of the jejunum near the gastrojejunostomy site (black arrow, mesenteric mass; blue arrow, gastrojejunostomy site). Fig. 2 Second tumor in the mesentery of the jejunum (black arrow, mesenteric mass; red arrow, jejunojejunostomy site). Fig. 3 Second tumor in the mesentery of the jejunum before the jejunum was resected. Fig. 4 A 4.2-cm-sized mass in the periumbilical region by CT: (A) horizontal view (red arrow, mesentery mass), (B) coronal view (red arrows, mesentery mass). Fig. 5 Mild hypermetabolic mass in the periumbilical region by PET/CT (red arrow, mesenteric mass).

Fig. 3 Second tumor in the mesentery of the jejunum before the jejunum was resected. Fig. 4 A 4.2-cm-sized mass in the periumbilical region by CT: (A) horizontal view (red arrow, mesentery mass), (B) coronal view (red arrows, mesentery mass). Fig. 5 Mild hypermetabolic mass in the periumbilical region by PET/CT (red arrow, mesenteric mass). Fig. 6 Mesenteric mass and ileum excised completely. (A) resected specimen. (B) cross-sectional view. Fig. 7 Histologically, proliferation of spindle-shaped cells with uniform cytologic features and focal dense collagen deposition is seen (H&E, ×100). Fig. 8 Immunohistochemically, the tumor cells showed diffuse β-catenin nuclear staining (×200).

INTRODUCTION Sparganosis is a rare infection disease caused by sparganum, a plerocercoid tapeworm larva of genus Spirometra. In humans, it is accidentally acquired by ingestion of larvae-containing water or by eating raw snakes and frogs. The larvae are commonly found in the abdomen, urogenital organs, extremities, central nervous system, chest, and orbital region [1]. The breast is a rare site of infection. The most common clinical manifestation of sparganosis is a migrating subcutaneous mass. Clinically and radiologically, the mass may mimic a neoplasm. It is very difficult to diagnose preoperatively in most cases [2]. We report an interesting case of axillary sparganosis involving multiple axillary lymph nodes in a breast cancer patient receiving neoadjuvant chemotherapy that was confused as axillary metastasis.

ally and radiologically, the mass may mimic a neoplasm. It is very difficult to diagnose preoperatively in most cases [2]. We report an interesting case of axillary sparganosis involving multiple axillary lymph nodes in a breast cancer patient receiving neoadjuvant chemotherapy that was confused as axillary metastasis. CASE REPORT A 52-year-old woman visited Konkuk University Medical Center to have an examination on her right-side breast mass, palpable from one month prior. She said that the right-side breast mass had been noticed one month before, which then grew bigger. Pain did not accompany, and nipple discharge did not exist. An image-guided core needle biopsy showed invasive ductal carcinoma. Initial breast MRI revealed a 5-cmsized regional enhancement at the right upper breast with negative findings in the right axilla (Fig. 1A). And 18F-fluoro-2-D-glucose (18FDG) PET/CT demonstrated a hypermetabolic mass with SUVmax 13.0 at the upper outer quadrant of the right breast without significant hypermetabolism at the right axilla (Fig. 1B). The patient underwent neoadjuvant chemotherapy consisting of doxorubicin and cyclophosphamide, every 3 weeks. After three cycles, efficacy was assessed. The breast MRI showed a decreased size and volume of cancer from 5 cm to 3 cm and newly appearing enlarged lymph nodes that were considered metastasis at the right axilla (Fig. 2A). Also, 18FDG PET/CT showed a decreased size and activity of cancer and newly developed hypermetabolic lymph nodes with SUVmax 7.2 at the right axilla (Fig. 2B). So, we concluded the breast cancer progression and decided upon curative surgical treatment with breast-conserving surgery by right axillary dissection. In the surgical field, whitish and shiny worms were found inside the lymph nodes, which confirmed as spargana (Fig. 3). The histologic findings confirmed degenerative parasitic organisms with granulomatous chronic inflammation and eosinophilic infiltration (Fig. 4). And there was no metastasis in the 15 lymph nodes.

n. In the surgical field, whitish and shiny worms were found inside the lymph nodes, which confirmed as spargana (Fig. 3). The histologic findings confirmed degenerative parasitic organisms with granulomatous chronic inflammation and eosinophilic infiltration (Fig. 4). And there was no metastasis in the 15 lymph nodes. The patient completed 3-cycle postoperative chemotherapy, and radiation therapy. Herceptin was administered every 3 weeks, due to ER(-). PR(-), c-erb-B2(3+). It has been 15 months since the first treatment, and the patient is in good shape without recurrence (Fig. 5).

n. In the surgical field, whitish and shiny worms were found inside the lymph nodes, which confirmed as spargana (Fig. 3). The histologic findings confirmed degenerative parasitic organisms with granulomatous chronic inflammation and eosinophilic infiltration (Fig. 4). And there was no metastasis in the 15 lymph nodes. The patient completed 3-cycle postoperative chemotherapy, and radiation therapy. Herceptin was administered every 3 weeks, due to ER(-). PR(-), c-erb-B2(3+). It has been 15 months since the first treatment, and the patient is in good shape without recurrence (Fig. 5). DISCUSSION Sparganosis caused by the migrating procercoid larvae of Diphyllobothrium mansoni is an extremely rare disease. The most common route of infection is via ingestion of contaminated water containing procercoids, which can penetrate into the intestine and migrate to the muscle or subcutaneous tissue. The second route is from ingestion of raw or partially cooked fish, frogs, snakes, and chickens. Infection in this case also occurs from migration of the procercoid through the intestine. The third route of infection may occur from poultice applications that may be infested with Cyclops containing procercoids that are utilized to open wounds or eyes [3]. In the past, the typical route of infection was direct oral consumption of plero-cercoid-infected reptiles or amphibians, most frequently an intermediary host such as snakes or frogs or eating uncooked mammals such as pigs [4]. It is possible that economic development and advancement in sanitation have influenced routes, sites of infection, and latent period in recent times. Our patient denied eating either snakes or frogs. But, only once, she admitted to drinking water from a spring when climbing a mountain. Therefore, a history of drinking impure water should be considered a cause of axillary sparganosis.

tion have influenced routes, sites of infection, and latent period in recent times. Our patient denied eating either snakes or frogs. But, only once, she admitted to drinking water from a spring when climbing a mountain. Therefore, a history of drinking impure water should be considered a cause of axillary sparganosis. Spargana larvae can be found in any part of the human body and have a preference for subcutaneous involvement and migration. In the extramammary organs, sparganosis most frequently manifests as a migrating subcutaneous nodule and it presents clinically with vague or indeterminate symptoms [5]. The clinical features of breast sparganosis were reported an as indolent palpable mass that was similar to malignancy with the absence of any inflammatory reaction such as a warm sensation or painful swelling [6]. Currently, the majority of suspicious or indeterminate breast lesions undergo core needle biopsy. However, preoperative biopsy procedures may result in fragmenting the worms, thus preventing complete surgical removal and possibly promoting recurrences. The definitive diagnosis of sparganosis can only be performed by excisional biopsy and by confirmation of the existence of a sparganum larva. This condition is too difficult to diagnose [7]. In our case, sparganosis was revealed in a newly developed axillary mass with follow-up MRI and 18FDG PET/CT after neoadjuvant chemotherapy. and it was mistaken for breast cancer progression, axillary metastasis. It was an unusual case, because the main breast cancer had decreased having partial response to chemotherapy. We decided on curative surgical treatment; breast-conserving surgery with axillary dissection. Eventually, the diagnosis was established at surgery with identification of the worm in the axillary lymph nodes. There was no lymph node metastasis.

e main breast cancer had decreased having partial response to chemotherapy. We decided on curative surgical treatment; breast-conserving surgery with axillary dissection. Eventually, the diagnosis was established at surgery with identification of the worm in the axillary lymph nodes. There was no lymph node metastasis. When sparganum is ingested, it penetrates the intestinal wall to reach the peritoneal cavity and begins to migrate systemically. The longevity of sparagana is thought to be under 1 year. However, some articles have reported finding a live worm after more than 10 years [4]. We experienced an interesting case of sparganosis that had been latent for only one month without symptoms. In this case, we concluded that the sparganum migrated to the axillary lymph nodes and the immunosuppressant therapy might have caused lymphadenopathy. Although the exact length of latency is not specific in most published articles, our case could be the shortest known latent period of spargnosis. The short-term survival of the parasites during chemotherapy may result from their immunomodulatory ability with respect to the host. Axillary and inguinal sparganosis in an immunosuppressed patient with lymphoma who had received allo-peripheral stem cell transplant and cyclosporine therapy has been reported [8]. Further research is required in order to understand the role of sparganum as a valuable model for alleviating symptoms of immune-mediated disease.

y and inguinal sparganosis in an immunosuppressed patient with lymphoma who had received allo-peripheral stem cell transplant and cyclosporine therapy has been reported [8]. Further research is required in order to understand the role of sparganum as a valuable model for alleviating symptoms of immune-mediated disease. Human sparganosis is a rare disease. And the infection route, latent period, and symptoms of the disease are changing with economic development. In this respect, surgeons should be carefully taking patient history in order to make a differential diagnosis. In this report, we speculate that the extremely short period of spargana could have been under one month with a parasitic infection occurring in the right axillary lymph nodes following neoadjuvant chemotherapy. No potential conflict of interest relevant to this article was reported. Fig. 1 Initial breast imaging. (A) Breast MRI shows 5-cm-sized regional enhancement at right upper breast with negative finding in right axilla. (B) 18F-fluoro-2-D-glucose positron PET-CT shows hypermetabolic lesions in right upper breast without significant hypermetabolism at right axilla. Fig. 2 Follow-up breast imaging after 3 cycles of neoadjuvant chemotherapy. (A) Breast MRI shows interval decrease of nonmass-like enhancement in right breast and newly appeared enlarged lymph nodes at right axilla. (B) 18F-fluoro-2-D-glucose PET-CT shows a decreased size and activity of right breast cancer and newly developed hypermetabolic lymph nodes at right axilla.

oadjuvant chemotherapy. (A) Breast MRI shows interval decrease of nonmass-like enhancement in right breast and newly appeared enlarged lymph nodes at right axilla. (B) 18F-fluoro-2-D-glucose PET-CT shows a decreased size and activity of right breast cancer and newly developed hypermetabolic lymph nodes at right axilla. Fig. 3 Gross appearance of whitish flat sparganum extracted from the axillary lymph nodes by surgeon in the operating room. Fig. 4 Histologic findings showed body of the sparganum embedded in axillary lymph node and granulomatous inflammation with serpiginous necrosis and ghosty eggs (H&E, ×40). Fig. 5 Follow-up breast imaging after 1 year of operation. Hypermetabolism, left neck level II lymph node. Inflammatory lesion, more likely Otherwise, no significant abnormal hypermetabolic lesion suggesting malignancy.

INTRODUCTION Situs solitus refers to the normal positioning of the thoracic and abdominal organs, while situs inversus is a congenital condition resulting in the reversal of internal organs from the right to the left side of the body [1,2]. Situs ambiguous is defined as the abnormal arrangement of the thoracic and abdominal organs, which are not clearly lateralized [3]. Congenital heart disease affects 50%-100% of patients with situs ambiguous [4]. Isolated levocardia is a rare complication of situs anomaly, in which thoracic situs solitus is noted along with dextro-positioning of the abdominal viscera such as situs inversus or situs ambiguous. Splenic and cardiac defects commonly accompany levocardia.

isease affects 50%-100% of patients with situs ambiguous [4]. Isolated levocardia is a rare complication of situs anomaly, in which thoracic situs solitus is noted along with dextro-positioning of the abdominal viscera such as situs inversus or situs ambiguous. Splenic and cardiac defects commonly accompany levocardia. We recently encountered a patient with a rare form of situs ambiguous including the following: (1) isolated levocardia with a specific distribution of abdominal viscera, (2) malrotation of the intestines, and (3) a lack of splenic or cardiac anomalies. The anatomic anomalies of the patient were detected during preoperative imaging studies for possible common bile duct (CBD) cancer requiring a pancreaticoduodenectomy. Despite the rising incidence, cholangiocarcinoma is one of the most uncommon malignancies, and concomitant cholangiocarcinoma with situs ambiguous is even rarer. To our knowledge, pancreaticoduodenectomy in a patient with isolated levocardia, intestinal malrotation, and situs ambiguous without splenic defects, has not been previously reported. Here, we report the case of a patient in whom pylorus preserving pancreaticoduodenectomy was successful in the setting of rare situs anomalies.

knowledge, pancreaticoduodenectomy in a patient with isolated levocardia, intestinal malrotation, and situs ambiguous without splenic defects, has not been previously reported. Here, we report the case of a patient in whom pylorus preserving pancreaticoduodenectomy was successful in the setting of rare situs anomalies. CASE REPORT A 59-year-old male patient presented with epigastric pain and jaundice. With the exception of diabetes mellitus, the patient had no significant past medical, surgical, or family history as well as no prior hospitalizations. During physical examination, the patient was alert and afebrile, although he was jaundiced, as evidenced by icteric sclera. Abdominal examination revealed epigastric pain without tenderness. Abdominal inspection revealed no evidence of distension or palpable masses. AST/ALT and total bilirubin/direct bilirubin levels were elevated (251/415 IU/L [normal, <34/40 IU/L] and 9.7/7.9 mg/dL [normal, <1.3/0.4 mg/dL]). In addition, marked elevations in the levels of ALP and γ-GT were noted (2,466 IU/L [104 IU/L < normal < 338 IU/L] and 949 IU/L [5 IU/L < normal < 55 IU/L]). The levels of serum tumor marker CA 19-9 were also elevated (205.0 U/mL [normal, <27 U/mL]).

/L [normal, <34/40 IU/L] and 9.7/7.9 mg/dL [normal, <1.3/0.4 mg/dL]). In addition, marked elevations in the levels of ALP and γ-GT were noted (2,466 IU/L [104 IU/L < normal < 338 IU/L] and 949 IU/L [5 IU/L < normal < 55 IU/L]). The levels of serum tumor marker CA 19-9 were also elevated (205.0 U/mL [normal, <27 U/mL]). CT scan revealed segmental concentric wall thickening in the suprapancreatic CBD, with biliary tree dilatation and abnormal intra-abdominal organ positioning. We determined that the liver was located in the middle of the upper abdomen, and that the gallbladder was in the middle of the upper abdomen. The inferior vena cava and portal vein showed nonspecific changes. The spleen was located in the right upper quadrant. In addition, the locations of the stomach and pancreas were reversed (Fig. 1). As a chest radiograph showed no specific abnormalities, a diagnosis of isolated levocardia with situs ambiguous was confirmed. For additional information on the concentric wall thickening in the suprapancreatic CBD, MRI, and PET CT were performed. Both imaging modalities suggested the presence of a focal cancerous lesion of the distal CBD, without significant lymphadenopathy. Therefore, we decided to carry out a surgical exploration based on the radiographic findings that were suggestive of distal CBD cancer.

suprapancreatic CBD, MRI, and PET CT were performed. Both imaging modalities suggested the presence of a focal cancerous lesion of the distal CBD, without significant lymphadenopathy. Therefore, we decided to carry out a surgical exploration based on the radiographic findings that were suggestive of distal CBD cancer. Upon opening the peritoneum, we noticed that the intraabdominal organs were not in their normal locations. The right liver lobe was located in the upper right-hand quadrant of the abdominal cavity, resting just below the right diaphragm, and the gall bladder was just beneath the right liver lobe, as was previously known. The left lobe of the liver was as large as the right lobe, and its anatomical segment was not clearly separated. The stomach and spleen were located in the upper right-hand quadrant of the abdomen under the right liver lobe, but there appeared to be no splenic defects or anomalies. Additionally, the stomach and first part of the duodenum were reversed and faced the left side. We were able to distinguish the first and second part of the duodenum; however, after the third part, the duodenum and jejunum were not clearly identified because the ligament of Treitz was absent. This indicated that the third and fourth parts of the duodenum were located in the peritoneal space, rather than retroperitoneally. The head of the pancreas was found on the second portion of the duodenum, and the uncinate process had not developed. The body of the pancreas was behind the stomach, and the tail was oriented toward the upper right-hand abdominal quadrant leading to the spleen. The small intestine was completely pushed to the right side of the abdomen, and the large intestine was present on the left side of the abdomen. Interestingly, the ascending colon was found to be a freely movable structure, because it was not fixed by the gastrocolic or duodenocolic ligaments (Fig. 2).

g to the spleen. The small intestine was completely pushed to the right side of the abdomen, and the large intestine was present on the left side of the abdomen. Interestingly, the ascending colon was found to be a freely movable structure, because it was not fixed by the gastrocolic or duodenocolic ligaments (Fig. 2). After omentectomy, cholecystectomy, and dissection around the CBD had been successfully performed, the margin of the proximal bile duct was found just below the hepatic duct bifurcation. Mobilization of the pancreas head and duodenum from the portal vein was carried out with a reverse-Kocher maneuver. The duodenum was subsequently transected, and the stomach was moved upward to allow for an easier approach to the pancreas. Pancreaticoduodenectomy was performed with end-to-end pancreaticojejunostomy, end-to-side duodenojejunostomy, and end-to-side hepaticojejunostomy (Fig. 3). The total operation time was 605 minutes, and the estimated intraoperative blood loss was 200 mL. Histopathology revealed a moderately differentiated adenocarcinoma of the CBD, and the tumor was classified as T3N0M0 stage IIA according to the TNM staging system of the American Joint Committee on Cancer. There was invasion into the pancreas and duodenum, but no involvement of the CBD, pancreatic, or duodenal resection margins. In addition, no metastasis was noted in the lymph nodes, which were removed intraoperatively.

ed as T3N0M0 stage IIA according to the TNM staging system of the American Joint Committee on Cancer. There was invasion into the pancreas and duodenum, but no involvement of the CBD, pancreatic, or duodenal resection margins. In addition, no metastasis was noted in the lymph nodes, which were removed intraoperatively. The patient recovered without major complications. Seven days after surgery, a follow-up abdominopelvic CT scan was performed that showed no abnormalities. Fifteen days after the operation, the patient was started on combined chemotherapy and radiotherapy. DISCUSSION Situs inversus is a condition in which the internal organs are reversed or mirrored from their normal positions. The incidence of situs inversus is approximately 1 in 10,000 [2]. The abnormal location of organs and vessels in a manner that is not clearly lateralized is known as situs ambiguous, which has an estimated incidence of at least 1 in 40,000 live births [5]. Situs anomaly accompanied by isolated levocardia, malrotation, and situs ambiguous, but without splenic or cardiac malformations, is extremely rare. A review of previous medical literature revealed only 12 reported cases of isolated levocardia without splenic or cardiac anomalies [6,7], and 5 reported cases of isolated levocardia with intestinal malrotation [7,8,9].

, malrotation, and situs ambiguous, but without splenic or cardiac malformations, is extremely rare. A review of previous medical literature revealed only 12 reported cases of isolated levocardia without splenic or cardiac anomalies [6,7], and 5 reported cases of isolated levocardia with intestinal malrotation [7,8,9]. Cholangiocarcinoma is also not a common malignancy of the gastrointestinal tract and has a reported incidence in the United States of 1 or 2 per 100,000 patients [10]. In this patient, all the unusual conditions discussed here as well as cholangiocarcinoma, were present-making this case even rarer. To the best of our knowledge, this report is the first to demonstrate the performance of a pancreaticoduodenectomy in a patient with isolated levocardia, intestinal malrotation, and situs ambiguous without splenic malformations (literature search conducted through PubMed). During the surgery, the surgeon stood on the right side of the patient as usual, and the surgical procedure was performed in the standard order of a pylorus preserving pancreaticoduodenectomy. A number of important findings during the surgery deserve additional attention.

Cholangiocarcinoma is also not a common malignancy of the gastrointestinal tract and has a reported incidence in the United States of 1 or 2 per 100,000 patients [10]. In this patient, all the unusual conditions discussed here as well as cholangiocarcinoma, were present-making this case even rarer. To the best of our knowledge, this report is the first to demonstrate the performance of a pancreaticoduodenectomy in a patient with isolated levocardia, intestinal malrotation, and situs ambiguous without splenic malformations (literature search conducted through PubMed). During the surgery, the surgeon stood on the right side of the patient as usual, and the surgical procedure was performed in the standard order of a pylorus preserving pancreaticoduodenectomy. A number of important findings during the surgery deserve additional attention. Firstly, anatomical variations of the vessels of the celiac trunk and superior mesenteric artery (SMA) were found. In this patient, the right gastric artery, normally derived from the common hepatic artery (CHA), arose directly from the celiac trunk (Fig. 4). In addition, the CHA and gastroepiploic artery originated from the SMA (Fig. 5). Specifically, the CHA was derived from the SMA at the inferior border of the pancreas and ran along the anterior surface of the pancreas to the liver. The course of the CHA was just above the neck of the pancreas, and was close to the resection margin; hence, extra care was taken while skeletonizing the CHA. After the resected pancreas head and duodenum were out of the way, repositioning of the skeletonized CHA presented a challenge. The proximal jejunum of the pancreaticojejunostomy was constricted, and the intraluminal passage of the proximal jejunum could easily have been disturbed by the position of the CHA. Therefore, we decided to place the CHA under the proximal jejunum, and performed the pancreaticojejunostomy (Fig. 3).

esented a challenge. The proximal jejunum of the pancreaticojejunostomy was constricted, and the intraluminal passage of the proximal jejunum could easily have been disturbed by the position of the CHA. Therefore, we decided to place the CHA under the proximal jejunum, and performed the pancreaticojejunostomy (Fig. 3). Secondly, the head of the pancreas only covered the anterior wall of the portal vein, indicating that the uncinate process was absent. Most surgeons take great care while detaching the head of the pancreas from the inferior vena cava with the Kocher maneuver. Because the head of the pancreas was smaller than that of a normal pancreas, a Kocher maneuver could be easily performed. In addition, more than half of the pancreas was located in the peritoneal cavity, rather than the retroperitoneum, making it convenient to dissect the head of the pancreas. Thirdly, malpositioning of the intestines due to congenital gut malrotation made proper identification of the visceral anatomy time consuming and difficult, leading to an extended operation time. However, it offered surgical benefits in other ways. For example, the duodenojejunal and hepatic flexures, which consist of the ligament of Treitz and the gastrocolic and duodenocolic ligaments, were absent. Therefore, some surgical procedures could be omitted, such as the creation of a window in the mesocolic attachment of the duodenum, using an extensive Kocher maneuver and pulling the jejunal loop into the right upper abdomen through the mesocolic window.

eitz and the gastrocolic and duodenocolic ligaments, were absent. Therefore, some surgical procedures could be omitted, such as the creation of a window in the mesocolic attachment of the duodenum, using an extensive Kocher maneuver and pulling the jejunal loop into the right upper abdomen through the mesocolic window. In conclusion, careful identification of anatomical anomalies using radiological imaging tools such as CT should be conducted prior to surgery in cases of situs ambiguous. Intestinal malrotation itself does not disrupt the surgical procedure, and its presence may be beneficial when attempting to reposition the proximal jejunum for anastomosis. Therefore, despite the rarity, if careful preoperative preparation and intraoperative examination of abdominal organs are carried out, a pancreaticoduodenectomy can be safely and successfully performed in a patient with isolated levocardia, intestinal malrotation, and situs ambiguous, who does not have splenic malformations. No potential conflict of interest relevant to this article was reported. Fig. 1 CT scan demonstrating a mass in the suprapancreatic common bile duct and abnormal positioning of intra-abdominal organs. Ao, aorta; Gb, gallbladder; H, heart; L, liver; P, pancreas; PV, portal vein; Sp, spleen; St, stomach; TM, tumor mass.

In conclusion, careful identification of anatomical anomalies using radiological imaging tools such as CT should be conducted prior to surgery in cases of situs ambiguous. Intestinal malrotation itself does not disrupt the surgical procedure, and its presence may be beneficial when attempting to reposition the proximal jejunum for anastomosis. Therefore, despite the rarity, if careful preoperative preparation and intraoperative examination of abdominal organs are carried out, a pancreaticoduodenectomy can be safely and successfully performed in a patient with isolated levocardia, intestinal malrotation, and situs ambiguous, who does not have splenic malformations. No potential conflict of interest relevant to this article was reported. Fig. 1 CT scan demonstrating a mass in the suprapancreatic common bile duct and abnormal positioning of intra-abdominal organs. Ao, aorta; Gb, gallbladder; H, heart; L, liver; P, pancreas; PV, portal vein; Sp, spleen; St, stomach; TM, tumor mass. Fig. 2 Schematic diagram of perioperative findings. Medial displacement of the liver but normally sided gallbladder and biliary duct, reversed pancreas and spleen, totally left-sided small intestine, and totally right-sided large intestine. C, colon; Gb, gallbladder; L, liver; P, pancreas; Sp, spleen; St, stomach. Fig. 3 Intraoperative photography after reconstruction. Common hepatic artery was positioned under the pancreaticojejunostomy. CBD, common bile duct; P, pancreas; St, stomach.

Fig. 2 Schematic diagram of perioperative findings. Medial displacement of the liver but normally sided gallbladder and biliary duct, reversed pancreas and spleen, totally left-sided small intestine, and totally right-sided large intestine. C, colon; Gb, gallbladder; L, liver; P, pancreas; Sp, spleen; St, stomach. Fig. 3 Intraoperative photography after reconstruction. Common hepatic artery was positioned under the pancreaticojejunostomy. CBD, common bile duct; P, pancreas; St, stomach. Fig. 4 CT scan demonstrating the right gastric artery arising from the celiac trunk. LGA, left gastric artery; RGA, right gastric artery. Fig. 5 CT scan demonstrating the common hepatic artery arising from the superior mesenteric artery. CHA, common hepatic artery; SMA, superior mesenteric artery.

INTRODUCTION According to the Barcelona Clinic Liver Cancer staging, extrahepatic metastasis of hepatocellular carcinoma (HCC) is a poor prognostic factor, and is regarded as advanced stage (C). Most patients with advanced stage receive palliative treatment. The most common site for extrahepatic metastasis of HCC is the lung, followed by regional lymph node, and bone [1,2]. Metastatic skin lesion of HCC is rare, accounting for less than 0.8% of all metastatic cutaneous tumors and occurring in 2.7%-3.4% of all HCCs [3,4]. Skin metastasis is a sign of poor prognosis, indicating the strong possibility of metastases in other regions of the body, and points to a median survival time of less than five months [5,6]. We report on a case of multiple metastases, including skin metastasis, which were treated with multidisciplinary therapy.

[3,4]. Skin metastasis is a sign of poor prognosis, indicating the strong possibility of metastases in other regions of the body, and points to a median survival time of less than five months [5,6]. We report on a case of multiple metastases, including skin metastasis, which were treated with multidisciplinary therapy. CASE REPORT A 52-year-old male patient with a history of type B viral hepatitis visited the hospital with abdominal distension; at that time, a huge mass (a mass measuring approximately 7 cm on segment 8, and a mass measuring 2.5 cm on segment 6) in the right hemiliver and hematomas around the liver were observed on abdominal computed tomography (CT) scan; the diagnosis was HCC rupture (Fig. 1). After transarterial chemoembolization (TACE), segment 8 segmentectomy and segment 6 wedge resection were performed (Fig. 2); hyperthermic intraperitoneal adriamycin irrigation was then performed for prevention of peritoneal seeding. According to the biopsy report, there was no viable tumor because of TACE. The patient was discharged with no specific complication and no evidence of recurrence was observed for seven years postoperative (During the seven years, ultrasonography or CT and tumor marker check was performed every 3 months, but there was no abnormal finding). However, 84 months after the initial operation, an abnormal splenic mass was observed on follow-up ultrasonography, and his tumor marker was elevated (α-fetoprotein, 1.94; protein induced by vitamin K absence or antagonist II, 309). Therefore, we performed positron emission tomography-CT, and multiple metastases were observed. The sites of metastases were brain, adrenal gland, spleen, kidney, skin (buttock), back muscle, and buttock muscle (Figs. 3, 4); however, there was no intrahepatic recurrence. Skin biopsy confirmed metastasis of HCC (Fig. 5). The patient then received radiation therapy for brain metastasis, and took oral medication with sorafenib (Nexavar, Bayer Health Care, Leverkusen, Germany). After one month, a new lesion was observed on his right thumb (Fig. 6). However, follow-up abdominal CT showed stable condition of the previously mentioned multiple metastases (mass of spleen, left adrenal gland, left kidney, back muscle, and buttock muscle), and the brain mass had shrunk. We performed en bloc resection of intra-abdominal metastatic masses (splenectomy, left adrenalectomy, left nephrectomy) and excision of the right thumb mass (Fig.

e previously mentioned multiple metastases (mass of spleen, left adrenal gland, left kidney, back muscle, and buttock muscle), and the brain mass had shrunk. We performed en bloc resection of intra-abdominal metastatic masses (splenectomy, left adrenalectomy, left nephrectomy) and excision of the right thumb mass (Fig. 7; Edmonson-Steiner grade of these masses are grade 2, and histologic type is trabecular, and cell type is hepatic cell). Currently, 18 months after initial diagnosis of multiple metastases, he is still alive, and he takes an oral medication with sorafenib for target therapy of remnant tumor in back muscle, buttock, and brain, which are unresectable (Fig. 8).

are grade 2, and histologic type is trabecular, and cell type is hepatic cell). Currently, 18 months after initial diagnosis of multiple metastases, he is still alive, and he takes an oral medication with sorafenib for target therapy of remnant tumor in back muscle, buttock, and brain, which are unresectable (Fig. 8). DISCUSSION Metastatic skin lesion of HCC is rare; fewer than 50 such cases have been reported in the literature with most of them diagnosed histologically by excision biopsy specimen [7]. Cutaneous metastases originating from HCC appear as rather rapidly growing nodules, usually on the scalp, chest, and shoulder. They appear as single or multiple, firm, painless, nonulcerative, reddish-blue nodules, measuring 1 to 2.5 cm in diameter [8]. Especially in cases of skin metastasis of HCC caused by systemic spread of disease, indicating the strong possibility of metastases in other regions of the body, the prognosis is dismal [5,6]. In addition, in this case, the patient had multiple metastatic lesions, including skin metastasis. Despite these poor prognostic factors, this patient seemed to have good tumor biology, for example, 100% tumor necrosis after initial TACE, recurrence after long period, good response to treatment after multiple site recurrence, and not highly elevated AFP. This favorable tumor biology may be an important factor of long-term survival in this patient.

ctors, this patient seemed to have good tumor biology, for example, 100% tumor necrosis after initial TACE, recurrence after long period, good response to treatment after multiple site recurrence, and not highly elevated AFP. This favorable tumor biology may be an important factor of long-term survival in this patient. In treatment of advanced HCC, to date, the only drug that has successfully made it into a phase III trial is sorafenib. Sorafenib is an oral multikinase inhibitor blocking tumor cell proliferation and angiogenesis by targeting the serine/threonine kinases Raf-1/B-Raf and the tyrosine kinases of vascular endothelial growth factor receptor-2/-3 and Platelet-derived growth factor receptors-b. Median survival and the time to radiologic progression were nearly three months longer for patients treated with sorafenib than for those who received placebo [9]. In this case, after diagnosis of multiple metastases, he was treated with sorafenib. Although we performed successful resection of intraabdominal metastatic masses, remnant tumors remain (brain, back muscle, and buttock muscle). Therefore, further survival of this patient is mainly dependent on sorafenib. No potential conflict of interest relevant to this article was reported. Fig. 1 Initial computed tomography image. A huge mass was observed in segment 8 (A), and an additional mass in segment 6 (B). Perihepatic leakage of contrast (C) was also seen, compatible with rupture of hepatocellular carcinoma.

In treatment of advanced HCC, to date, the only drug that has successfully made it into a phase III trial is sorafenib. Sorafenib is an oral multikinase inhibitor blocking tumor cell proliferation and angiogenesis by targeting the serine/threonine kinases Raf-1/B-Raf and the tyrosine kinases of vascular endothelial growth factor receptor-2/-3 and Platelet-derived growth factor receptors-b. Median survival and the time to radiologic progression were nearly three months longer for patients treated with sorafenib than for those who received placebo [9]. In this case, after diagnosis of multiple metastases, he was treated with sorafenib. Although we performed successful resection of intraabdominal metastatic masses, remnant tumors remain (brain, back muscle, and buttock muscle). Therefore, further survival of this patient is mainly dependent on sorafenib. No potential conflict of interest relevant to this article was reported. Fig. 1 Initial computed tomography image. A huge mass was observed in segment 8 (A), and an additional mass in segment 6 (B). Perihepatic leakage of contrast (C) was also seen, compatible with rupture of hepatocellular carcinoma. Fig. 2 (A) Gross findings after segmentectomy of segment 8, and wedge resection of segment 6. (B) Microscopic findings. Microscopic finding showed no viable hepatocellular carcinoma, believed to be due to initial transarterial chemoembolization (H&E: Left, ×10; Right, ×20).

Fig. 1 Initial computed tomography image. A huge mass was observed in segment 8 (A), and an additional mass in segment 6 (B). Perihepatic leakage of contrast (C) was also seen, compatible with rupture of hepatocellular carcinoma. Fig. 2 (A) Gross findings after segmentectomy of segment 8, and wedge resection of segment 6. (B) Microscopic findings. Microscopic finding showed no viable hepatocellular carcinoma, believed to be due to initial transarterial chemoembolization (H&E: Left, ×10; Right, ×20). Fig. 3 Computed tomography image shows multiple extrahepatic metastases spleen (A), left adrenal gland (B), back muscle (C), buttock muscle (D), and skin of hepatocellular carcinoma (E). Fig. 4 Magnetic resonance imaging (A, focal strong enhancing mass at left precentral gyrus) and positron emission tomography image (B, focal fludeoxyglucose hot uptake nodule on left parietal lobe) of brain metastasis. Brain metastasis was treated with radiation therapy. After radiation therapy, tumor had shrunk (C) Fig. 5 Skin lesion on computed tomography image (A, arrow) and excised mass on buttock (B). (C) Microscopic finding reveals skin metastasis of hepatocellular carcinoma (H&E: Left upper, ×10; Right upper, ×20; Left lower, ×20; Right lower, ×30). Fig. 6 (A) After diagnosis of multiple metastases, a new skin lesion was identified on the right thumb. (B) Magnetic resonance imaging also shows a pedunculated soft tissue mass. Fig. 7 (A) Gross findings of multiple extrahepatic metastases after en bloc resection. (B) Microscopic findings reveal metastases of hepatocellular carcinoma (H&E, ×30).

Fig. 6 (A) After diagnosis of multiple metastases, a new skin lesion was identified on the right thumb. (B) Magnetic resonance imaging also shows a pedunculated soft tissue mass. Fig. 7 (A) Gross findings of multiple extrahepatic metastases after en bloc resection. (B) Microscopic findings reveal metastases of hepatocellular carcinoma (H&E, ×30). Fig. 8 Remnant metastatic masses are still observed on back muscle (A) and buttock (B). Coronal view (C) also shows these masses.

INTRODUCTION Patients with extrahepatic portal vein obstruction usually present with symptoms of portal hypertension. Acute bleeding from esophageal and gastric varices is temporarily treated with sclerotherapy or variceal banding. Patients who experience continued bleeding despite medical treatment or who experience clinically significant symptoms of hypersplenism can be referred for surgery. Surgical options have historically included gastric devascularization procedures and various shunt operations [1-8]. The meso-Rex shunt, which was initially indicated for the treatment of extrahepatic portal vein thrombosis following liver transplantation in children, has been successfully used to treat nontransplant patients with thrombosis due to other etiologies [1-4]. The standard meso-Rex shunt technique uses the patient's own internal jugular vein conduit between the superior mesenteric vein and the intrahepatic left portal vein to restore hepatopetal flow [1-8]. The bypass can be constructed through the interposition of a conduit using the internal jugular vein, the saphenous vein, or the iliac vein from deceased donors [4-8]. Here, we describe a new method using the coronary vein, which is enlarged in most cases of portal hypertension, as an alternative to the standard meso-Rex shunt technique. This simplified technique decreases the total operating time, generates a transposed vein of sufficient length, and eliminates the need for simultaneous embolization of collaterals to augment portal flow and the harvest of autologous veins.

ortal hypertension, as an alternative to the standard meso-Rex shunt technique. This simplified technique decreases the total operating time, generates a transposed vein of sufficient length, and eliminates the need for simultaneous embolization of collaterals to augment portal flow and the harvest of autologous veins. CASE REPORT A meso-Rex shunt with transposition of the coronary vein was performed in a 20-year-old man. The patient had a previous clinical history of increased abdominal volume and five episodes of gastrointestinal bleeding, and was diagnosed with idiopathic portal vein obstruction at 5 years of age. Hypercoagulability studies were performed at the time of thediagnosis. Antithrombin III level was 58% of normal, but other parameters were all unremarkable. One month before the shunt operation, an endoscopy identified aggravated esophageal and paraesophageal varices and hypertensive gastropathy. The size and patency of the umbilical portion of the intrahepatic left portal vein were assessed by preoperative Doppler ultrasonography and computed tomography; there was massive splenomegaly and no detectable intrahepatic left portal vein (Fig. 1). A preoperative percutaneous transhepatic liver needle biopsy showed a noncirrhotic liver without fibrosis, and hepatic venous pressure gradient was 28 mmHg (pressure in the inferior vena cava 7 mmHg, wedged hepatic venous pressure 35 mmHg).

massive splenomegaly and no detectable intrahepatic left portal vein (Fig. 1). A preoperative percutaneous transhepatic liver needle biopsy showed a noncirrhotic liver without fibrosis, and hepatic venous pressure gradient was 28 mmHg (pressure in the inferior vena cava 7 mmHg, wedged hepatic venous pressure 35 mmHg). After laparotomy, the round ligament was dissected toward the distal part of the left portal vein at the level of the Rex recessus. The left portal vein was then approached, and its ventral and lateral aspects were dissected over a length of 3-4 cm. The intrahepatic left portal vein was evaluated by surgical exploration, and its diameter was approximately 3 mm. Splenectomy was performed because of massive splenomegaly. There was a nest of peripancreatic collaterals with flow toward the gastroesophageal junction through a series of large varices, which included the coronary vein with an adequate diameter and flow in the hepatopetal direction. This vein was fully mobilized, divided, and then transposed across the mesocolon and behind the pylorus to the intrahepatic left portal vein to which it was anastomosed end-to-side using nonabsorbable monofilament interrupted sutures (Fig. 2). Unclamping of the meso-Rex shunt immediately allowed adequate portal flow into the liver, as confirmed by intraoperative portography, and there were no remaining large portosystemic shunts (Fig. 3). Postoperative recovery was rapid and uneventful, with liver function tests within normal ranges and normal portal flow observed by Doppler ultrasonography and computed tomography (Fig. 4). Follow-up was uneventful, with improvement of the signs of portal hypertension, without any new episodes of gastrointestinal bleeding. Six months after surgery, computed tomography showed preserved portal vein flow via the shunt.

d normal portal flow observed by Doppler ultrasonography and computed tomography (Fig. 4). Follow-up was uneventful, with improvement of the signs of portal hypertension, without any new episodes of gastrointestinal bleeding. Six months after surgery, computed tomography showed preserved portal vein flow via the shunt. DISCUSSION Although the incidence and natural history of extrahepatic portal vein obstruction are not completely characterized, morbidity is mainly related to variceal bleeding, hypersplenism, limitations on quality of life, recurrent thrombosis, and symptomatic portal bilopathy [9]. Despite conservative treatment, patients who persistently present with clinically significant symptoms of portal hypertension are considered for surgical options such as gastric devascularization procedures and various shunt operations [1-8]. In the early 1990s, de Ville de Goyet et al. [2] reported the meso-Rex shunt as a therapeutic option to relieve extrahepatic portal hypertension after partial liver transplantation. Recently, the meso-Rex shunt has been successfully used to treat nontransplant patients with extrahepatic portal vein obstruction due to other etiologies [3,4]. The meso-Rex bypass procedure restores physiologic portal venous blood flow to the liver by connecting the superior mesenteric vein and the intrahepatic left portal vein branch, and can thereby effectively resolve or prevent all of the known complications of extrahepatic portal vein obstruction [9].

r etiologies [3,4]. The meso-Rex bypass procedure restores physiologic portal venous blood flow to the liver by connecting the superior mesenteric vein and the intrahepatic left portal vein branch, and can thereby effectively resolve or prevent all of the known complications of extrahepatic portal vein obstruction [9]. For successful application of the meso-Rex shunt, eligible patients must fulfill two preconditions: the hepatic structure must be within normal limits and the umbilical portion of the left portal vein must stay patent. When the intrahepatic left portal vein is permeable without acute liver necrosis or liver fibrosis, despite extrahepatic portal vein thrombosis, a meso-Rex shunt, which physiologically redirects portal flow to the liver, can be indicated. The umbilical portion of the left portal vein is accessible after the division of the liver bridge between segments 3 and 4. This part of the portal vein is generally intact and is not affected by changes to the main trunk of the portal vein following thrombosis [6]. Furthermore, this area is generally not involved in the cavernous transformation that may occur after thrombosis and recanalization [6].

e liver bridge between segments 3 and 4. This part of the portal vein is generally intact and is not affected by changes to the main trunk of the portal vein following thrombosis [6]. Furthermore, this area is generally not involved in the cavernous transformation that may occur after thrombosis and recanalization [6]. Although extension of thrombosis to the intrahepatic left portal vein sometimes precludes the use of a meso-Rex shunt, this technique is surgically feasible in most patients even when the intrahepatic left portal vein is poorly visible or not seen at all on routine preoperative imaging studies [9]. In such cases, the size and patency of the umbilical portion of the left portal vein must be confirmed by surgical exploration. A distal splenorenal shunt is an alternative to the meso-Rex shunt, but should only be implemented if the use of meso-Rex shunt is clearly not feasible, either owing to anatomical issues or to a lack of a usable portal vein at the time of surgical exploration of the Rex recessus [9]. Although this alternative procedure can be highly efficacious in both preventing recurrence of variceal bleeding and in decompressing the enlarged spleen with resolution of the hypersplenism, it does not restore mesenteric blood flow to the liver [6]. In most published case series in children, the patient's own internal jugular vein is used as an autograft for the meso-Rex shunt with good results [3-7]. In adult patients, the bypass can be constructed through interposition of a conduit using the patient's own saphenous vein or the iliac vein from deceased donors [5-7]. However, to harvest the internal jugular or saphenous vein, surgeons must perform neck or inguinal dissection. Iliac veins from deceased donors are not readily available and may show an inferior patency rate compared to the use of autologous vein graft because of gradual deterioration and degeneration [1].

onors [5-7]. However, to harvest the internal jugular or saphenous vein, surgeons must perform neck or inguinal dissection. Iliac veins from deceased donors are not readily available and may show an inferior patency rate compared to the use of autologous vein graft because of gradual deterioration and degeneration [1]. In this case report, we propose a new technique for the transposition of the coronary vein for the management of extrahepatic portal vein obstruction without a vascular conduit, which simplified the operative procedures, resulting in reduced total operating time and no need for procurement of autologous veins or for simultaneous embolization of collaterals to augment portal flow. This alternative technique can be safely used in most cases of portal hypertension with an enlarged coronary vein and was effective in treating portal hypertension in the patient presented here. The authors declare no potential conflict of interests in relation to this article. Fig. 1 (A, B) Preoperative axial and coronal reformatted computed tomography scan images showing an obliterated main (arrowhead) and left (open arrow) intrahepatic portal vein. Note the massively enlarged spleen (Sp). Fig. 2 Operative findings showing the transposed coronary vein (white arrows) anastomosed end-to-side to the ventral portion of the extrahepatic left portal vein using nonabsorbable monofilament interrupted sutures. Fig. 3 (A, B) Postoperative venogram of the splenic vein showing a brisk flow to the left intrahepatic portal vein (open arrows) via the meso-Rexshunt (arrowheads).

Fig. 2 Operative findings showing the transposed coronary vein (white arrows) anastomosed end-to-side to the ventral portion of the extrahepatic left portal vein using nonabsorbable monofilament interrupted sutures. Fig. 3 (A, B) Postoperative venogram of the splenic vein showing a brisk flow to the left intrahepatic portal vein (open arrows) via the meso-Rexshunt (arrowheads). Fig. 4 (A-C) Axial and coronal reformatted computed tomography scan images at the 22-day follow-up showing increased portal flow (open arrows) via the preserved meso-Rex shunt (arrowheads).

INTRODUCTION Current management for patients with differentiated thyroid cancer includes near total thyroidectomy and radioactive iodine therapy followed by administration of supraphysiological doses of levothyroxine (L-T4). Because hyperthyroidism accelerates bone turnover and shortens the normal bone remodeling cycle [1,2], it was expected that suppressive L-T4 therapy for differentiated thyroid cancer might influence bone mineral density (BMD). Although longitudinal studies in patients with suppressive L-T4 therapy for differentiated thyroid cancer have reported conflicting data [3-12], the majority of investigators have concluded that recommended dose of L-T4 for postoperative therapy does not have negative effects on bone density [13]. However, the effects of suppressive L-T4 therapy on bone density in the Korean population have not been well defined. The aim of our study is to evaluate the impact of long-term suppressive therapy with L-T4 on BMD and bone turnover markers in Korean female patients who have undergone suppressive therapy for more than 10 years.

the effects of suppressive L-T4 therapy on bone density in the Korean population have not been well defined. The aim of our study is to evaluate the impact of long-term suppressive therapy with L-T4 on BMD and bone turnover markers in Korean female patients who have undergone suppressive therapy for more than 10 years. METHODS Subjects This cross-sectional study was conducted at a single center, Yonsei University Wonju College of Medicine, Korea. Ninety-four female subjects (range, 35-79 years) who underwent total or near total thyroidectomy and radioactive iodine therapy due to thyroid-differentiated carcinoma were enrolled in the study. We enrolled subjects from October 2009 to October 2010. Mean follow-up period was 12.17 ± 4.27 years (median, 12.00 years; range, 5-22 years) and 60.4% of enrolled subjects had been receiving L-thyroxine for more than 10 years. The mean dosage of L-thyroxine during the follow-up period was 160 µg (range, 25-200 µg/day). The percentage of subjects who were premenopausal was 66.7%. Patients with a history of vertebral or femoral fracture that were treated with agents that could interfere with bone metabolism, such as steroids and bisphosphonates, were excluded. To examine the effects of L-T4 on skeletal tissue, we analyzed BMD, bone turnover markers, and biochemical parameters from all subjects, who were divided into three groups by thyroid stimulating hormone (TSH) level (group 1 with TSH level ≤0.001 µIU/mL; group 2 with TSH level between 0.001 and 0.17 µIU/mL; group 3 with TSH level >0.17 µIU/mL) and four groups by quartile of free T4 level. Because most patient TSH levels were suppressed below 0.01 µIU/mL (61.4% of subjects), TSH level could not be grouped into tertiles. Instead, patients with TSH level above 0.01 µIU/mL were divided into two groups-upper 50% and lower 50%.

group 3 with TSH level >0.17 µIU/mL) and four groups by quartile of free T4 level. Because most patient TSH levels were suppressed below 0.01 µIU/mL (61.4% of subjects), TSH level could not be grouped into tertiles. Instead, patients with TSH level above 0.01 µIU/mL were divided into two groups-upper 50% and lower 50%. BMD and laboratory assays BMD was measured at the lumbar spine (levels L2-4), femur neck, and trochanter by dual-energy radiographic absorptiometry (LUNAR prodigy, GE Healthcare, Little Chalfont, UK). T-score was defined as the number of standard deviations (SDs) between measured values and the mean for a control group from the general population matched for gender at 25-45 years of age. T-score ≤-2.5 SD at the lumbar spine, femur neck, or femur trochanter was defined as osteoporosis; T-score between -2.5 and -1.0 SD was defined as osteopenia; T-score ≥ -1.0 was defined as normal. A serum sample was taken from each participant without overnight fasting. We measured free T4 and TSH using the Centaur system (Siemens, Munich, Germany). For bone turnover markers, osteocalcin representative bone formation marker and C-telopeptides of type I collagen (CTX, Modular E170, Hoffmann-La Roche, Basel, Switzerland) representative bone resorption marker were measured.

ight fasting. We measured free T4 and TSH using the Centaur system (Siemens, Munich, Germany). For bone turnover markers, osteocalcin representative bone formation marker and C-telopeptides of type I collagen (CTX, Modular E170, Hoffmann-La Roche, Basel, Switzerland) representative bone resorption marker were measured. Statistical analysis Data were expressed as the mean ± SD. A one-way analysis of variance was used for the comparison of various anthropometric parameters, biochemical parameters, and BMD. The associations between the prevalence of osteoporosis or osteopenia and TSH and FT4 stratified groups were assessed using a chisquare test. The odds ratios were analyzed using logistic regression. All analyses were done using PASW ver. 18.0 (SPSS Inc., Chicago, IL, USA) and SAS ver. 9.2 (SAS Institute, Cary, NC, USA). A P-value <0.05 was considered significant.

teoporosis or osteopenia and TSH and FT4 stratified groups were assessed using a chisquare test. The odds ratios were analyzed using logistic regression. All analyses were done using PASW ver. 18.0 (SPSS Inc., Chicago, IL, USA) and SAS ver. 9.2 (SAS Institute, Cary, NC, USA). A P-value <0.05 was considered significant. RESULTS The clinical characteristics of the subjects are summarized in Table 1. Mean duration of LT4 treatment was 15.0 ± 5.7 years, and mean L-T4 dose was 125.27 ± 38.81 µg/day (range, 25-200 µg/day). Because most patient TSH levels were suppressed below 0.01 µU/mL, the subjects of group 1 defined by TSH ≤0.001 µIU/mL represented 61.17% of participants. The subjects of group 2 defined by TSH >0.001 to ≤0.17 µIU/mL and group 3 defined by TSH >0.17 µIU/mL accounted for 17% and 21% of patients, respectively. Mean BMD contents and T-scores for each group divided by TSH level did not differ significantly among groups (Table 2). Also, bone turnover markers and prevalence of osteoporosis and osteopenia were not different among groups (Table 2). For grouping by FT4 level, all subjects were divided into FT4 quartiles. The subjects of Q1, Q2, Q3, and Q4 were defined by FT4 ≤1.44 ng/dL, FT4 >1.44 through ≤1.63 ng/dL, FT4 >1.63 through ≤1.86 ng/dL, and FT4 >1.86 ng/dL, respectively. The relationship between BMD and prevalence of osteoporosis and osteopenia also did not show any differences among the four FT4 groups (Table 3). No differences existed between BMD and bone turnover markers among groups according to FT4 and TSH levels when subgroup analysis was performed according to state of menopause (data not shown). The odds ratios for risk of osteoporosis and osteopenia in groups 2 and 3 were not significant when compared to the reference group (group 1) (Table 4). The odds ratios for risk of osteoporosis and osteopenia in Q2, Q3, and Q4 by FT4 were not significantly larger than the reference group (Q 1) (Table 4). Also, the prevalence of osteoporosis and osteopenia was not different among groups (Table 4).

not significant when compared to the reference group (group 1) (Table 4). The odds ratios for risk of osteoporosis and osteopenia in Q2, Q3, and Q4 by FT4 were not significantly larger than the reference group (Q 1) (Table 4). Also, the prevalence of osteoporosis and osteopenia was not different among groups (Table 4). DISCUSSION Although overt endogenous hyperthyroidism is known to be an important risk factor of osteoporosis, osteopenia, and osteoporotic fracture [14-17], the clinical outcome of patients with subclinical hyperthyroidism, mild thyrotoxicosis associated with treatment of levothyroxine for hypothyroidism, or suppression therapy after thyroid cancer remains unclear [3-8,18,19]. Abe et al. [20] reported that the TSH receptor is expressed in osteoblasts and osteoclasts. Also, TSH treatment could suppress bone turnover and prevent bone loss [20,21]. Two other in vitro studies reported that increased thyroid hormone-not decreased TSH level-induced bone loss [22,23]. Subsequently, although composited results also exist [24], the roles of thyroid hormone and TSH on BMD have been emphasized by clinicians. Patients with differentiated thyroid cancer have been treated with a supraphysiological dose of levothyroxine for inhibition of tumor recurrence and metastasis after total or near total thyroidectomy. Clinical studies regarding the relationship between levothyroxine treatment and bone turnover markers or BMD do not show consistent results. Thus, the effect of high dose levothyroxine on bone metabolism remains controversial.

ne for inhibition of tumor recurrence and metastasis after total or near total thyroidectomy. Clinical studies regarding the relationship between levothyroxine treatment and bone turnover markers or BMD do not show consistent results. Thus, the effect of high dose levothyroxine on bone metabolism remains controversial. There have been no data about levothyroxine or BMD reported from patients with differentiated thyroid cancer in Korea. In our data, the prevalence of osteoporosis and osteopenia were not different between patients with different TSH suppression and different levels of FT4. Also, BMD and bone turnover markers were not different among the patient groups. However, the prevalence of osteoporosis and osteopenia did not show consistent change according to increase of TSH or decrease of FT4 level. Although we expected that the prevalence of osteoporosis and osteopenia would decrease incrementally according to TSH level, the results were contrary to our expectation. This may be due to the number of subjects: because a large number of patients were treated with levothyroxine up to TSH level < 0.003 µIU/mL, the number of subjects with high TSH level and low FT4 level was relatively small. Therefore, the prevalence of osteoporosis and osteopenia among subjects with high TSH level and low FT4 level may seem improbably high. Because the purpose of TSH suppression is prevention of tumor recurrence, we attempted to suppress the TSH level below the undetectable level. But, for patients with old age, comorbid condition, or reduced adherence to medication due to thyrotoxic symptoms, we suppressed the TSH level to 0.1-2.0 µIU/mL. So, the majority of the subjects showed TSH levels of <0.003 µIU/mL.

of tumor recurrence, we attempted to suppress the TSH level below the undetectable level. But, for patients with old age, comorbid condition, or reduced adherence to medication due to thyrotoxic symptoms, we suppressed the TSH level to 0.1-2.0 µIU/mL. So, the majority of the subjects showed TSH levels of <0.003 µIU/mL. The limitations of our study include small sample size and the fact that all participants were enrolled at a single center. Also, we could not analyze daily calcium intake or exercise-both known to be influencing factors for osteoporosis and osteopenia. Finally, because we performed a cross-sectional study, we could not obtain the initial BMD and other markers that was the another limitation of our study. So, further prospective studies are needed. In conclusion, we suggest that the degree of TSH suppression in thyroid cancer patients is not directly related to bone health, and long-term treatment with levothyroxine can be safely used in patients with total or subtotal thyroidectomy after thyroid cancer. No potential conflict of interest relevant to this article was reported. Table 1 Characteristics of participants (n = 94) Values are presented as mean ± standard deviaion. L-T4, levothyroxine; FT4, free T4; TSH, thyroid stimulating hormone; Tg Ag, thyroglobulin antigen; CTX, C-telopeptides of type I collagen; BMD, bone mineral density. Table 2 BMD and prevalence of osteoporosis or osteopenia grouped by TSH level Values are presented as mean ± standard deviaion.

Values are presented as mean ± standard deviaion. L-T4, levothyroxine; FT4, free T4; TSH, thyroid stimulating hormone; Tg Ag, thyroglobulin antigen; CTX, C-telopeptides of type I collagen; BMD, bone mineral density. Table 2 BMD and prevalence of osteoporosis or osteopenia grouped by TSH level Values are presented as mean ± standard deviaion. BMD, bone mineral density; TSH, thyroid stimulating hormone; L-T4, levothyroxine; FT4, free T4; Tg Ag, thyroglobulin antigen; CTX, C-telopeptides of type I collagen. Table 3 BMD and prevalence of osteoporosis or osteopenia grouped by FT4 quartile Values are presented as mean ± standard deviaion. BMD, bone mineral density; FT4, free T4; L-T4, levothyroxine; TSH, thyroid stimulating hormone; Tg Ag, thyroglobulin antigen; CTX, C-telopeptides of type I collagen. Table 4 Odds ratios of osteoporosis and osteopenia by regression analysis according to FT4 and TSH groups FT4, free T4; TSH, thyroid stimulating hormone; OR, odds ratio; CI, confidence interval.

INTRODUCTION Since the introduction of laparoscopic liver resection in 1991 [1], laparoscopic liver resection has been frequently proposed with improvements in technology and instruments. From benign disease to malignant disease, from nonanatomical minor resection to anatomical major resection, from hand-assisted surgery to pure laparoscopic surgery, laparoscopic surgery has been in wide spread use and refinement of technology has increased. Many studies have demonstrated the feasibility and safety of laparoscopic liver resection. And like other laparoscopic surgeries, short-term benefits such as less pain, less bleeding, less hospital stay have been reported [2-9]. But a few studies of oncological outcome in laparoscopic liver resection for hepatocellular carcinoma (HCC) have been reported and debated. The aim of this retrospective study is to compare the operative outcome and oncological outcome of open liver resection versus laparoscopic liver resection for HCC. METHODS From January 2004 to December 2012, clinical data of 70 patients who underwent laparoscopic liver resection for HCC (laparoscopic liver resection group, lapa-group) were collected and analyzed retrospectively.

INTRODUCTION Since the introduction of laparoscopic liver resection in 1991 [1], laparoscopic liver resection has been frequently proposed with improvements in technology and instruments. From benign disease to malignant disease, from nonanatomical minor resection to anatomical major resection, from hand-assisted surgery to pure laparoscopic surgery, laparoscopic surgery has been in wide spread use and refinement of technology has increased. Many studies have demonstrated the feasibility and safety of laparoscopic liver resection. And like other laparoscopic surgeries, short-term benefits such as less pain, less bleeding, less hospital stay have been reported [2-9]. But a few studies of oncological outcome in laparoscopic liver resection for hepatocellular carcinoma (HCC) have been reported and debated. The aim of this retrospective study is to compare the operative outcome and oncological outcome of open liver resection versus laparoscopic liver resection for HCC. METHODS From January 2004 to December 2012, clinical data of 70 patients who underwent laparoscopic liver resection for HCC (laparoscopic liver resection group, lapa-group) were collected and analyzed retrospectively. Inclusion and exclusion criteria Although the best indication for laparoscopic liver resection is peripherally located small lesions, larger size of tumor is not a contraindication for laparoscopic liver resection. In addition, tumor number was not a contraindication. Difficult tumor location is relative contraindication for laparoscopic liver resection, for example, located very closely to major vascular or biliary structures. Portal or hepatic vein involvement and invasion to adjacent organs was not an indication for laparoscopic liver resection. From January 2004 to December 2012, 77 patients underwent laparoscopic liver resection for HCC. Five patients did not reveal HCC on permanent biopsy, and so were excluded form this study. In addition, 2 patients who underwent laparoscopic microwave ablation or radiofrequency ablation were excluded, because it was not liver resection.

04 to December 2012, 77 patients underwent laparoscopic liver resection for HCC. Five patients did not reveal HCC on permanent biopsy, and so were excluded form this study. In addition, 2 patients who underwent laparoscopic microwave ablation or radiofrequency ablation were excluded, because it was not liver resection. Control group Control group (open liver resection group, open-group) patients were selected by propensity score matching method (AUC = 0.712, Fig. 1), and retrospectively matched for the following criteria: sex, age, international normalized ratio (INR), albumin, α-fetoprotein (AFP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), total bilirubin, indocyanine green (ICG) R15, hepatitis, tumor size, tumor location, type of resection. Operative outcomes were analyzed by resection margin, operative time, rate of blood transfusion, total amount of intraoperative blood transfusion, postoperative complication. Oncological outcomes were analyzed by disease-free survival (DFS), overall survival (OS), and recurrence pattern.

or location, type of resection. Operative outcomes were analyzed by resection margin, operative time, rate of blood transfusion, total amount of intraoperative blood transfusion, postoperative complication. Oncological outcomes were analyzed by disease-free survival (DFS), overall survival (OS), and recurrence pattern. Surgical technique All procedures were performed under general anesthesia. Patients were positioned in supine or left lateral decubitus position according to the tumor location. The pneumoperitoneum with carbon dioxide was introduced, and then intraabdominal pressure was monitored and maintained below 14 mmHg. Four or five trocars were used, depending on the surgical requirements. The trocar insertion sites were determined by the tumor locations. A flexible laparoscopic ultrasound probe was used to localize the tumor and determine the transection line before parenchymal dissection. If anatomical resection was planned such as segmentectomy, hepatic vein for resection margin was firstly recognized with intraoperative ultrasound, then portal pedicle was divided intraparenchymally, then liver parenchyma is dissected along the areas of demarcation of the liver surface. One to 2 cm depth of liver parenchyma was transected using a Harmonic Scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA). An ultrasonic dissector (CUSA Excel, Integra Lifesciences Co., Plainsboro, NJ, USA) was used to dissect deep portions of the liver to skeletonize the portal and hepatic vein. An endoclip was used to control larger structures. We did not routinely apply the Pringle maneuver to control blood flow to the liver, but in selected cases, we used selective extraglissonian pedicle clamping with laparoscopic bulldog clamp for bleeding control or anatomical resection. The specimen was extracted using a vinyl bag. An argon beam coagulator was used on the cut liver surface to control bleeding with ventilation due to the risk of air embolism. Finally, fibrin glue was applied to the cut surface.

dicle clamping with laparoscopic bulldog clamp for bleeding control or anatomical resection. The specimen was extracted using a vinyl bag. An argon beam coagulator was used on the cut liver surface to control bleeding with ventilation due to the risk of air embolism. Finally, fibrin glue was applied to the cut surface. Postoperative management After liver resection operation, all patients were provided intensive care unit care routinely. On principle of early enteral feeding, patients were allowed sips of water at postoperative day 1 and soft diet at postoperative day 2 if no other problems were found. All patients in these study groups were checked by abdomen computed tomography (CT) after 7 days from operation. If no other problems were found in abdomen CT, discharge and outpatient department follow-up was done. Tumor markers (AFP, PIVKA-II) are checked every 2-3 months. And ultrasonography or CT was checked every 6 months. Statistical analysis Statistical analysis was carried out with IBM SPSS ver. 20.0 (IBM Co., Armonk, NY, USA) Control groups were selected by propensity score match with medcalcs 12.7.2 (MedCalc, Ostend, Belgium). Comparisons between categorical variables were analyzed with chi-square test and comparisons of continuous variables were analyzed with Student t-test. DFS and OS rates were calculated using the Kaplan-Meier method, and the log-rank test was used to compare differences in survival between the groups. Values of P < 0.05 were considered statistically significant. The 2 groups were compared on an intention-to-treat basis.

uous variables were analyzed with Student t-test. DFS and OS rates were calculated using the Kaplan-Meier method, and the log-rank test was used to compare differences in survival between the groups. Values of P < 0.05 were considered statistically significant. The 2 groups were compared on an intention-to-treat basis. RESULTS Demographics Demographics features and tumor characteristics are summarized in Table 1. As defined by the matching criteria, both group patients were matched for sex, age, INR, albumin, AFP, AST/ALT, total bilirubin, ICG R15, hepatitis, tumor characteristics (size, location). Mean age was 59.3 years (standard deviation [SD], ±9.43) in the lapa-group and 57.41 years (SD, ±8.64) in the open-group (P = 0.566). Female to male ratio was similar between two groups (lapa-group, 12 [17.14%]:58 [82.86%]; open-group, 18 [23.68%]:58 [76.32%]; P = 0.220). The mean INR was 1.19 (SD, ±1.72) in the lapa-group and 1.04 (SD, ±0.29) in the open-group (P = 0.20). Moreover, additional parameters like albumin, AFP, ICG R15, tumor size and location, liver function test, etiology of hepatitis were similar between the two groups. Therefore, lapa-group and open-group were considered well matched.

as 1.19 (SD, ±1.72) in the lapa-group and 1.04 (SD, ±0.29) in the open-group (P = 0.20). Moreover, additional parameters like albumin, AFP, ICG R15, tumor size and location, liver function test, etiology of hepatitis were similar between the two groups. Therefore, lapa-group and open-group were considered well matched. Operative outcome The operative outcomes are summarized in Table 2. No difference of the type of resection was found between the two groups (P = 0.673). The mean operation time was shorter in the lapa-group than open-group (215.5 vs. 282.30, P = 0.001). The rate of intraoperative transfusion in lapa-group was smaller than that of open-group (24.28 % vs. 40.78 %, P = 0.001). The total amount of intraoperative transfusion in lapa-group was significantly less than the open-group (148.57 vs. 311.71, P = 0.001). In all patients, HCC was confirmed pathologically. Tumor differentiation (Ednomson-steiner grade) and pathologic staing (Union for International Cancer Control staging) were similar between two groups (P = 0.173 and P = 0.683, respectively). Patients were monitored for development of ascites, pleural effusion, bleeding, infection, etc. There was similar rate of postoperative complications between two groups (7.14% vs.14.47%, P = 0.450). No bleeding, wound infection, and pneumonia were observed in the lapa-group, but 3 cases of bleeding, 4 cases of wound infection and 1 case of pneumonia were observed in the open-group. There was 1 postoperative acute renal failure (ARF) in the lapa-group, but no ARF in the open-group. All complications were resolved by conservative treatments. In conclusion, there were no significant differences in complication rates between the two groups, but in the lapa-group there were less than in the open-group. There were six cases (8.57%) of laparoscopic to open conversion; three cases were due to bleeding, one case was due to inadequate resection, one case was due to invisible mass in ultrasonography, one case was due to tumor rupture. We reviewed histological reports focused on resection margin. In the lapa-group mean resection margin was 1.07 cm (SD, ± 1.37) and in the open-group mean resection margin was 0.80 cm (SD, ± 0.82). No significant difference between two groups was found (P = 0.147).

in ultrasonography, one case was due to tumor rupture. We reviewed histological reports focused on resection margin. In the lapa-group mean resection margin was 1.07 cm (SD, ± 1.37) and in the open-group mean resection margin was 0.80 cm (SD, ± 0.82). No significant difference between two groups was found (P = 0.147). Oncological outcome The mean follow-up time was 48.64 months (range, 2-66 months) in the lapa-group and 78.33 months (range, 1-150 months) in the open-group. The OS rate after laparoscopic surgery was 65.3% at 3 years, and 60.3% at 5 years and, respectively, 65.7%, 57.7% after open surgery. Overall survival rate was similar between the two groups (Fig. 2) (P = 0.610). The DFS rate after laparoscopic surgery was 58.3% at 3 years, and 51.0% at 5 years and, respectively, 62.6% and 54.3% after open surgery. DFS rate was similar between the two groups (Fig. 3) (P = 0.773).

Oncological outcome The mean follow-up time was 48.64 months (range, 2-66 months) in the lapa-group and 78.33 months (range, 1-150 months) in the open-group. The OS rate after laparoscopic surgery was 65.3% at 3 years, and 60.3% at 5 years and, respectively, 65.7%, 57.7% after open surgery. Overall survival rate was similar between the two groups (Fig. 2) (P = 0.610). The DFS rate after laparoscopic surgery was 58.3% at 3 years, and 51.0% at 5 years and, respectively, 62.6% and 54.3% after open surgery. DFS rate was similar between the two groups (Fig. 3) (P = 0.773). Recurrence types of each group are summarized in Table 3. In the lapa-group, 30 patients developed recurrence (resection marginal recur, n = 6; one nodular recur, n = 16; multinodular diffuse recur, n = 7; lymph node metastasis, n = 1). One of 7 multinodular diffuse recurrence patients was found with lung metastasis and another one was found with lymph node metastasis. In the open-group, 21 patients developed recurrence (resection marginal recur, n = 3; one nodular recur, n = 9; multinodular diffuse recur, n = 8; lymph node metastasis, n = 1). One of 9 one-nodular recurrence patients was found with other distant metastasis. Disease recurrence rate was similar between the two groups (42.86% vs. 27.63%, P = 0.406).

developed recurrence (resection marginal recur, n = 3; one nodular recur, n = 9; multinodular diffuse recur, n = 8; lymph node metastasis, n = 1). One of 9 one-nodular recurrence patients was found with other distant metastasis. Disease recurrence rate was similar between the two groups (42.86% vs. 27.63%, P = 0.406). Types of treatment of first recurrence are summarized in Table 4. In the lapa-group, 14 patients were treated by transarterial chemoembolisation (TACE), one patient was treated by intra-arterial chemotherapy (IA CTx), and one patient was treated by radiotherapy. The remaining 14 patients were treated in other ways (Per-oral chemotherapy, conservative treatment, etc.). In the open-group, 13 patients were treated by TACE, two patients were treated by IA CTx, two patients were treated by reoperation, and four patients were treated by other ways. Distributions of treatment after recurrence were similar between two groups (P = 0.360). DISCUSSION In the Louisville statement, in the year 2008 [10], the best indication for laparoscopic liver resection for HCC seems to be smaller than 5 cm, single nodule, peripheral lesion (segment 2-6). So, simple comparison between laparoscopic surgery and open surgery could have selection bias. Therefore, this study describes the results of case-matched comparative analysis between laparoscopic and open liver resections for HCC. Two groups were matched for patients' demographics, features, and tumor characteristics (location, size, number) to minimize the selection bias.

pen surgery could have selection bias. Therefore, this study describes the results of case-matched comparative analysis between laparoscopic and open liver resections for HCC. Two groups were matched for patients' demographics, features, and tumor characteristics (location, size, number) to minimize the selection bias. As the technique has developed recently and experience has been accumulated, these indications seem to gradually be developed, so tumor size and location seemed to be not important. In our case, lesser than that of the open group, but there were nine cases for the segment 7, 8 operation. Recently, the intercostal approach operation has been adopted for posterosuperior located HCC; therefore, limitations due to tumor location seems likely to gradually disappear in the future [11]. Furthermore, tumor size itself may not be a contraindication for laparoscopic liver resection [12]. There were 3 cases of operations for tumors bigger than 5 cm.

eration has been adopted for posterosuperior located HCC; therefore, limitations due to tumor location seems likely to gradually disappear in the future [11]. Furthermore, tumor size itself may not be a contraindication for laparoscopic liver resection [12]. There were 3 cases of operations for tumors bigger than 5 cm. There are several advantages of laparoscopic surgery such as less pain, less wound, less bleeding, less adhesion, etc. These advantages correspond with Enhanced Recovery After Surgery, in order to reduce the possibility of inflammatory, humoral and immune response after surgery. Thus, this surgery can decrease complications, including postoperative ileus, making patients' hospital stay decreased [13-15]. Especially, the lack of adhesion is able to enhance the possibility of repeated resection such as HCC, which can easily recur [16]. In the future, planning of liver transplantation can be positively influenced by the surgery [17]. Moreover, this study has shown a significant difference in operation time, which can be shortened in lapa-group.

adhesion is able to enhance the possibility of repeated resection such as HCC, which can easily recur [16]. In the future, planning of liver transplantation can be positively influenced by the surgery [17]. Moreover, this study has shown a significant difference in operation time, which can be shortened in lapa-group. Laparoscopic surgery also has the difficulty of bleeding control. In this study, one of the significant reasons of open conversion is failure to control bleeding. However, there are several other methods to prevent it; laparoscopic Pringle method or selective glissonian pedicle clamping/stapling. Several ways which have been carried out anatomical liver resection are shown using extrahepatic glissonian pedicle approach or intrahepatic glissonian pedicle approach [18,19]. In our case, we did not use the Pringle method, but there were some cases using laparoscopic bulldog clamp to control selective inflow control (Fig. 4). This case contributes not only bleeding control but also anatomical resection through color demarcation lines. And, in our study, rate and amount of intraoperative blood transfusion were smaller in lapa-group than in open-group.

e some cases using laparoscopic bulldog clamp to control selective inflow control (Fig. 4). This case contributes not only bleeding control but also anatomical resection through color demarcation lines. And, in our study, rate and amount of intraoperative blood transfusion were smaller in lapa-group than in open-group. While taking the laparoscopic operation, there are many operative benefits; however, one of the reasons why the laparoscopic operation is not generally accepted is because of the oncologic outcome. In many studies, they indicated that there are no differences in DFS rate and OS rate between laparoscopic surgery and open surgery [5,9,20,21]. As our results show, we have not found significant differences of DFS, OS, and recurrence pattern between the two groups. A large-scale, controlled randomized study seems clinically difficult, but it seems to be necessary as long-term results can be well designed at a large scale. Other limitations of laparoscopic surgery are tumor cell seeding or tumor recurrence through port site. Tumor seeding can occur in open surgery, though we have only one case of tumor seeding. We can anticipate and prevent tumor seeding by careful manipulation. In conclusion, laparoscopic liver resection for HCC is feasible and safe in a large number of patients, and not inferior to open liver resection in regard to operative outcome. And oncologic outcome of laparoscopic liver resection for HCC is not inferior to open liver resection. To prevent tumor seeding, we must manipulate tumor masses carefully.

liver resection for HCC is feasible and safe in a large number of patients, and not inferior to open liver resection in regard to operative outcome. And oncologic outcome of laparoscopic liver resection for HCC is not inferior to open liver resection. To prevent tumor seeding, we must manipulate tumor masses carefully. ACKNOWLEDGEMENTS This research was supported by grant of Yeungnam University Medical Center (2010). No potential conflict of interest relevant to this article was reported. Fig. 1 Receiver operating characteristic (ROC) curve. AUC, area under the curve. Fig. 2 Overall survival rate. Fig. 3 Disease-free survival rate. Fig. 4 Right glissonian pedicle was clamped by laparoscopic intestinal clamp (A), then demarcation line is noted (B). Right glissonian pedicle is clamped by laparoscopic bulldog (C), then liver parenchyma is transected using an energy device (D). Table 1 Demographic characteristics and tumors and liver characteristics Values are presented as mean ± standard deviation or number (%). Lapa-group, laparoscopic liver resection group; open-group, open liver resection group; INR, international normalized ratio; AFP, α-fetoprotein; AST, aspartate aminotransferase; ALT, alanine aminotransferase; ICG, indocyanine green; HBV, hepatitis B virus; HCV, hepatitis C virus. Table 2 Operative outcomes Values are presented as number (%) or mean ± standard deviation. Lapa-group, laparoscopic liver resection group; open-group, open liver resection group; ARF, acute renal failure; US, ultrasonography; UICC, Union for International Cancer Control. Table 3 Recurrence type

Lapa-group, laparoscopic liver resection group; open-group, open liver resection group; INR, international normalized ratio; AFP, α-fetoprotein; AST, aspartate aminotransferase; ALT, alanine aminotransferase; ICG, indocyanine green; HBV, hepatitis B virus; HCV, hepatitis C virus. Table 2 Operative outcomes Values are presented as number (%) or mean ± standard deviation. Lapa-group, laparoscopic liver resection group; open-group, open liver resection group; ARF, acute renal failure; US, ultrasonography; UICC, Union for International Cancer Control. Table 3 Recurrence type Lapa-group, laparoscopic liver resection group; open-group, open liver resection group. Table 4 Type of treatment the first recurrence Lapa-group, laparoscopic liver resection group; open-group, open liver resection group; TACE, transarterial chemoembolization; IA CTx, intra-arterial chemotherapy; RT, radiotherapy; RFA, Radiofrequency ablation; PEIT, percutaneous ethanol injection therapy.

INTRODUCTION Colorectal cancers are the second most common cancer in males and third most common cancer in females in Korea. The incidence of colorectal cancers in 2010 was about 12.8% of all cancers. The incidence rate of colorectal cancers has continued to increase in both sexes in Korea [1]. Main treatment modalities for colorectal cancers are surgery, radiotherapy, and chemotherapy. Chemotherapy is frequently used as the main regimen in most advanced colorectal cancers. Oxaliplatin, a third-generation platinum complex, is one of the most effective chemotherapeutic agents in advanced colorectal cancers. It differs from cisplatin (1st generation platinum complex) in lack of nephrotoxicity and from carboplatin (2nd generation platinum complex) in mild hematological toxicity. However, it causes serious dose-related side effects such as peripheral neuropathy. The acting mechanism causing oxaliplatin to show stronger cytotoxicity to cancer cell with resistance to the other platinum compound drugs and the reason it is more effective when combined with other anticancer drugs are not known [2]. However, repressing expression of survivin that suppresses apoptosis was reported to be one of the mechanisms of oxaliplatin [3,4].

w stronger cytotoxicity to cancer cell with resistance to the other platinum compound drugs and the reason it is more effective when combined with other anticancer drugs are not known [2]. However, repressing expression of survivin that suppresses apoptosis was reported to be one of the mechanisms of oxaliplatin [3,4]. But tumor resistance to chemotherapy (chemo-resistance) presents a major cause of failure in chemotherapy [5]. So, many researchers have been searching for effective chemosensitizing agents. Many potential chemosensitizers are natural agents such as resveratrol. Resveratrol, one of the main constituents of red wine, is a natural agent with potential as an effective chemo-sensitizers [6]. Resveratrol can sensitize tumor cells to many chemotherapeutic agents by overcoming one or more mechanisms of chemoresistance, including survivin down regulation [7,8]. Resveratrol inhibits the growth of a wide variety of tumor cells in culture [9]. Resveratrol has been shown to potentiate the cytotoxic effects of paclitaxel, cisplatin and gemcitabine [10-12]. But in some tumor cells, resveratrol has been shown to act as cytoprotector. Expression of survivin in cancer cells decreased even at low doses of resveratrol, but the effects were dose-dependent [8].

e [9]. Resveratrol has been shown to potentiate the cytotoxic effects of paclitaxel, cisplatin and gemcitabine [10-12]. But in some tumor cells, resveratrol has been shown to act as cytoprotector. Expression of survivin in cancer cells decreased even at low doses of resveratrol, but the effects were dose-dependent [8]. Some cell survival proteins were associated with development of chemoresistance, including c-FLIP [13], X-linked inhibitor of apoptosis [14], and survivin [15]. Survivin is highly expressed in human cancers, including colorectal cancers, but not detectable in nonproliferating normal adult tissues [16]. The role of survivin in the pathogenesis of cancer is inhibition of apoptosis, regulation of the mitotic spindle checkpoint, promotion of angiogenesis and chemoresistance [17]. And high survivin level is related to poor prognosis and resistance to therapy, radiation and chemotherapeutic agents [18]. Thus, survivin is a promising target for sensitization of cancer cells to radiation and chemotherapeutic agents [15]. Our previous studies show that oxaliplatin can suppress survivin expression of colon cancer cells. In order to maximize oxaliplatin therapy, we examined whether resveratrol, a natural phytochemical known to have chemopreventive effects on cancers, can have a chemosensitizing effect upon cotreatment with oxaliplatin. Contrary to our expectation, we found that survivin suppression by YM155 or oxaliplatin pretreatment can be nullified by resveratrol posttreatment. Resveratrol can have a recovering effect on oxaliplatin-mediated cytotoxicity in HCT116 cells.

ancers, can have a chemosensitizing effect upon cotreatment with oxaliplatin. Contrary to our expectation, we found that survivin suppression by YM155 or oxaliplatin pretreatment can be nullified by resveratrol posttreatment. Resveratrol can have a recovering effect on oxaliplatin-mediated cytotoxicity in HCT116 cells. METHODS Cell line and reagents HCT116 human colon cancer cells were obtained from Korean Cell Bank (Seoul, Korea). Cells were cultured in Roswell Park Memorial Institute (RPMI) 1640 medium supplemented with 10% fetal bovine serum (FBS), 100 U/mL penicillin and 100 µg/mL streptomycin in a humidified incubator at 37℃ in an atmosphere of 90% air and 5% CO2. Oxaliplatin was obtained from Sanofi-Synderabo (Seoul, Korea), diluted in sterile phosphate buffered saline (PBS) and stored at 4℃. Penicillin, streptomycin, RPMI 1640, FBS, resveratrol, crystal violet, Hoechest 33258 and YM155 were purchased from Sigma (Sigma-Aldrich Co., St. Louis, MO, USA). MTT kit for cell proliferation was purchased from Promega (Fitchburg, WI, USA). The experimental concentration of oxaliplatin was used according to our previous study [4]. Antibodies against survivin (FL-142, sc-10811), Bcl-2 (100, sc-509), caspase-3 (H-277, sc-7148) and Erk2 (sc-154) were purchased from Santa Cruz Biotechnology (Santa Cruz, CA, USA).

Oxaliplatin was obtained from Sanofi-Synderabo (Seoul, Korea), diluted in sterile phosphate buffered saline (PBS) and stored at 4℃. Penicillin, streptomycin, RPMI 1640, FBS, resveratrol, crystal violet, Hoechest 33258 and YM155 were purchased from Sigma (Sigma-Aldrich Co., St. Louis, MO, USA). MTT kit for cell proliferation was purchased from Promega (Fitchburg, WI, USA). The experimental concentration of oxaliplatin was used according to our previous study [4]. Antibodies against survivin (FL-142, sc-10811), Bcl-2 (100, sc-509), caspase-3 (H-277, sc-7148) and Erk2 (sc-154) were purchased from Santa Cruz Biotechnology (Santa Cruz, CA, USA). Growth inhibition assay Inhibition of cell growth by oxaliplatin, resveratrol and YM155 was assessed by 3-(4,5-dimethylthiazol-2yl) 2,5-diphenyltetrazolium bromide (MTT) assay. After pretreatment with oxaliplatin (2, 5 µM) or resveratrol (30, 50 µM) for 48 hours, the surviving cells were harvested and posttreated with oxaliplatin and resveratrol separately or in combination for 48 hours. Cells were pretreated with YM155 (1 mM) for 1 hour and medium was exchanged with new fresh media containing oxaliplatin, resveratrol, and a combination of oxaliplatin and resveratrol and maintained for 48 hours.

Growth inhibition assay Inhibition of cell growth by oxaliplatin, resveratrol and YM155 was assessed by 3-(4,5-dimethylthiazol-2yl) 2,5-diphenyltetrazolium bromide (MTT) assay. After pretreatment with oxaliplatin (2, 5 µM) or resveratrol (30, 50 µM) for 48 hours, the surviving cells were harvested and posttreated with oxaliplatin and resveratrol separately or in combination for 48 hours. Cells were pretreated with YM155 (1 mM) for 1 hour and medium was exchanged with new fresh media containing oxaliplatin, resveratrol, and a combination of oxaliplatin and resveratrol and maintained for 48 hours. Healthy growing HCT116 cells were detached by trypsin-ethylenediaminetetraacetic acid (EDTA) treatment and 2.5 × 104 cells per ml were resuspended in RPMI containing 10% FBS, which were then seeded into 96-well culture plates with six duplicates. After 24 hours, the culture was maintained for an additional 48 hours in the absence (control) or presence of oxaliplatin, resveratrol, and YM155 as described in the figure legends. After 48 hours culture, 20 µL of 5 mg/mL stock of MTT was added into each well. After 1 hour incubation, culture media was removed and 0.1 mL of dimethyl sulfoxide was added into each well to dissolve the formazan crystals. The intensity of color was measured at 570 nm. All values were normalized to control wells.

nds. After 48 hours culture, 20 µL of 5 mg/mL stock of MTT was added into each well. After 1 hour incubation, culture media was removed and 0.1 mL of dimethyl sulfoxide was added into each well to dissolve the formazan crystals. The intensity of color was measured at 570 nm. All values were normalized to control wells. Crystal violet staining Fifty percent confluent HCT116 cells in 24-well plates were treated with oxaliplatin, resveratrol, and in combination of oxaliplatin and resveratrol for 24 hours. Cells were then fixed in 10% buffered formalin, washed with PBS, incubated with 1% crystal violet (Sigma-Aldrich Co.), solubilized with 1% Triton X-100 and analyzed for absorbance value at 590 nm on a Tecan GENios Plus (Tecan Group Ltd., Zurich, Switzerland). Apoptosis and morphologic assay HCT116 cells were cultured with oxaliplatin (2, 5 µM), resveratrol (30, 50 µM), and oxaliplatin with resveratrol. After 24 hours incubation, cells were stained with Hoechest 33258 and observed in fluorescent microscope (IX71, Olympus Co., Tokyo, Japan). Morphologically apoptotic cells were counted in four randomly selected different sections of each culture.

tin (2, 5 µM), resveratrol (30, 50 µM), and oxaliplatin with resveratrol. After 24 hours incubation, cells were stained with Hoechest 33258 and observed in fluorescent microscope (IX71, Olympus Co., Tokyo, Japan). Morphologically apoptotic cells were counted in four randomly selected different sections of each culture. Reverse transcription-polymerase chain reaction Total RNA was isolated from the cells (1×106 cells/sample) using Trizol reagent (Life Technologies, Rockville, MD, USA). The following primer sequences were used for polymerase chain reaction (PCR) amplifications of survivin: (forward: 5'-CCACCGCATCTCTACATTCA-3' and reverse: 5'-TATGTTCCTCTATGGGGTCG-3'), survivin-2B ( forward: 5'-CCACCGCATCTCTACATTCA-3' and reverse: 5'-AGTGCTGGTATTACAGGCGT-3'), survivin-ΔEx3 (for ward: 5'-CCACCGCATCTCTACATTCA-3' and reverse: 5'-TTTCCTTTGCATGGGGTC-3'), GAPDH (forward: 5'-TGGACCTGACCTACGGCAACAGATA-3' and reverse: 5'-GCCCTCATACTGGAAACCC-3') genes.

and reverse: 5'-TATGTTCCTCTATGGGGTCG-3'), survivin-2B ( forward: 5'-CCACCGCATCTCTACATTCA-3' and reverse: 5'-AGTGCTGGTATTACAGGCGT-3'), survivin-ΔEx3 (for ward: 5'-CCACCGCATCTCTACATTCA-3' and reverse: 5'-TTTCCTTTGCATGGGGTC-3'), GAPDH (forward: 5'-TGGACCTGACCTACGGCAACAGATA-3' and reverse: 5'-GCCCTCATACTGGAAACCC-3') genes. Cells that were cultured were dissolved in 1 mL of cold Trizol solution and lysed. Then, they went through the centrifuge at 12,000 g at 4℃ for 10 minutes, and the supernatant was moved into a new eppendorf tube and was then settled at room temperature for 5 minutes. Chloroform, 200 µL, was added, thoroughly agitated for 15 seconds, and centrifuged at 12,000 g at 4℃ for 15 minutes after being settled for 3 minutes at room temperature. Supernatant-containing RNA was carefully moved to a new eppendorf tube, and 500 µL of isopropyl alcohol was added and centrifuged at 12,000 g at 4℃ for 10 minutes after being settled at room temperature for 10 minutes. Supernatant was removed after checking the presence of RNA clusters, and 1 mL of 75% ethanol was added to clean it. Then, it was centrifuged at 7,500 g at 4℃ for 5 minutes, ethanol was removed, and the RNA was obtained after drying it in the air for 15 minutes. This RNA was dissolved in secondary distilled water that was treated with diethyl pyrocarbonate (DEPC, Sigma Chemical Co.), and the concentration of RNA was measured with a spectrophotometer measuring the optical density at 260/280 nm. The separated RNA was stored at -80℃.

ned after drying it in the air for 15 minutes. This RNA was dissolved in secondary distilled water that was treated with diethyl pyrocarbonate (DEPC, Sigma Chemical Co.), and the concentration of RNA was measured with a spectrophotometer measuring the optical density at 260/280 nm. The separated RNA was stored at -80℃. In creating the cDNA, 2 µL of Oligo dT (Promega) and secondary distilled water that was treated with DEPC were added to 5 µg/µL of the RNA obtained from the HCT116 colon cancer cell strain until the mixture was 10 µL. Then, a fixation reaction was allowed to occur for 10 minutes at 70℃, the mixture was then cooled with ice for 10 minutes, and a master mix (5 × first strand buffer, 4 µL; 0.1 M dithiothreitol, 2 µL; 2.5 M deoxyribonucleotide triphosphates (dNTPs), 2 µL; RNase inhibitor, 1 µL) was added. The mixture was reacted for 2 minutes at 42℃, 1 µL of reverse transcriptase (superscript II [Life Technologies] was added, and the mixture was reacted again for 50 minutes at 42℃ and 15 minutes at 70℃ to finally obtain the cDNA). Secondary distilled water without nuclease, 36.5 µL, and 5 µL of master mix (10 × buffer [500 mM KCl, 100 mM Tris-HCl {pH 8.3}, 15 mM MgCl2]), 4 µL of dNTP, 1 µL of primer sense, 1 µL of primer antisense, and 0.5 µL of Taq DNA polymerase (TaKaRa Taq, Takara, Shiga, Japan) were added to 2 µL of cDNA. Then, the mixture was placed in a DNA thermal cycler (GeneAmp PCR system 9700, Applied Biosystems, Foster City, CA, UAS) for 2 minutes at 94℃, 1 minute (denaturing) at 94℃, 1 minute (annealing) at 60℃, and 1 minute (extension) at 72℃. Under the conditions of PCR, the process was repeated 28 times to amplify the reaction. After the PCR reaction, electrophoresis was executed in 1.5% agarose gel, and GAPDH was modified by using the same method.

2 minutes at 94℃, 1 minute (denaturing) at 94℃, 1 minute (annealing) at 60℃, and 1 minute (extension) at 72℃. Under the conditions of PCR, the process was repeated 28 times to amplify the reaction. After the PCR reaction, electrophoresis was executed in 1.5% agarose gel, and GAPDH was modified by using the same method. Western blot analysis The cells were lysed in lysis buffer (50 mM Tris, 100 mM NaCl, 2.5 mM EDTA, 1% Triton X-100, 1% Nonidet P-40, 25 µg/mL aprotinin, 25 µg/mL leupeptin, 25 µg/mL pepstatin A, and 1 mM phenylmethysulfnyl fluoride). After centrifugation at 10,000 g for 15 minutes, the supernatant was used for Western blot analysis. Protein concentration was determined by the Bio-Rad Protein Assay kit (Bio-Rad, Hercules, CA, USA). Aliquotes of cell lysates containing 50 µg of protein were separated by 3% sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Following electrophoresis, proteins were transferred electronically onto polyvinylidene fluoride membranes (Bio-Rad). Membranes were incubated for 1 hour at room temperature with blocking buffer, TBS-T (20 mM Tris, pH 7.6, 100 mM NaCl, 0.1% Tween-20) and 5% nonfat dry milk with gentle agitation. After washing the membranes with TBS-T three times, membranes were incubated overnight at 4℃ in TBS-T buffer containing 5% nonfat dry milk and with one of the following antibodies (1:1,000 dilution): survivin (sc-10811), Bcl-2 (sc-509), caspase-3 (sc-7148). The membranes were washed three times with TBS-T and incubated with secondary antibodies (1:5,000 dilution) in TBS-T buffer containing 5% nonfat dry milk for 2 hours at room temperature with gentle agitation. The membranes were washed again three time with TBS-T, the protein bands were visualized by enhanced chemiluminescence detection system (Amersham, Little Chalfont, UK). The reacted bands were detected with an image analyzer (LAS-2000, Fuji Film, Tokyo, Japan).

milk for 2 hours at room temperature with gentle agitation. The membranes were washed again three time with TBS-T, the protein bands were visualized by enhanced chemiluminescence detection system (Amersham, Little Chalfont, UK). The reacted bands were detected with an image analyzer (LAS-2000, Fuji Film, Tokyo, Japan). Membranes were stripped in a stripping buffer containing 100 mM2-mercaptoethanol, 2% sodium dodecyl sulfate, 62.5 mM Tris-HCl, pH 6.7 at 55℃. The membranes were reprobed for the level of ERK-2. All Western blots were performed at least 3 times for each experiment. Statistical analysis The results were analyzed using analysis of variance followed by Tukey multiple comparisons of means (95% family-wise confidence level). A P-value of <0.05 was designated as the level of significance. RESULTS Resveratrol posttreatment nullifies oxaliplatin pretreatment induced survivin suppression Survivin mRNA expression is suppressed with oxaliplatin treatment (5 µM) for 2 days. However, when we treated the cells with resveratrol (30, 50 µM for 2 days incubation), survivin mRNA expression was not suppressed (Fig. 1A). With surviving cells upon oxaliplatin pretreatment (5 µM, for 2 days), we posttreated with resveratrol (50 µM), oxaliplatin (5 µM), and combination of resveratrol and oxaliplatin for 2 days. Survivin mRNA expression was suppressed with preoxaliplatin treatment. However, when resveratrol was posttreated on the surviving cells, the survivin mRNA expression was restored. This restoration effect was also detected in survivin delta Ex3, 2B variants (Fig. 1B).

mbination of resveratrol and oxaliplatin for 2 days. Survivin mRNA expression was suppressed with preoxaliplatin treatment. However, when resveratrol was posttreated on the surviving cells, the survivin mRNA expression was restored. This restoration effect was also detected in survivin delta Ex3, 2B variants (Fig. 1B). And a reciprocal experiment was performed in this setting. When we posttreated with oxaliplatin on the surviving cells with resveratrol pretreatment, survivin mRNA expression was suppressed. However, when we posttreated with resveratrol or oxaliplatin + resveratrol on these cells, the survivin mRNA expression was restored. We also observed restoration of survivin delta Ex3, 2B variants. When we pretreat HCT116 cells with resveratrol, oxaliplatin-mediated surviving suppression was restored (Fig. 1C). Resveratrol posttreatment nullifies YM155 and oxaliplatin pretreatment induced cell proliferation suppression We pretreated HCT116 cells with YM155, a specific survivin inhibitor to suppress the survivin expression for 1 hour. After YM155 pretreatment, cells were treated with oxaliplatin, resveratrol, and a combination of oxaliplatin and resveratrol for 24 hours. Cells were then stained with crystal violet and analyzed for viability of cells by measuring absorbance at 590 nm. Resveratrol restored cell viability upon YM155 mediated survivin suppression. This restoration effect of resveratrol also occurred in combined pretreatment of YM155 and oxaliplatin as shown in Fig. 2.

urs. Cells were then stained with crystal violet and analyzed for viability of cells by measuring absorbance at 590 nm. Resveratrol restored cell viability upon YM155 mediated survivin suppression. This restoration effect of resveratrol also occurred in combined pretreatment of YM155 and oxaliplatin as shown in Fig. 2. Resveratrol posttreatment nullifies YM155 and oxaliplatin pretreatment induced apoptotic activity We also stained the treated cells with Hoechst to assess the apoptotic cells. Resveratrol showed a cytoprotective effect restoring from undergoing apoptosis. Oxaliplatin induced apoptosis. However, when cells were treated with oxaliplatin + resveratrol, apoptotic cells were markedly decreased (Fig. 3A, B). When we inhibited survivin expression by YM155, resveratrol treatment protected cells from undergoing apoptosis even in combined treatment with oxaliplatin (Fig. 3C). Resveratrol had a cytoprotective effect on HCT116 cells restoring from undergoing apoptosis induced by YM155 and oxaliplatin. Combined treatment with oxaliplatin and resveratrol abolished oxaliplatin-mediated apoptotic induction.

ted cells from undergoing apoptosis even in combined treatment with oxaliplatin (Fig. 3C). Resveratrol had a cytoprotective effect on HCT116 cells restoring from undergoing apoptosis induced by YM155 and oxaliplatin. Combined treatment with oxaliplatin and resveratrol abolished oxaliplatin-mediated apoptotic induction. Resveratrol posttreatment nullifies YM155 and oxaliplatin pretreatment induced protein expression. Oxaliplatin pretreatment suppressed expression of survivin, Bcl-2, caspase-3 protein levels in HCT116 cells. YM155 abolished expression of survivin, bcl-2, and calspae-3 protein levels additively upon oxaliplatin cotreatment. However, resveratrol posttreatment restored expression of survivin, Bcl-2, caspase-3 protein levels down-regulated by oxaliplatin. Decreased expression of bcl-2 and caspase-3 protein levels by YM155 and oxaliplatin seems to be related to survivin suppression but expression of bcl-2 and caspase-3 protein levels was restored with combined treatment with resveratrol (Fig. 4). Taken together, resveratrol may directly induce restoration of survivin suppressed by oxaliplatin and YM155 pretreatment. Importantly, resveratrol may play a role as a cytoprotector in survivin suppressed cells in some cancer cells.

aspase-3 protein levels was restored with combined treatment with resveratrol (Fig. 4). Taken together, resveratrol may directly induce restoration of survivin suppressed by oxaliplatin and YM155 pretreatment. Importantly, resveratrol may play a role as a cytoprotector in survivin suppressed cells in some cancer cells. DISCUSSION Oxaliplatin, a third-generation platinum complex, is the one of the most effective chemotherapeutic agents for the treatment of advanced stages of colorectal cancers in clinic. The advantage of oxaliplatin therapy over other platinum compound drugs is stronger cytotoxic activity on platinum refractory cancers but the mechanism of action is not well established [2]. One of the potential mechanisms of oxaliplatin superiority could be due to down-regulation of survivin expression upon oxaliplatin treatment [3,4].

xaliplatin therapy over other platinum compound drugs is stronger cytotoxic activity on platinum refractory cancers but the mechanism of action is not well established [2]. One of the potential mechanisms of oxaliplatin superiority could be due to down-regulation of survivin expression upon oxaliplatin treatment [3,4]. Our data have shown that oxaliplatin can suppress survivin expression in both transcripts and protein level of HCT116 cells. Alternative splicing variants of survivin (2B, deltaEx3) were also suppressed upon oxaliplatin challenge. Furthermore, pretreatment of YM155, a small molecule known to specifically inhibit survivin, additively suppressed survivin expression of HCT116 cells upon oxaliplatin challenge. YM155 pretreatment and oxaliplatin change additively suppressed protein expression level of Bcl-2 and caspase-3 of HCT116 cells. Taken together, combinatorial treatment of YM155 and oxaliplatin may increase cytotoxic effects on colon cancers. Thus, we propose that combination treatment of oxaliplatin and YM155 could be a promising treatment modality for advanced stages of colon cancers in clinics.

on level of Bcl-2 and caspase-3 of HCT116 cells. Taken together, combinatorial treatment of YM155 and oxaliplatin may increase cytotoxic effects on colon cancers. Thus, we propose that combination treatment of oxaliplatin and YM155 could be a promising treatment modality for advanced stages of colon cancers in clinics. Chemotherapy is the main regimen in most advanced colorectal cancers to prevent recurrence or metastases. But tumor resistance to chemotherapy (chemo-resistance) presents a major cause of failure in chemotherapy [5]. Also, chemotherapeutic agents have considerable side effects. Because of chemoresistance and side effects, many researchers have been searching for effective chemosensitizing agents to potentiate the chemotherapeutic effect and reduce the side effects. Many phytochemicals have been studied for chemosensitization activity. Resveratrol, one of the main constituents of red wine, is a natural agent found to be an effective potential chemo-sensitizers [6]. Resveratrol (3, 4', 5-trihydroxy-trans-stilbene) was first isolated in 1940 and has anti-infective, antioxidant, and cardioprotective functions [19]. In 1997, resveratrol was found to have anticancer potential [20] and the anticancer activities are mediated through modulation of several cell signaling molecules that regulate cell cycle progression, inflammation, proliferation, apoptosis, invasion, metastases, and angiogenesis of tumor cells [9,21,22].

unctions [19]. In 1997, resveratrol was found to have anticancer potential [20] and the anticancer activities are mediated through modulation of several cell signaling molecules that regulate cell cycle progression, inflammation, proliferation, apoptosis, invasion, metastases, and angiogenesis of tumor cells [9,21,22]. Most of the reports indicate that resveratrol sensitize tumor cells to chemotherapeutic agents by modulating cell survival proteins. Resveratrol potentiated apoptosis induced by chemotherapeutic agents by down-regulating survivin expression and increasing apoptosis [7]. Resveratrol has also been shown to sensitize tumor cells by inducing caspase activation. It was reported that resveratrol may affect many intracellular signaling molecules including suppression of survivin. But in some cancer cells resveratrol may act with a cytoprotection effect.

pression and increasing apoptosis [7]. Resveratrol has also been shown to sensitize tumor cells by inducing caspase activation. It was reported that resveratrol may affect many intracellular signaling molecules including suppression of survivin. But in some cancer cells resveratrol may act with a cytoprotection effect. Due to the chemosensitizing effect of resveratrol, we initially anticipated that resveratrol cotreatment with oxaliplatin may additively suppress survivin expression of HCT116 cells. Upon resveratrol cotreatment with oxaliplatin, however, there was no additive suppression of survivin in HCT116 cells. More surprisingly, we observed that resveratrol challenge on oxaliplatin pretreated HCT116 cells can nullify oxaliplatin-mediated survivin suppression and restore survivin expression of HCT116 cells in both transcripts and protein level. Oxaliplatin challenge on resveratrol pretreated HCT 116 cells, however, cannot nullify oxaliplatin-mediated survivin suppression of HCT116 cells. Taken together, our results clearly showed that resveratrol has a strong recovering effect on oxaliplatin-mediated cellular toxicity. To further examine resveratrol-mediated recovering effects, we performed cell proliferation and apoptosis assays. Oxaliplatin pretreated HCT116 cells, which underwent suppression of cell proliferation activity and induction of apoptosis, were able to restore their cellular viability upon resveratrol challenge. Furthermore, YM155 pretreated HCT116 cells, which underwent survivin suppression in both transcripts and protein level, were able to restore their survivin expression levels upon resveratrol challenge. In Western blot analysis, we were able to show restoration of survivin, BCl-2, and caspase-3 protein levels of HCT116 cells upon resveratrol post-treatment on YM155 and oxaliplatin pretreated HCT116 cells.

h transcripts and protein level, were able to restore their survivin expression levels upon resveratrol challenge. In Western blot analysis, we were able to show restoration of survivin, BCl-2, and caspase-3 protein levels of HCT116 cells upon resveratrol post-treatment on YM155 and oxaliplatin pretreated HCT116 cells. But unlike its proapoptotic action in tumor cells, resveratrol has antiapoptotic effect on chondrocytes [23], and inhibit p53-dependent apoptosis [21]. Expression of survivin in cancer cells decreased even at low doses of resveratrol, but the effects were dose-dependent [8]. Effects of resveratrol were dependent on cell, tissue type and concentration. Survivin constituted the fourth top "transcriptome" in colorectal, lung, brain, and breast cancer by genome-wide searches [24]. This reflects an "oncofetal" pattern of expression because survivin is highly expressed in embryonic organs, is nearly undetectable in most differentiated normal tissue, and becomes dramatically re-expressed during tumor development [25,26]. Survivin participates in the cellular stress response, in which binding of the protein to the molecular chaperone heat shock protein 90 helps tumor cells cope with unfavorable environments and other exogenous stresses and thus preserve cell proliferation and cell viability [27,28].

Survivin constituted the fourth top "transcriptome" in colorectal, lung, brain, and breast cancer by genome-wide searches [24]. This reflects an "oncofetal" pattern of expression because survivin is highly expressed in embryonic organs, is nearly undetectable in most differentiated normal tissue, and becomes dramatically re-expressed during tumor development [25,26]. Survivin participates in the cellular stress response, in which binding of the protein to the molecular chaperone heat shock protein 90 helps tumor cells cope with unfavorable environments and other exogenous stresses and thus preserve cell proliferation and cell viability [27,28]. Inhinition of survivin by the Eli-Lilly survivin specific synthetic single stranded DNA-antisense oligonucleotides (LY2181308) resulted in significantly increased apoptosis, and decreased clonogenic survival when combined with radiation and also suggested that survivin shows a radioresistance factor and molecular biomarker, predicting tumor response in patients with rectal cancer treated with neoadjuvant radiochemotherapy [29]. The role of survivin in the pathogenesis of cancer is inhibition of apoptosis, regulation of the mitotic spindle checkpoint, promotion of angiogenesis and chemoresistance [17]. And high survivin level is related to poor prognosis and resistance to the therapy, radiation and chemotherapeutic agents [18]. So attention has been given to survivin as a target for sensitization of cancer cells to radiation and chemotherapeutic agents [15].

The role of survivin in the pathogenesis of cancer is inhibition of apoptosis, regulation of the mitotic spindle checkpoint, promotion of angiogenesis and chemoresistance [17]. And high survivin level is related to poor prognosis and resistance to the therapy, radiation and chemotherapeutic agents [18]. So attention has been given to survivin as a target for sensitization of cancer cells to radiation and chemotherapeutic agents [15]. In this paper, resveratrol may act as cytoprotective agent in HCT116 colon cancer cells. Especially, resveratrol can restore survivin suppression induced by oxaliplatin or YM155, specific survivin inhibitor. Also, it protects the HCT116 colon cancer cells from apoptosis by oxaliplatin and YM155. We recommend cautious use of resveratrol as a chemoprevention or chemosensitizing agent though resverstrol's chemosensitizing effect is in the process of being establishment by many other studies. ACKNOWLEDGEMENTS The present research was conducted by the research fund of Dankook University in 2011. No potential conflict of interest relevant to this article was reported.

We recommend cautious use of resveratrol as a chemoprevention or chemosensitizing agent though resverstrol's chemosensitizing effect is in the process of being establishment by many other studies. ACKNOWLEDGEMENTS The present research was conducted by the research fund of Dankook University in 2011. No potential conflict of interest relevant to this article was reported. Fig. 1 Resveratrol posttreatment nullifies oxaliplatin pretreatment induced survivin suppression. (A) HCT116 cells were incubated with oxaliplatin (2, 5 µM), resveratrol (30, 50 µM). Expression of survivin mRNA and its alternative splicing variants (Delta Ex3, 2B) was measured by reverse transcription-polymerase chain reaction (RT-PCR). The primers used were described in materials and methods. (B) Surviving cells pretreated with oxaliplatin (5 µM for 24 hours) were collected and posttreated with oxaliplatin (5 µM) and resveratrol (5 µM) for 24 hours additionally. And expression of survivin mRNA and its alternative splicing variants (Delta Ex3, 2B) was measured by RT-PCR. (C) Surviving cells pretreated with resveratrol (50 µM for 24 hours) were collected and treated with oxaliplatin (5 µM) and resveratrol (50 µM) for 24 hours additionally. And the expression of survivin mRNA and its alternative splicing variants (Delta Ex3, 2B) was measured by RT-PCR.

ta Ex3, 2B) was measured by RT-PCR. (C) Surviving cells pretreated with resveratrol (50 µM for 24 hours) were collected and treated with oxaliplatin (5 µM) and resveratrol (50 µM) for 24 hours additionally. And the expression of survivin mRNA and its alternative splicing variants (Delta Ex3, 2B) was measured by RT-PCR. Fig. 2 Resveratrol post-treatment nullifies YM155 and oxaliplatin pre-treatment induced cell proliferation suppression. HCT116 cells were pre-treated with YM155 (survivin inhibitor) for 1 hour. Cells were, then, treated with oxaliplatin and posttreated with resveratrol as described in METHODS section. Cell proliferation activity was measured by crystal violet staining analysis as described in METHODS section. Cell proliferation activity was additively suppressed by oxaliplatin and YM155 copretreatment. The suppressive effect by copretreatment nullified by resveratrol post-treatment (*P < 0.05. **P < 0.05).

section. Cell proliferation activity was measured by crystal violet staining analysis as described in METHODS section. Cell proliferation activity was additively suppressed by oxaliplatin and YM155 copretreatment. The suppressive effect by copretreatment nullified by resveratrol post-treatment (*P < 0.05. **P < 0.05). Fig. 3 Resveratrol post-treatment nullifies YM155 and oxaliplatin pretreatment induced apoptotic activity. (A) HCT116 cells were pretreated with YM155 (survivin inhibitor) for 1 hour. Cells were, then, treated with oxaliplatin and posttreated with resveratrol as described in METHODS section. Cells were stained with Hoechest 33258 and photos were taken for morphological analysis as described in METHODS section. (B) Resveratrol posttreatment nullified oxaliplatin pretreatment induced apoptotic activity (*P < 0.005). (C) Resveratrol post-treatment nullified YM155 and oxaliplatin copretreatment induced apoptotic activity (*P < 0.05. **P < 0.005. ***P < 0.005). The results were analyzed using analysis of variance followed by Tukey multiple comparisons of means (95% family-wise confidence level). A P-value of <0.05 was designated as the level of significance.

tment nullified YM155 and oxaliplatin copretreatment induced apoptotic activity (*P < 0.05. **P < 0.005. ***P < 0.005). The results were analyzed using analysis of variance followed by Tukey multiple comparisons of means (95% family-wise confidence level). A P-value of <0.05 was designated as the level of significance. Fig. 4 Resveratrol posttreatment nullifies YM155 and oxaliplatin pretreatment induced protein expression. HCT116 cells were pretreated with YM155 (survivin inhibitor) for 1 hour. Cells were, then, treated with oxaliplatin and posttreated with resveratrol as described in METHODS section. Protein expression of survivin, Bcl-2, and caspase-3 was examined by Western blot analysis. Protein expression levels of survivin, Bcl-2, and caspase-3 were additively suppressed by oxaliplatin and YM155 co-pretreatment. The suppressive effect by co-pretreatment was nullified by resveratrol posttreatment.

INTRODUCTION In most cases of type A esophageal atresia (EA), immediate primary anastomosis is difficult to perform because the intervals between both ends of the esophagus are longer than that in other types of EA. Usually, gastrostomy can be priorly performed, followed by either esophageal replacement or delayed primary anastomosis; however, each procedure has its own advantages and disadvantages [1]. The advantage of performing early gastrostomy followed by esophageal replacement with gastric tube is that the anastomosis can be performed by reducing the tension in cases where the length of the esophagus is insufficient; however, this has been reported to result in gastroesophageal reflux (GER) and anastomotic stenosis because of the change in the location of the gastroesophageal junction to the chest, which is caused by raising the mobilized stomach through the hiatus [2]. In cases where delayed primary anastomosis after early gastrostomy is performed, the prognosis associated with GER and swallowing function is reportedly better because the native esophagus is preserved [1]. However, providing continuous treatment in the neonatal intensive care unit (ICU) until the esophagus reaches an appropriate length has disadvantages that such as the cost and the risk of pathogenic infections, including repeated pneumonia due to aspiration [3]. Therefore, in this study, we aimed to compare the outcomes of different types of surgical treatment for type A EA by evaluating the patients from a single institution.

In cases where delayed primary anastomosis after early gastrostomy is performed, the prognosis associated with GER and swallowing function is reportedly better because the native esophagus is preserved [1]. However, providing continuous treatment in the neonatal intensive care unit (ICU) until the esophagus reaches an appropriate length has disadvantages that such as the cost and the risk of pathogenic infections, including repeated pneumonia due to aspiration [3]. Therefore, in this study, we aimed to compare the outcomes of different types of surgical treatment for type A EA by evaluating the patients from a single institution. METHODS We performed a retrospective study using the medical records of 22 patients (13.4%) who were found to have type A EA, among 164 patients diagnosed with EA at our institution from January 1980 to December 2011. The demographic factors such as sex, birth weight, gestational age and associated anomalies, as well as the diagnostic method, operative method, complications, treatment for the complications, and outcomes were investigated. If asymptomatic stenosis at the anastomosis site was detected on esophagography, it was categorized as mild; in addition, cases that improved after endoscopic balloon dilatation (EBD) were categorized as moderate, whereas and those requiring surgical treatment were categorized as severe. With regard to GER and anastomosis leakage, cases that exhibited an improment after conservative treatment were categorized as mild to moderate, whereas those requiring surgical treatment were categorized as severe.

were categorized as moderate, whereas and those requiring surgical treatment were categorized as severe. With regard to GER and anastomosis leakage, cases that exhibited an improment after conservative treatment were categorized as mild to moderate, whereas those requiring surgical treatment were categorized as severe. For the analysis of outcomes according to operative methods, 21 patients excluding 1 patient who received primary esophageal end-to-end anastomosis without gastrostomy were divided into the end-to-end (E-E) and esophago-gastric tube (E-G) groups. The E-G group was further divided into the isoperistaltic and antiperistaltic groups depending on the peristaltic direction of the gastric tube. We used PASW ver. 18.0 (SPSS Inc., Chicago, IL, USA) for statistical analysis, along with the Mann-Whitney U test and the Fisher exact test; the significance level was set at P < 0.05.

roup was further divided into the isoperistaltic and antiperistaltic groups depending on the peristaltic direction of the gastric tube. We used PASW ver. 18.0 (SPSS Inc., Chicago, IL, USA) for statistical analysis, along with the Mann-Whitney U test and the Fisher exact test; the significance level was set at P < 0.05. RESULTS Patient demographics The 22 type A EA patients who received surgery at our institution comprised 12 male and 10 female patients (ratio, 1.2:1). Except for 1 patient for whom the gestational and birth weights were unknown, the median value for gestational age in the other 21 patients was 37.5 weeks (range, 32-42 weeks) and the median birth weight was 2.5 kg (range, 1.5-3.3 kg). Seven patients (31.8%) were premature babies aged <37 weeks, 11 patients (50%) were low birth weight babies weighing <2.5 kg, and 1 patient was a very low birth weight baby weighing <1.5 kg (Table 1). Among the 22 patients, 14 (63.6%) showed a total of 38 associated anomalies. Cardiovascular malformations accounted for the highest frequency of anomalies (9 patients, 40.9%) (Table 2). The median gap between the proximal and distal esophagus in all patients was 6 (range, 2-7) vertebral distance (VD).

RESULTS Patient demographics The 22 type A EA patients who received surgery at our institution comprised 12 male and 10 female patients (ratio, 1.2:1). Except for 1 patient for whom the gestational and birth weights were unknown, the median value for gestational age in the other 21 patients was 37.5 weeks (range, 32-42 weeks) and the median birth weight was 2.5 kg (range, 1.5-3.3 kg). Seven patients (31.8%) were premature babies aged <37 weeks, 11 patients (50%) were low birth weight babies weighing <2.5 kg, and 1 patient was a very low birth weight baby weighing <1.5 kg (Table 1). Among the 22 patients, 14 (63.6%) showed a total of 38 associated anomalies. Cardiovascular malformations accounted for the highest frequency of anomalies (9 patients, 40.9%) (Table 2). The median gap between the proximal and distal esophagus in all patients was 6 (range, 2-7) vertebral distance (VD). Diagnostic method Among the 22 patients, 10 patients received prenatal diagnosis based on the presence of polyhydramnios and the absence of gastric air shadow on fetal ultrasonography. In cases where type A EA was suspected, the diagnosis was confirmed based on the absence of air shadow on plain abdominal images and the twisting of the gastric tube with a blocked entrance after birth. Twelve patients were diagnosed postnatally; 10 patients showed no gas shadow on the x-ray with a blocked gastric tube entrance after birth, whereas the other 2 patients were diagnosed based on the finding of a barium esophagogram at different institutions. The distance between the both ends of the esophagus was measured by using the VD.

re diagnosed postnatally; 10 patients showed no gas shadow on the x-ray with a blocked gastric tube entrance after birth, whereas the other 2 patients were diagnosed based on the finding of a barium esophagogram at different institutions. The distance between the both ends of the esophagus was measured by using the VD. Operative method In 1 patient, primary esophageal end-to-end anastomosis was performed because the esophageal end-to-end length was found to be 1.5 VD even when thoracotomy was done without gastrostomy. In the other 21 patients, gastrostomy was priorly performed, whereas 2 patients also underwent cervical esophagostomy, at different institutions, because of severe drooling despite continuous postoperative oral suction. Nasogastric tube insertion was performed through the proximal esophagus at the time of the definitive surgery, and the esophageal end-to-end distance was measured using the radiograph taken with a Hegar dilator in situ in the distal esophagus through the gastrostomy. When the length was less than 4 VD, end-to-end anastomosis was performed; however, if the length was same or more than 4 VD, esophago-gastric tube anastomosis was performed. End-to-end anastomosis of the esophagus was performed in 7 patients after gastrostomy, and esophago-gastric tube anastomosis after gastrostomy was performed in 14 patients.

han 4 VD, end-to-end anastomosis was performed; however, if the length was same or more than 4 VD, esophago-gastric tube anastomosis was performed. End-to-end anastomosis of the esophagus was performed in 7 patients after gastrostomy, and esophago-gastric tube anastomosis after gastrostomy was performed in 14 patients. Gastrostomy Of 21 patients, 10 patients were transferred to our institution from other institutions after gastrostomy, whereas the other 11 patients received the procedure at our institution. We performed tube gastrostomy according the Stamm method using a 14-Fr Malecot tube or a silicon-type gastrostomy tube. Gastrostomy was performed in the antrum of the greater curvature of the stomach, considering the possibility that gastric tube replacement would subsequently be performed. Esophageal end-to-end anastomosis For esophageal end-to-end anastomosis, all procedures were performed in the right fourth intercostal incision, excluding 1 case performed in the thoracoabdominal incision. Intrathoracic anastomosis was performed in all cases. Among these cases, anastomosis was performed in 4 patients by the dissection of the gastroesophageal junction and the stomach fundus using an additional abdominal incision, as the distal esophagus had great tension during anastomosis. In 2 cases, pyloroplasty was performed because of suspected damage to the vagus nerve during surgery. In 2 patients, we attempted to extend the length of the distal esophagus by using bougination through a gastrostomy between the primary gastrostomy and secondary esophageal end-to-end anastomosis procedure.

nastomosis. In 2 cases, pyloroplasty was performed because of suspected damage to the vagus nerve during surgery. In 2 patients, we attempted to extend the length of the distal esophagus by using bougination through a gastrostomy between the primary gastrostomy and secondary esophageal end-to-end anastomosis procedure. Esophago-gastric tube anastomosis A gastric tube was created with greater curvature of the stomach by using GIA, and the diameter of the gastric tube was determined on the basis of chest tube (12-20 Fr) depending on the patients' weight (if body weight at operation <2.5 kg, 12 Fr was used; whereas if that ≥2.5 kg, 14 Fr or 20 Fr was used.) An isoperistaltic conduit, which involves the alignment of the gastric tube in the same direction as the gastric peristalsis, was applied in 9 patients, whereas an antiperistaltic conduit, wherein the alignment is in the opposite direction of the gastric peristalsis, was used in 5 patients. In addition, the gastric tube was placed through the mediastinal route in 11 patients; however, in 3 patients, the retrosternal route was used because of a history of operation at the mediastinal area or combined heart disease. Anastomosis was performed by using a thoracic approach in cases where the esophageal proximal blind pouch was located in close to the carina, or by using the cervical approach in cases where the proximal blind pouch was located in the cervical area or in the thoracic inlet.

Esophago-gastric tube anastomosis A gastric tube was created with greater curvature of the stomach by using GIA, and the diameter of the gastric tube was determined on the basis of chest tube (12-20 Fr) depending on the patients' weight (if body weight at operation <2.5 kg, 12 Fr was used; whereas if that ≥2.5 kg, 14 Fr or 20 Fr was used.) An isoperistaltic conduit, which involves the alignment of the gastric tube in the same direction as the gastric peristalsis, was applied in 9 patients, whereas an antiperistaltic conduit, wherein the alignment is in the opposite direction of the gastric peristalsis, was used in 5 patients. In addition, the gastric tube was placed through the mediastinal route in 11 patients; however, in 3 patients, the retrosternal route was used because of a history of operation at the mediastinal area or combined heart disease. Anastomosis was performed by using a thoracic approach in cases where the esophageal proximal blind pouch was located in close to the carina, or by using the cervical approach in cases where the proximal blind pouch was located in the cervical area or in the thoracic inlet. Anastomosis of the gastric tube was performed in the thoracic esophagus in 4 patients and in the cervical esophagus in 10 patients. For thoracic anastomosis, the right second intercostal space (ICS) approach was used for 1 patient, whereas the fourth ICS approach was used for 3 patients. Cervical anastomosis was performed by using the left side in 7 patients, the right side in 1 patient, and the previous esophagostomy site in 2 patients. In 3 cases, vagus nerve injury was suspected and pyloroplasty was simultaneously performed.

sed for 1 patient, whereas the fourth ICS approach was used for 3 patients. Cervical anastomosis was performed by using the left side in 7 patients, the right side in 1 patient, and the previous esophagostomy site in 2 patients. In 3 cases, vagus nerve injury was suspected and pyloroplasty was simultaneously performed. Postoperative management For the stabilization of the anastomosis site after esophageal end-to-end anastomosis or esophago-gastric tube anastomosis, ventilator care with sedation was maintained for 2 days. After surgery, a nasogastric tube was kept for 7 days, and we checked esophagography on the 7th postoperative day. Food intake was permitted in cases where no leakage was detected. In case food intake was difficult owing to swallowing discoordination or reflux caused by long-term fasting, a nasogastric tube was used to support nutrition and it was kept when the patients were discharged from the hospital. After discharge, they kept feeding via nasogastric tube and they could eat orally without nasogastric tube within postoperative 3-6 months. The 1 patient who received primary esophageal end-to-end anastomosis without gastrostomy was born in 1980, and is the first such case. This patient was a male who was born at the gestational age of 38 weeks; his birth weight was 2,500 g, and he did not have any associated anomalies. He was transferred to our institution 7 days after birth because of continuous vomiting and pneumonia, where he received esophageal end-to-end anastomosis on the 9th day of birth. His VD was 1.5 and his weight at the time of surgery was 2,610 g.

is birth weight was 2,500 g, and he did not have any associated anomalies. He was transferred to our institution 7 days after birth because of continuous vomiting and pneumonia, where he received esophageal end-to-end anastomosis on the 9th day of birth. His VD was 1.5 and his weight at the time of surgery was 2,610 g. At the time of gastrostomy, the median age was 1 day (range, 0-9 days). Moreover, the median weight at the time of surgery was 2.4 kg (range, 2.1-3.3 kg), and the median postoperative ICU treatment period was 15 days (range, 4-23 days). Except for 1 patient who received primary esophageal end-to-end anastomosis, the median age at the definitive surgery was 8 months (range, 4-12 months). The median weight at the time of surgery was 8.2 kg (range, 6.1-12.3 kg), the mean postoperative ICU treatment period was 4 days (range, 1-14 days), and the median interval between primary surgery and definitive surgery was 259 days (range, 145-370 days). The median follow-up period was 94.5 months (range, 1-316 months) and there were no deaths among the 22 patients during the follow-up period. Complications Among 21 patients who received gastrostomy, 3 patients (14.3%) had gastrostomy-associated complications. Two patients had gastrostomy malposition, and 1 patient had gastrostomy leakage. All patients underwent gastrostomy revision and showed improvements.

The median follow-up period was 94.5 months (range, 1-316 months) and there were no deaths among the 22 patients during the follow-up period. Complications Among 21 patients who received gastrostomy, 3 patients (14.3%) had gastrostomy-associated complications. Two patients had gastrostomy malposition, and 1 patient had gastrostomy leakage. All patients underwent gastrostomy revision and showed improvements. However, complications were noted found in all cases after the definitive surgery. Anastomosis leakage occurred in 3 patients (13.6%). This was found to be mild in 2 patients who recovered after conservative management such as tube feeding and were discharged after oral food intake on the 19th and 29th days after the surgery. However, 1 patient showed signs of mediastinal expansion on the 2nd postoperative day with suspected anastomosis leakage; in this case, we repaired the leakage site after explorative thoracotomy.

tive management such as tube feeding and were discharged after oral food intake on the 19th and 29th days after the surgery. However, 1 patient showed signs of mediastinal expansion on the 2nd postoperative day with suspected anastomosis leakage; in this case, we repaired the leakage site after explorative thoracotomy. Anastomosis stenosis was detected in 9 patients (42.9%). Except for 1 patient who did not have symptoms, EBD was performed in 8 patients with stenosis. EBD was performed repeatedly from 2 to 9 times (average number of times, 4) from the 27th day of the anastomosis. Three of 8 patients who received EBD showed improvement (33.3%); however, 5 patients did not show improvement and required resection of the stenosis area and underwent reanastomosis. Among the 5 patients who received resection of the stenosis area, 2 patients smoothly progressed to meal intake whereas the remaining 3 patients again developed stenosis after surgery and received EBD from 2 to 5 times; at present, they are on a normal diet without any problems. GER was observed in 20 patients (90.9%). The symptoms were severe in 1 patient, and Nissen fundoplication and pyloroplasty were performed. Nineteen patients showed mild to moderate symptoms and received conservative treatment such as medication therapy. During the follow-up period, 11 patients did not experience any reflux symptoms and 11 patients showed mild symptoms such as intermittent coughing after overeating or at night.

pyloroplasty were performed. Nineteen patients showed mild to moderate symptoms and received conservative treatment such as medication therapy. During the follow-up period, 11 patients did not experience any reflux symptoms and 11 patients showed mild symptoms such as intermittent coughing after overeating or at night. In addition, complications such as pleural effusion, wound infection, pneumonia, esophageal hiatal hernia, delayed gastric emptying, cardiac arrest, ileus, and dumping syndrome were observed. Ileus, pleural effusion, delayed gastric emptying, and dumping syndrome improved with conservative management, whereas esophageal hiatal hernia is being observed through the outpatient clinic as it is asymptomatic. Comparison of secondary E-E vs. E-G The median gap was 3 VD for the E-E group and 6 VD for the E-G group, with the E-E group showing a significantly short gap. There was no significant difference between the 2 groups with regard to patient demographics, weight, and age at the time of surgery (Table 3). No significant difference was noted between the 2 groups with regard to anastomosis leakage. Stenosis was found to develop more frequently in the E-E group than in the E-G group (P = 0.001). In particular, severe stenosis occurred in 57.1% of patients in the E-E group, which was significantly higher than that in the E-G group. In addition, GER was found to develop more frequently in the E-G group than in the E-E group, but the difference was not statistically significant. In the E-G group, GER occurred in all patients (Table 4).

No significant difference was noted between the 2 groups with regard to anastomosis leakage. Stenosis was found to develop more frequently in the E-E group than in the E-G group (P = 0.001). In particular, severe stenosis occurred in 57.1% of patients in the E-E group, which was significantly higher than that in the E-G group. In addition, GER was found to develop more frequently in the E-G group than in the E-E group, but the difference was not statistically significant. In the E-G group, GER occurred in all patients (Table 4). No significant difference was noted between the 2 groups with regard to the other complications. Among the patients in the E-G group, when comparing the patients according to the use of an isoperistaltic tube or an antiperistaltic tube, no difference was noted in the frequencies of leakage, postoperative stenosis, or GER (Table 5). DISCUSSION Type A EA is characterized by a wide interval between the proximal and distal esophageal blind ends, which makes primary anastomosis difficult [4]. According to Humphreys and Ferrer Jr [5], the first case with a successful surgery of type A EA was in 1946. The baby was born in 1935 and was survived with maintaining food intake via gastrostomy [5]. In type A EA, primary anastomosis is possible if the gap between both esophageal ends is short; however, in cases with a wide gap, esophageal reconstruction is performed by using various organs.

DISCUSSION Type A EA is characterized by a wide interval between the proximal and distal esophageal blind ends, which makes primary anastomosis difficult [4]. According to Humphreys and Ferrer Jr [5], the first case with a successful surgery of type A EA was in 1946. The baby was born in 1935 and was survived with maintaining food intake via gastrostomy [5]. In type A EA, primary anastomosis is possible if the gap between both esophageal ends is short; however, in cases with a wide gap, esophageal reconstruction is performed by using various organs. Since Howard and Myers [6] performed successfully delayed esophageal end-to-end anastomosis by expanding the upper esophagus with a mercury bougie for 5 weeks, delayed esophageal end-to-end anastomosis after upper esophagus expansion had been performed until the late 1970s. Thereafter, esophageal end-to-end anastomosis as a delayed procedure has been performed widely for its physiological approach, postoperative functionality, and high patient satisfaction.

ougie for 5 weeks, delayed esophageal end-to-end anastomosis after upper esophagus expansion had been performed until the late 1970s. Thereafter, esophageal end-to-end anastomosis as a delayed procedure has been performed widely for its physiological approach, postoperative functionality, and high patient satisfaction. Despite a slight abnormality in the peristalsis of the esophagus, conservation of the native esophagus has been preferred as it is the best conduit in itself [7]. In addition, as the physiological function and structure of the esophagus are conserved as much as possible for patients who received primary end-to-end anastomosis, it has been reported that superior prognosis is noted in terms of function related to swallowing and GER [1]. Maksoud-Filho et al. [1] also reported that the long-term prognosis was good in terms of swallowing and GER for patients in whom the esophagus was conserved. After 12 weeks from the birth, it is reported that esophageal end-to-end anastomosis could be successfully performed by complete dissection around the esophagus, maintenance of ventilator care, and circular muscle resection in order to avoid excessive tension after surgery [7]. In the initial period after birth, the growth of the esophagus is fast and secondary GER or the stenosis caused by this reflux can be medically treated. It has been argued that the esophagus with anastomosis does not show the abnormal mucosal lesion that in observed in other reconstructive operations, and follow-up shows good functional outcomes [8].

h, the growth of the esophagus is fast and secondary GER or the stenosis caused by this reflux can be medically treated. It has been argued that the esophagus with anastomosis does not show the abnormal mucosal lesion that in observed in other reconstructive operations, and follow-up shows good functional outcomes [8]. However, conserving the native esophagus in EA patients with long gaps is not always feasible. In that case, end-to-end esophageal anastomosis can cause high perioperative complications. Therefore, it is necessary to reduce the tension and facilitate the surgical process by creating a "conduit" [9]. In other words, after creating and developing an esophagostomy and gastrostomy, esophageal replacement using other structures, such as the colon, stomach, small intestine, and the damaged part of the esophagus, is performed [8].

sary to reduce the tension and facilitate the surgical process by creating a "conduit" [9]. In other words, after creating and developing an esophagostomy and gastrostomy, esophageal replacement using other structures, such as the colon, stomach, small intestine, and the damaged part of the esophagus, is performed [8]. Esophageal replacement with the colon has been widely performed until the late 1980s, as the procedure was easy to perform. Postoperative leakage of esophago-colon anastomosis occurred in 30%-50% patients, and accompanied various complications such as anastomosis stenosis, sagging and stasis of the intrathoracic dislocated colon, and necrosis of the bowel segment [8]. Recently, stomach replacement has been widely used, and Spitz et al. [10] has argued that this procedure is desirable as it has higher patient satisfaction and lower rate of postoperative complications than the colon replacement method. However, careful monitoring is necessary for the early diagnosis of postoperative esophagitis, Barrett's changes, and atrophic gastritis. In some cases, it has been argued that using the stomach route in EA is preferable, as the blood flow is sufficient and the length can be measured; moreover, there is an original resistance to acid and the ability to maintain the shape of the tube without separate expansion [11]. Reconstructive surgery using the small intestine includes the Roux-en-Y method or the transposition method with a small intestine graft by using microvascular anastomosis; however, this is rarely performed in children due to the unstable vascular connection created after anastomosis [12]. Various esophageal replacement surgeries can reduce esophageal stenosis and GER by reducing the postoperative tension in the anastomosis site; however, they are time consuming, complex, and may result in the expansion and change in the shape of the organ, as well as ulcers or bleeding due to reflux [13].

stomosis [12]. Various esophageal replacement surgeries can reduce esophageal stenosis and GER by reducing the postoperative tension in the anastomosis site; however, they are time consuming, complex, and may result in the expansion and change in the shape of the organ, as well as ulcers or bleeding due to reflux [13]. The need for esophageal replacement by using a conduit and end-to-end anastomosis is determined depending on the gap between the esophageal ends; however, identifying the esophageal gap is difficult. At the time of EA diagnosis, the location of the proximal esophagus can be predicted roughly by means of x-ray images, on the basis of the location of the Levin tube; however, the location of the distal esophagus cannot be identified accurately despite the use of ultrasonography. Even if the VD was identified in the combination of ultrasonography and the gastrography with contrast via gastrostomy, most cases show discrepancies with actual surgical findings [7]. In this study, we attempted to identify the location of the distal esophagus by using a metal probe via gastrostomy before surgery, and this provided a more accurate assessment of the location than the gastrostomy tube contrast method before surgery, and also matched the findings confirmed during surgery. Therefore, we suggest using a metal probe in order to accurately identify the location of the distal esophagus.

e via gastrostomy before surgery, and this provided a more accurate assessment of the location than the gastrostomy tube contrast method before surgery, and also matched the findings confirmed during surgery. Therefore, we suggest using a metal probe in order to accurately identify the location of the distal esophagus. Among the 22 patients examined in this study, 1 patient who received the first surgery in 1980 underwent esophageal end-to-end anastomosis without bridge operation, whereas the other 21 patients all received primary gastrostomy. The VD of the E-E group and the E-G group were 3 and 6, respectively, with the E-E group showing a significantly short gap. The results of this study indicate that, in the case of type A EA, definitive surgery is considered if the weight is approximately 9 kg at 8-9 months after the primary gastrostomy, and the decision of whether to perform end-to-end anastomosis or esophago-gastric tube anastomosis should be based on the VD at the time of the definitive surgery. Postoperative complications mostly involve anastomosis [14,15]. According to a previous study, anastomosis leakage, anastomosis stenosis, GER, repeated pneumonia, and sepsis with GER accounted for most of the cases of complications [16].

Among the 22 patients examined in this study, 1 patient who received the first surgery in 1980 underwent esophageal end-to-end anastomosis without bridge operation, whereas the other 21 patients all received primary gastrostomy. The VD of the E-E group and the E-G group were 3 and 6, respectively, with the E-E group showing a significantly short gap. The results of this study indicate that, in the case of type A EA, definitive surgery is considered if the weight is approximately 9 kg at 8-9 months after the primary gastrostomy, and the decision of whether to perform end-to-end anastomosis or esophago-gastric tube anastomosis should be based on the VD at the time of the definitive surgery. Postoperative complications mostly involve anastomosis [14,15]. According to a previous study, anastomosis leakage, anastomosis stenosis, GER, repeated pneumonia, and sepsis with GER accounted for most of the cases of complications [16]. Anastomosis leakage has been reported to occur in 37.5%-45.0% of patients [17]. The factors involved in anastomosis leakage include the use of silk sutures, anastomosis tension, ischemia due to an excessive dissection in the distal esophagus, and technical failure [18]. Anastomosis leakage is an important complication directly associated with death. In the cases of mild leakage, conservative treatment can include parenteral nutrition with antibiotics under fasting conditions; however, in cases where leakage is severe, appropriate drainage is most important [19]. Rescorla et al. [20] reported that approximately 50% of patients from the esophageal end-to-end anastomosis group showed anastomosis leakage but spontaneous recovery was noted after conservative treatment. The leakage rate in this study was 13.6%, which is lower than that reported in previous studies. In addition, there was no statistical significance as it occurred in 28.6% of the group receiving end-to-end anastomosis or in 7.1% of the esophago-gastric tube anastomosis group, with a slightly higher tendency in the end-to-end anastomosis group. This result supports previous findings that esophageal replacement with gastric tube helps in reducing tension in anastomosis and lowers anastomosis leakage by sufficiently adjusting the length and allowing for good blood flow compared with replacement with other organs.