Annals of Surgical Treatment and Research最新文献

Compared with other treatments, surgical resection is an effective treatment method with the lowest local recurrence rate and the highest survival rate for hepatocellular carcinoma (HCC). To achieve excellent results after surgical treatment, it is essential to carefully select patients who are suitable for hepatic resection and minimize postoperative complications and liver function decline through standardized surgical methods and pre- and postoperative management. However, domestic and international treatment guidelines only broadly recommend the application of hepatic resection for HCC with a single tumor and good liver function. Hence, practical treatment guidelines are required that can be standardized and used according to the varying clinical environments, including indications for hepatic resection, preoperative evaluation, basic principles of hepatic resection, minimally invasive hepatic resection, pre- and postoperative patient management, surgical treatment considerations in specific infection situations, and follow-up after surgical resection. Accordingly, an expert group from the Korean Liver Cancer Association Research Committee has developed practical recommendations based on expert consensus regarding the surgical treatment of HCC through a Delphi study.

Purpose: According to the guidelines of the Japanese Gastric Cancer Association, endoscopic submucosal dissection (ESD) is safe for gastric cancer (GC) patients with absolute indications because the possibility of lymph node metastasis (LNM) is 0%. The aim of this study was to reveal the exact proportion of Korean GC patients with LNM whose pathological examination revealed indications for ESD.

Methods: Data were extracted from the '2019 Korean Nationwide Retrospective Database' managed by the Korean Gastric Cancer Association. Among the 14,076 patients, 4,220 patients with stage T1a cancer after radical gastrectomy were enrolled. Pathological examination was performed to ascertain the tumor diameter, depth of invasion, tumor differentiation, presence of lymphovascular/perineural invasion, and presence of ulceration.

Results: The proportion of patients with LNM and absolute indications was 2.4% (49 of 2,012). The 95% confidence interval for the proportion of patients with LNM was greater than 1.0% across all subgroups in terms of absolute indications. According to the multivariate regression model, the risk factors for LNM were lymphovascular invasion (odds ratio [OR], 7.56), perineural invasion (OR, 3.02), a tumor size >2 cm (OR, 2.37), undifferentiated tumors (OR, 2.30), and ulceration (OR, 1.66).

Conclusion: Compared with Japanese studies, this study revealed a relatively high proportion of Korean GC patients with LNM and absolute indications for ESD. The Japanese guidelines for ESD could be applied to Korean GC patients if done carefully.

Purpose: With neoadjuvant treatment (NAT) broadening the surgical indication for advanced pancreatic cancer, the growing use of robotic platforms in pancreaticoduodenectomy (PD) necessitates the evaluation of its feasibility in advanced pancreatic cancer patients who have undergone NAT.

Methods: We compared clinicopathological outcomes of advanced pancreatic cancer patients who received either robot-assisted or open PD after NAT at a tertiary hospital from 2015 to 2023. Propensity score matching was performed based on age, sex, and TNM staging.

Results: Among 223 patients who received conversion surgery after NAT, 42 open PD and 14 robot-assisted PD patients were matched in a 3:1 ratio. There was a trend of shorter hospital stays (11.4 days vs. 9.8 days, P = 0.218) and less severe postoperative complications (21.4% vs. 7.1%; P = 0.227) in the robot-assisted PD group. Lymph node (LN) yield, LN metastasis rate, and R0 resection rates were similar between the 2 groups. The overall (OS) and disease-free survival (DFS) rates between the 2 groups were comparable (5-year OS rate: 55.7% vs. 72.7%, P = 0.264; 5-year DFS rate: 54.4% vs. 58.4%, P = 0.759).

Conclusion: Robot-assisted PD offers comparable short-term and long-term outcomes to open PD, even in patients undergoing conversion surgery after NAT.

Purpose: Oncocytic carcinoma (OCA) has been reclassified from follicular thyroid carcinoma due to its unique features. Its rarity has resulted in limited studies on differentiating OCA from oncocytic adenoma (OA). This study aimed to compare the clinicopathologic and preoperative features of OCA and OA and evaluate the effectiveness of ultrasonography and cytology.

Methods: We conducted a retrospective study involving 83 patients (23 with OCA and 60 with OA) who underwent thyroid surgery between 2011 and 2024. We reviewed clinical, ultrasonographic, cytologic, and histopathologic data to assess diagnostic performance.

Results: OCA cases had larger tumors than OA in both sonographic (4.2 ± 1.7 cm vs. 2.7 ± 1.4 cm, P < 0.001) and pathologic measurements (3.8 ± 1.7 cm vs. 2.3 ± 1.4 cm, P < 0.001). K-TIRADS (the Korean Thyroid Imaging Reporting and Data System) did not effectively distinguish OCA from OA; however, ACR TI-RADS (the American College of Radiology Thyroid Imaging Reporting and Data System) categorized more OCA cases into higher-risk groups (17.4% vs. 1.7%, P = 0.016). Trabecular formation and intranodular vascularity were more frequent in OCA (17.4% vs. 1.7%, P = 0.019; 65.2% vs. 33.3%, P = 0.049). Cytologically, 87% of OCAs were classified as follicular neoplasms compared to 20% of OAs.

Conclusion: Predicting malignancy in oncocytic neoplasms is challenging. Larger tumor size, higher ACR TI-RADS scores, and trabecular formation are potential indicators for OCA. Cytologic subcategorization within Bethesda IV suggests follicular neoplasms carry a higher malignancy risk than oncocytic neoplasms. Multicenter studies are needed to validate these findings.

Purpose: Hilar cholangiocarcinoma is known for its poor prognosis due to late diagnosis. To achieve long-term survival, curative resection often is necessary. However, after surgical resection, the 5-year survival rates vary from 14% to 48%. The aim of this study is to evaluate the prognostic factors for long-term survival in hilar cholangiocarcinoma.

Methods: Patients who underwent curative resection for hilar cholangiocarcinoma at Samsung Medical Center from January 2000 to December 2020 were included. Demographics, surgical and oncological outcomes, short-term complications, recurrence, pathologic results, and survival were analyzed. Prognostic factors were analyzed with Cox proportional hazards models.

Results: A total of 449 patients diagnosed with hilar cholangiocarcinoma who underwent intent-to-treat resection at Samsung Medical Center from 2000 to 2020 were included in this study. The median disease-free survival was 19 months, and the median survival was 40 months. One-, 3-, and 5-year survival rates were 82.8%, 53.7%, and 35.8%, respectively.

Conclusion: The 5-year survival rate of patients with hilar cholangiocarcinoma was 35.8% at Samsung Medical Center. Median survival was 40 months. N2 stage and tumor biology were factors affecting 5-year survival.

Purpose: The selection of primary tumor resection (PTR) vs. self-expanding metallic stents (SEMS) in obstructive unresectable stage IV colorectal cancer (CRC) is critical, profoundly impacting patient outcome. This study evaluates the influence of PTR and SEMS on overall survival (OS) in conjunction with chemotherapy.

Methods: The analysis included 137 patients with obstructive, unresectable stage IV CRC who underwent PTR or attempted SEMS placement. The primary objective was to assess the OS of patients, specifically examining how PTR and SEMS interventions influence these survival outcomes.

Results: In a cohort of 137 patients with obstructive, unresectable stage IV CRC, 30 initially opted for PTR, while stent placement was attempted in 107 cases. Following 14 stent failures, which resulted in 8 diversions and 6 additional PTR interventions, exclusions due to elective surgeries led to a final analysis of 36 PTR and 72 SEMS cases. Cox regression analysis identified no significant survival advantage between PTR and SEMS interventions (hazard ratio [HR], 0.848; 95% confidence interval [CI], 0.555-1.298; P = 0.449). Critical findings highlighted that the absence of chemotherapy markedly reduced survival prospects (HR, 1.963; 95% CI, 1.200-3.211; P = 0.007). These insights were substantiated through propensity score matching.

Conclusion: The comparative analysis reveals that neither PTR nor SEMS offers a definitive survival advantage in managing obstructive, unresectable stage IV CRC. However, the necessity for subsequent invasive interventions is notably lower in the PTR group.

Purpose: This study investigates risk factors for recurrence in patients who underwent laparoscopic primary closure (PC) for pyloroduodenal ulcer perforation (PUP).

Methods: We retrospectively analyzed data from patients who underwent laparoscopic PC with or without highly selective vagotomy (HSV) for PUP at a tertiary hospital from 2010 to 2019. Demographics, surgical outcomes, proton pump inhibitor (PPI) use, Helicobacter pylori status, and endoscopic findings were reviewed. Long-term (5 years) endoscopic and clinical outcomes regarding ulcer and perforation recurrence, were collected.

Results: A total of 139 patients were included in the analysis. Of these, 109 (78.4%) were male, and 76 (54.7%) were current smokers. Ninety-five patients (68.3%) underwent PC only, while 44 (31.7%) received PC + HSV. During the follow-up period, ulcer recurrence was observed in 19 patients (13.7%) and perforation recurrence in 9 (6.5%). In Cox proportional analysis for ulcer recurrence, smoking (hazard ratio [HR], 6.476; 95% confidence interval [CI], 1.834-22.873; P = 0.004) and older age (HR, 1.049; 95% CI, 1.012-1.088; P = 0.009) were identified as significant factors. For peptic ulcer perforation recurrence, smoking (HR, 19.129; 95% CI, 2.048-178.702; P = 0.010) and older age (HR, 1.062; 95% CI, 1.009-1.118; P = 0.021) were significant. No significant associations were found between sex, duration of PPI therapy, H. pylori eradication success, or surgery type and the risk of either ulcer or perforation recurrence.

Conclusion: Smoking and age are important factors for recurrence following laparoscopic PC for PUP. These findings emphasize the need for smoking cessation and close postoperative monitoring.

Purpose: This study introduced adenomas per polypectomy (APP) as a novel metric for evaluating the progression of lesion discrimination skills among colonoscopy trainees.

Methods: This retrospective study was conducted at the National Cancer Center, Korea between March 2020 and February 2023. Nine colorectal surgeons who completed a structured 1-year colonoscopy training program were included, and their performance was compared with that of 5 expert endoscopists. APP was defined as the number of histologically confirmed adenomas among the total number of polypectomies performed. The APPs were calculated serially to assess changes from the beginning to the end of the training.

Results: A total of 8,072 colonoscopies were performed by 9 trainees and 11,687 by 5 experts. The average APP of the 9 trainees was 67.0%, which was significantly different from the 73.9% APP of the experts (P < 0.001). The APP progression of trainees exhibited 3 phases: phase 1 (<200 cases) showed increasing polyp detection and APP; phase 2 (200-500 cases) displayed a sharp rise in the number of polypectomies but a decline in APP; and phase 3 (>500 cases) demonstrated a decrease in the number of polypectomies with a moderate rise in APP. However, even in phase 3, the trainees' APP remained significantly lower than that of the experts (69.9% vs. 73.9%, P = 0.027).

Conclusion: APP, a measure of visual adenoma discrimination ability, undergoes 3 stages of progression during colonoscopy training. This progression suggests that the APP may serve as an additional metric for assessing the effectiveness of colonoscopy training.

Purpose: Given the widening of the donor pool to include patients with steatosis, small-for-size grafts, and older patients, this study examined the effect of age on liver volumetric regeneration after a donor right hepatectomy.

Methods: We enrolled 33 older (≥55 years) and 277 younger (<30 years) donors who underwent donor right hepatectomy between March 2012 and December 2022. After propensity score-matched analysis, the perioperative surgical outcomes and growth rates of the remnant liver in 63 younger and 32 older donors were compared. Liver regeneration was assessed using CT volumetry for up to 6 months after surgery. Poor liver regeneration was defined as restoration of less than 80% of the original liver volume. The risk factors for poor liver regeneration were analyzed using a binary logistic regression model.

Results: The mean age of older and younger donors was 58.0 and 24.3 years, respectively. Despite comparable preoperative factors, older donors showed significantly lower regeneration rates at all observed time points (1 month: 75.5% vs. 82.3%, P = 0.001; 3 months: 80.4% vs. 90.5%, P < 0.001; and 6 months: 87.9% vs. 95.8, P = 0.006, compared to total liver volume). A large total liver volume and older age were identified as risk factors for poor liver regeneration.

Conclusion: Older donors showed a reduced capacity for liver regeneration. This finding suggests the need for the development of more conservative criteria for residual liver volume in older donors than for younger donors to ensure donor safety.

Purpose: The oncologic benefits of adjuvant chemotherapy for resected ampulla of Vater cancer (AoVCa) remain contentious. This study aimed to evaluate the long-term oncologic effects of postoperative adjuvant chemotherapy (PACT) in patients who underwent radical surgery for AoVCa.

Methods: From 2005 to 2019, clinical and pathological data of 306 AoVCa patients who underwent pancreatoduodenectomy were retrospectively reviewed. Patients were divided into the PACT (+) and PACT (-) groups. Propensity score matching (PSM) was conducted to adjust for clinical factors.

Results: The PACT (+) group (n = 124) and PACT (-) group (n = 182) showed significant differences in cancer stage, lymph node metastasis, perineural invasion, lymphovascular invasion, and cancer differentiation. Lower overall survival (OS) (P < 0.001) and disease-free survival (DFS) (P < 0.001) were observed in the PACT (+) group. After PSM, no significant differences in OS or DFS were found between the groups. Multivariate analysis identified lymph node metastasis and perineural invasion as significant prognostic factors, while PACT did not significantly impact long-term survival. Paradoxically, PACT was associated with worse outcomes in patients with favorable prognostic factors.

Conclusion: This study suggests that PACT does not provide a clear oncologic benefit for resected AoVCa patients and may even be detrimental for those with favorable prognostic factors. There is an urgent need to develop effective anticancer treatments and consider tailored therapeutic approaches based on individual patient profiles. Future research should focus on long-term follow-up and the integration of precision medicine to improve outcomes for AoVCa patients.