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Postoperative fluid collection is a common complication of pancreatic resection without clear management guidelines. This study aimed to compare outcomes of endoscopic ultrasound (EUS)-guided trans-gastric drainage and percutaneous catheter drainage (PCD) in patients who experienced this adverse event after pancreaticoduodenectomy (PD).Demographic and clinical data and intervention outcomes of 53 patients who underwent drainage procedure (EUS-guided, n = 32; PCD, n = 21) for fluid collection after PD between January 2015 and June 2019 in our tertiary referral center were retrospectively analyzed.Prior to drainage, 83.0% had leukocytosis and 92.5% presented with one or more of the following signs or symptoms: fever (69.8%), abdominal pain (69.8%), and nausea/vomiting (17.0%). Within 8 weeks of drainage, 77.4% showed a diameter decrease of more than 50% (87.5% in EUS vs. 66.7% in PCD,EUS-guided drainage and PCD are both safe and effective methods for managing fluid collection after PD. However, EUS-guided drainage can shorten hospital stay and duration of intravenous antibiotics use.

Background and Aims Endoscopic ultrasonography-guided ethanol lavage and Taxol injection (EUS-ELTI) in pancreatic cystic lesions have been recently performed in some medical centers. This study aimed to optimize the patient selection and analyze the outcomes in patients who underwent surgery after EUS-ELTI in pancreatic cystic lesions. Methods Among 310 patients who underwent EUS-ELTI between January 2007 and December 2014, 23 underwent surgery after EUS-ELTI owing to incomplete treatment and/or adverse events. We evaluated the surgical outcomes in patients who underwent surgery after EUS-ELTI. Then, we retrospectively compared the clinical outcomes of the patients who underwent the surgery after EUS-ELTI with those of patients who underwent upfront surgery for left-sided pancreatic lesions without the EUS-ELTI procedure. Results The pathology revealed degenerated cysts in 12 patients, mucinous cyst neoplasms in five patients, neuroendocrine tumors in two patients, and one intraductal papillary mucinous neoplasm (IPMN), one solid pseudopapillary tumor, one pancreatic ductal adenocarcinoma arising from an IPMN, and one hepatoid carcinoma. Twelve patients underwent laparoscopic distal pancreatectomy and five patients underwent open distal pancreatectomy. All six patients who had lesions in the pancreatic head underwent open pancreaticoduodenectomy. When we retrospectively compared the clinical outcomes between patients who underwent laparoscopic distal pancreatectomy after EUS-ELTI and those who did not receive the EUS-ELTI procedure, the spleen-preserving rate was 0% in the EUS-ELTI group and 61.7% (365/592) in the non-EUS-ELTI group (P

Backgrounds/aims A superior mesenteric artery first approach (SFA) technique can improve the complete resection rate. It can be used to determine whether an operation can be performed by invading the superior mesenteric artery before performing a pancreatic transection in patients with pancreatic ductal adenocarcinoma (PDAC). The aim of this study was to compare perioperative outcomes between laparoscopic and open SFA for PDAC. Methods Between January 2017 and August 2019, consecutive patients who underwent laparoscopic and open pancreaticoduodenectomy (PD) for PDAC using SFA procedures were included and compared between laparoscopic and open procedures. Results Fourteen and 83 patients underwent laparoscopic and open surgeries, respectively. In perioperative outcomes, there were no significant differences in the amount of intraoperative blood loss or transfusion rate between the two groups. In the laparoscopic group, the operation time was longer with less patients showing wound infection. R0 resection rate and the number of retrieved lymph nodes showed no significant difference. The average time to adjuvant chemotherapy was longer in the open group. There was no significant difference in the mean survival time or the recurrence free period. Conclusions Patients who underwent laparoscopic PD using SFA showed perioperative outcomes comparable compared to those of patients who underwent open procedures performed by experienced surgeons.

Pancreatic cancer is the eighth most common cancer and the fifth most common cause of cancer-related deaths in Korea. Despite the increasing incidence and high mortality rate of pancreatic cancer, there are no appropriate surgical practice guidelines for the current domestic medical situation. To enable standardization of management and facilitate improvements in surgical outcome, a total of 10 pancreatic surgical experts who are members of Korean Association of Hepato-Biliary-Pancreatic Surgery have developed new recommendations that integrate the most up-to-date, evidence-based research findings and expert opinions. This is an English version of the Korean Surgical Practice Guideline for Pancreatic Cancer 2022. This guideline includes 13 surgical questions and 15 statements. Due to the lack of high-level evidence, strong recommendation is almost impossible. However, we believe that this guideline will help surgeons understand the current status of evidence and suggest what to investigate further to establish more solid recommendations in the future.

Introduction The survival outcomes and optimal extent of surgery of T2 gallbladder cancers remain controversial. We aimed to investigate the difference in overall/disease-free survival rates and assess the prognosis of T2 gallbladder cancers. Methods We retrospectively reviewed electronic medical records of 147 patients who underwent surgical resection for pathologically confirmed T2 gallbladder cancer between January 2003 and December 2012. Patients were categorized into two groups according to the tumor location (T2a vs. T2b) and three groups according to surgery method (simple cholecystectomy, cholecystectomy with lymph node dissection, and extended cholecystectomy). We compared the overall and disease-free survival rates according to T2 subgroups and surgery methods. Cox proportional hazard analysis was performed to evaluate prognostic factors for the overall survival of T2 gallbladder cancer. Results Of all patients, 40 (27.2%) and 107 (72.8%) were diagnosed with T2a and T2b gallbladder cancers, respectively. The 5-year overall and disease-free survival rates were 75.0% vs. 73.8% (p = 0.653) and 72.5% vs. 70.1% (p = 0.479) in T2a and T2b gallbladder cancers, respectively. There was no difference in the survival rate among T2a gallbladder cancer according to the surgery method. However, in T2b gallbladder cancer, extended cholecystectomy showed a better overall survival than simple cholecystectomy and cholecystectomy with lymph node dissection groups (p = 0.043 and p = 0.003, respectively). Conclusions There is no difference in overall and disease-free survival rates according to the location of T2 gallbladder cancers. Extended cholecystectomy increases overall survival rate, especially in T2b gallbladder cancers.

Introduction Postoperative fluid collection (POFC) is a common complication of pancreas resection with no clear management guidelines and high morbidity rates. This study aims to analyze clinical features of patients with POFC and compare outcomes of endoscopic ultrasound (EUS) guided and percutaneous drainage in patients with POFC after pancreaticoduodenectomy (PD). Methods We analyzed demographic data, clinical data and intervention outcomes of 53 (EUS guided = 32, percutaneous = 21) patients who underwent PD between January 1, 2015 and June 30, 2019 at our center. Results Prior to drainage, 83.0% had leukocytosis and 92.5% presented with one or more of the following signs or symptoms: fever (69.8%), abdominal pain (79.2%), and nausea/vomiting (17.0%). Fluid collection diameters showed a mean of 95 mm (range, 33 to 191 mm), of which 77.4% showed a diameter decrease of more than 50% within 8 weeks of drainage (EUS = 87.5% vs. PCD = 61.9%, p = 0.085). Eighty-two percent of sampled fluid collections showed positive culture results and post procedural IV antibiotics were used for an average of 8.1 ± 4.3 and 12.4 ± 7.4 days for EUS group (EG) and PCD group (PG) respectively (p = 0.012). EG had a shorter post-procedural hospital stay than PG (9.8 ± 1.1 vs. 15.8 ± 2.2 days, p = 0.004) with no statistically significant differences in technical and clinical success rates, reintervention rates and adverse event rates. Conclusions EUS guided drainage (EUSD) and percutaneous catheter drainage (PCD) are both equally safe and effective in managing POFC after PD. However, EUSD was associated with shorter IV antibiotic treatment and shorter hospital stay.

Introduction Situs ambiguous known as heterotaxy syndrome or isomerism can be classified into situs ambiguous with polysplenia or asplenia. Situs ambiguous with asplenia is a second subcategory of situs ambiguous that is generally characterized by an abnormal arrangement of the abdominal organs and absence of the spleen. Laparoscopic cholecystectomy for acute cholecystitis in patient with this disorder is challenging. Methods A 19-year-old female patient was a situs ambiguous with asplenia patient with transverse liver with gallbladder, left-side stomach, congenital heart disease, and right isomerism. This patient underwent Fontan operation at 4 years of age due to double outlet right ventricle with ventricular septal defect and dextrocardia. This patient had undergone heart transplantation and re-heart transplantation one year ago. Six months ago, Acute pancreatitis with peripancreatic infiltration and gall bladder stone with common bile duct stone were identified on MRCP. We determined Laparoscopic cholecystectomy after ERCP through multidiscipline care. Results We performed laparoscopic cholecystectomy for these patients with 4-port insertion. The operation time was 59 minutes and the operation was completed without any special event. The patient went on a sips of water and soft diet on POD 1 and was discharged without complications on POD 2. The pathologic result was chronic cholecystitis. Conclusions Laparoscopic treatment is a feasible option for selective patients with these disease entity. Surgeons need to be careful because of reversed anatomy, and unaccustomed working hand.

Introduction Although minimally invasive pancreaticoduodenectomy (MIPD) is expanded from benign to malignant disease, oncologic outcome of MIPD for common bile duct cancer (CBDC) were not confirmed yet. Methods The patients who underwent PD for CBDC were identified from 2015 to 2019 in a tertiary referral center. They were divided into open PD (OPD) (n = 342) and MIPD (n = 87) and perioperative and oncologic outcomes were compared between two groups after propensity score matched (PSM) analysis including patients` characteristics, pathology and adjuvant therapy. Results OPD group showed higher T stage (p < 0.001) and frequent adjuvant chemotherapy (p = 0.017) compared with MIPD before PSM and discordance between OPD (n = 78) and MIPD (n = 78) groups were matched with standardized mean difference

Introduction Based on the development and expansion of treatment strategies since the 2000s, we identify the chronologic changes of the clinical and postoperative outcomes of minimal invasive distal pancreatectomy (MIDP) for left-sided pancreatic tumor. Methods Between 2005 and 2019, 2,212 patients underwent planned MIDP. The chronologic change in MIDP was analyzed according to procedure (open distal pancreatectomy [OPD] vs. MIDP), age, spleen preserving, and maligancy. In addition, the difference in clinical and postoperative outcomes was identified by dividing the periods at 5-year intervals, and prognostic factors of open converison and severe postoperative complication were analyzed. Results MIDP has been increasing steadily over 15 years when comparing ODP (from 10.8% to 84.9%). Benign disease has a plateau pattern with a proportion of around 90% from 2010, but in pancreatic ductal adenocarcinoma (PDAC), the proportion of MIDP from 5.6% to 68.4% has been steadily increasing. In the second half of 15 years, compared to the first five years, PDAC increased from 8.3% to 32.8%, and above all, the proportion of RAMPS increased significantly. The open conversion rate was 3.5%, and the risk factors for open conversion in multivariate logistic regression analysis was malignancy, extended pancreatectomy, and site of tumor lesion (body). Also, the poor prognostic factor of severe complication was malignancy, extended pancreatectomy, and ASA classification ≥ 3. Conclusions In benign disease, MIDP is considered a standard procedure. However, MIDP at PDAC still has a technical and oncological challenge. We need high quality randomized controlled trials for acceptable of MIDP in PDAC.

Introduction Laparoscopic pancreaticoduodenectomy with major vein resection is a challenging procedure. We aimed to evaluate the feasibility and safety of laparoscopic vein resection in pancreatic head cancer with portal/superior mesenteric vein invasion and compared differences in the survival of laparoscopic surgery with that of open surgery. Additionally, we assessed prognostic factors for disease-free survival in patients with pancreatic head cancer with major vein invasion. Methods We retrospectively reviewed the electronic medical records of all patients whose surgery was performed by a single surgeon from January 2016 to December 2017. We plotted the Kaplan-Meier curve to compare disease-free survival between patients who underwent laparoscopic surgery and open surgery. We used Cox-proportional hazard models to analyze prognostic factors for survival. Results Among a total of 53 patients, 41 patients had open surgery, and 12 patients had laparoscopic surgery. There was no significant difference in complication rates including portal vein stenosis and portal vein thrombus, recurrence of tumors, and pathological outcomes after surgery. There was no significant difference in disease-free survival (p = 0.541) between the two groups. Additionally, the surgery method was not an independent prognostic factor for pancreatic head cancer with major vein invasion after adjusting for potential confounders. Conclusions The disease-free survival and complication outcomes were not inferior in laparoscopic surgery compared with open surgery. Surgery method was not an independent prognostic factor for pancreatic head cancer with major vein invasion in our analysis.

Introduction To evaluate the predictive factors associated with the early recurrence of early-stage pancreatic ductal adenocarcinoma (PDAC). Methods This study enrolled 407 patients with stage I PDAC undergoing upfront surgical resection between January 2000 and April 2016. Early recurrence was defined as a diagnosis of recurrence within 6 months of surgery. The optimal cutoff values were determined by receiver operating characteristic (ROC) analyses. Univariate and multivariate analyses were performed to identify the risk factors for early recurrence. Results Of the 407 patients, 304 (74.7%) experienced disease recurrence within a median time of 10 months. Among 98 patients (24.1%) with early recurrence, 26 (26.5%) and 72 (73.5%) experienced local and distant recurrences, respectively. In total, 253 (62.2%) patients received adjuvant chemotherapy. The optimal cutoff values for early recurrence were 70 U/mL and 2.85 cm for carbohydrate antigen (CA) 19-9 levels and tumor size, respectively, on ROC curve analysis. Of 181 patients with CA 19-9 levels of > 70 U/mL, 59 (32.6%) had early recurrence, compared to 39 (17.4%) among 226 patients with CA 19-9 levels of ≤ 70 U/mL (p 70 U/mL (p = 0.006), tumor size > 2.85 cm (p = 0.004), poor differentiation (p = 0.008), and non-adjuvant chemotherapy (p = 0.025) were significant risk factors for early recurrence in early-stage PDAC. Conclusions Elevated CA 19-9 level (cutoff value > 70 U/mL) can be a reliable predictive factor for early recurrence in early-stage PDAC. As adjuvant chemotherapy can prevent early recurrence, it should be recommended for patients susceptible to early recurrence.

We aimed to examine the predictive value of changes in perioperative carbohydrate antigen (CA) 19-9 levels for patients operated for perihilar cholangiocarcinoma (pCCA). A total of 322 patients who underwent curative resection for pCCA were divided into three groups: normal preoperative CA19-9 (CA19-9 ≤ 37 U/mL), normalization (preoperative CA19-9 &gt, 37 U/mL, postoperative CA19-9 ≤ 37 U/mL), and non-normalization (pre- and postoperative CA19-9 &gt, 37 U/mL) groups. The association of clinicopathological factors with overall survival (OS) was investigated. The non-normalization group (n = 82) demonstrated significantly worse OS than the normal CA19-9 (n = 114) and normalization (n = 126) groups (5-year OS, 16.9%, 29.4%, and 34.4%, respectively, both p ≤ 0.001). The cutoff points of 300 U/mL for preoperative (p = 0.001) and 37 U/mL for postoperative (p &lt, 0.001) CA19-9 levels showed the strongest prognostic values. In the non-normalization group, patients who underwent R1 resection displayed significantly worse OS than those who underwent R0 resection (median OS, 10.2 vs. 15.7 months, p = 0.016). Multivariate analysis revealed that lymph node metastasis (hazard ratio (HR), 2.07, p &lt, 0.001), postoperative CA19-9 &gt, 37 U/mL (HR, 1.94, 0.001), transfusion (HR, 1.74, p = 0.002), and T stage (T3,4) (HR, 1.67, p = 0.006) were related to worse OS. Persistent high CA19-9 level after resection of pCCA and R1 resection, especially in the non-normalization group, was associated with poor OS. A high postoperative CA19-9 level was an independent prognostic factor in resected pCCA.

Backgrounds/Aims This study aimed to validate the eighth edition of the American Joint Committee on Cancer (AJCC) staging system for pancreatic adenocarcinoma and to propose an improved staging system for this disease. Methods Between 2000 and 2014, 1656 patients underwent surgical resection for pancreatic ductal adenocarcinoma at Asan Medical Center, Seoul, South Korea. The 1169 patients included in this study were recategorized according to the eighth edition of the AJCC staging system. Patients were also categorized according to a new staging system, based on tumor size and number of metastatic lymph nodes. Results The seventh edition of the AJCC staging system categorized 93.7% of patients as having stage T3 tumors. Stages were distributed more evenly with the eighth edition. In the N0 group, classification according to the seventh edition showed no statistically significant differences in survival rate between patients with T1 and T2 (p=0.717) and with IA and IB (p=0.717) tumors. Survival rates classified according to the eighth edition differed significantly for all pairs of T stages (p

Backgrounds/Aims Elderly patients aged >80 yr have high morbidity and mortality rates after biliary surgery, especially in emergency operations. We conducted this study to determine the effect of preoperative management on the outcome of elderly patients undergoing cholecystectomy. Methods The medical records of 452 elderly (≥80 yr old) patients who underwent cholecystectomy from January 1997 to December 2015 were reviewed retrospectively. We divided the patients into 2 groups: intervention (preoperative biliary drainage) and non-intervention groups. We evaluated the effects of preoperative management on the American Society of Anesthesiology (ASA) score and perioperative outcomes. Results Among the preoperative biliary drainage intervention group (n=286), 48 patients (51.7%) were diagnosed as having gallbladder stone combined with common bile duct stone. On admission, the proportion of patients with ASA score ≥3 and WBC counts were significantly higher in the intervention group than in the non-intervention group (p

Backgrounds/aims After centralization policy, clinical outcomes have been improved in patients underwent pancreaticoduodenectomy for pancreatic cancer. However, centralization could exacerbate the prolongation of surgical waiting time. This study aims to investigate whether the shorter waiting time correlates with the better survival and to identify the major confounders that influence the association between those. Methods In this retrospective cohort study, a total 554 patients with pathologically confirmed pancreatic ductal adenocarcinoma were assessed the eligibility from 2014 through 2015. Patients with neoadjuvant chemotherapy, body-tail resection, total pancreatectomy and combined adjacent organ resection were excluded. All patients were divided into two groups by median waiting time, 21 days, defined as the date difference between initial imaging diagnosis and operation. Results Median overall survival did not differ between long and short waiting group (30.4 vs 24.8 months, p=0.35; HR=0.84, 95% CI=0.58-1.21). The proportion of cancer stage shifting, the difference between clinical and pathologic staging, did not differ depending on waiting time group (p=0.811 and 0.255, each of reviewers). Short waiting time was highly correlated with high initial clinical stage (Spearman correlation coefficients -0.201 (p=0.006) and -0.100 (p=0.175), each of reviewers). Conclusions Initial clinical stage had confounding effect on the association between waiting time and overall survival. Therefore, in evaluating centralization policy at the national level, evidence for maximum acceptable waiting time should be investigated in the near future with considering that surgical waiting time could be affected by initial clinical stage.

Backgrounds/aims In adult choledochal cysts, complete excision of cyst with Roux-en-Y hepaticojejunostomy by laparoscopy is typically been performed, but there is now a trend towards adopting robot-assisted resection. Methods From January 2014 to December 2017, 22 patients who underwent robotic procedure were classified as Group 1, and 34 patients who underwent the same laparoscopic procedure as Group 2. In addition, from September 2009 to July 2011, 13 patients who underwent laparoscopic procedure were classified as Group 3. The perioperative outcomes and short-term postoperative morbidity levels were evaluated in three groups. Results In all groups, there were more women than men, and the mean age and BMI did not differ significantly. Since 2014, jejunojejunostomy was performed extracorporeally and the mean operation time was shorter in Group 1 (258.5±52.9 min) and Group 2 (236.2±62.9 min) than Group 3 (395.2±85.9 min). [p=0.00 (1 vs 3), 0.00 (2 vs 3)] The median hospital stay was 7 days in Group 1 and 2, and shorter than 9 days in Group 3. [p=0.00 (1 vs 3), 0.011 (2 vs 3)] In Group 1, there were three postoperative complications, which included cholangitis, bile leakage and umbilical herniation, respectively). In Group 2, there were seven of postoperative complications, which included choledochojejunostomy site stricture & intrahepatic duct stone, choledochojejunostomy site stone, jejunal branch bleeding, portal vein thrombus, acute pancreatitis, adhesive ileus, and A-loop syndrome. In Group 3, there were three of postoperative complications, which included 2 hepaticojejunostomy site stricture and 1 paralytic ileus. Conclusions Robot-assisted resection of a choledochal cyst with Roux-en-y hepaticojejunostomy is a safe and feasible approach with short-term results that are comparable to those of laparoscopic surgery.